A life-or-death decision by Maplewood paramedics, who stopped life support for an elderly woman at her husband's insistence, underscores why individuals should have legal documents spelling out the care they want in what can be frantic and confusing end-of-life emergencies, health officials said Wednesday.
Paramedics and nursing home workers across Minnesota can relate to the difficult decision that was made Aug. 7, when medics initially revived 71-year-old Linda Sandhei and started wheeling her to an ambulance, only to have the woman's husband tell them to stop, according to a police report of the incident. Sandhei died soon after.
Advance directives and do-not-resuscitate (DNR) orders can provide clear guidance for such high-stress decisions. But absent those documents, medics are often asked to trust relatives who are distraught and may not know the wishes of their dying loved ones, said Dr. Jeffrey Ho, medical director for Hennepin County Medical Center's emergency management services (EMS).
"What we're trying to avoid is some random person coming up to us and saying, 'Stop, I don't want Mabel resuscitated!' And we ask, 'Well, who are you?' and he says, 'Oh, I'm her son,' " Ho said. "We have no way of verifying if that's true or not, and we really have no way of verifying whether Mabel would actually want to be resuscitated or not."
Research has shown that patients' wishes are followed more often when spelled out in advance directives, and that relatives suffer less stress and anxiety. But such documents remain uncommon, even after a coordinated campaign called Honoring Choices by Minnesota's eight major health care systems to get more people to complete them. The state's top system had completed directives from just 32 percent of its elderly outpatients, according to a study last year.
Sandhei, who had suffered from Parkinson's disease for two decades, either hadn't completed a directive or didn't have one filed with the Good Samaritan nursing home in Maplewood. She was transferred there in July after being admitted to Regions Hospital, according to a police report.
Her son was at her bedside around 4 p.m. Aug. 7 when she vomited in her sleep and stopped breathing. Sandhei's husband, Tom, arrived later and stopped the medics from loading his wife in an ambulance for transfer to a hospital. He declined to discuss the incident when reached by phone Wednesday.
Written directives aren't always the final word in a high-stress situation when someone is dying and relatives are angry or scared. Paramedic Mike Trullinger has tried to follow DNR orders for dying patients only to be threatened by distraught relatives with lawsuits, a baseball bat and, in one rural case, a shotgun pointed at him.
"The patient had a DNR order, but the family member had a shotgun. So we performed CPR anyway," said Trullinger, now a supervisor for HCMC's EMS. A sheriff's deputy eventually arrived and the man put down the weapon and became apologetic, Trullinger said. CPR failed.
Ho said his medics, too, have experienced tough situations even when patients had written documents. Sometimes the document might be improperly dated or lack a doctor's signature, calling it into question. Other times relatives are scrambling to dig up the document from files while medics are proceeding with CPR.
Frequently, relatives who thought they were prepared to see a loved one die have a change of heart when the moment arrives.
Regardless, Ho said having that paperwork completed resolves more confusion than it creates and leaves people feeling confident in their end-of-life decisions.
"It's a very difficult decision to be making in a split second with limited information," he said. "It's tough to be second-guessed afterward."
Err on the side of life
The Maplewood Fire Department policy manual instructs medics to follow written orders but otherwise pursue resuscitation: "Until properly completed orders are presented, pre-hospital personnel will assume that no valid DNR orders exist and proceed with standing orders for resuscitation as medically indicated."
A Hennepin County protocol governing HCMC, North Memorial, Allina, Ridgeview and Edina EMS agencies provides similar advice.
"If we are going to start a resuscitation, we need to do it right then and there," Ho said. "If the information is not clear to us, then we are erring on the side of starting resuscitation, because we can always stop it later."
Nursing home workers operate under similar assumptions, said Patti Cullen of Care Providers of Minnesota, a trade group for nursing homes. "From a legal perspective, we advise our members that without the presence of this DNR that is signed, that's official, they've got to do every lifesaving measure, because families will sue if you don't save a life. They won't sue if you break ribs because you did CPR."
The fact that the Maplewood medics halted life support in the absence of a written directive for Sandhei suggested to Ho and Cullen that they had enough information from the relatives or nursing home staff to override the bias toward continuing lifesaving efforts.
Maplewood police made no arrests in the case after an investigation concluded that the medics acted in "good faith." The term is defined in the state's advance-directive statute as acting in the best interests of a patient in any way short of assisted suicide.
Six Maplewood firefighters, including the chief, were suspended after a complaint was filed, but city officials declined to confirm whether the complaint was linked to Sandhei.
Cullen sympathized with the relatives and first responders, who she said appeared to act in the best interests of the family and patient.
"You know, the reason for doing that legal document," she said, "is to get all of the family members on the same page."
Staff Writer Kevin Giles contributed to this report.
Jeremy Olson • 612-673-7744