OBVIOUS And EXPECTED DEATH

Reporting a death can be a difficult experience for a caller, tasked with informing a stranger with finality that someone, possibly dear to them, is gone. Though these calls normally last only a couple of minutes on average, the interaction can echo in the caller’s mind for much longer.

As the Emergency Medical Dispatcher (EMD), your understanding of OBVIOUS and EXPECTED DEATH situations and critical intervention decisions can help you seamlessly provide compassionate care, send accurate responses, and professionally address the concerns of the caller during these grim moments.

OBVIOUS DEATH
The Medical Priority Dispatch System^™ (MPDS^®) Protocol 9: Cardiac or Respiratory Arrest/Death only comprises about 1.75% of emergency medical calls, according to the International Academies of Emergency Dispatch^® (IAED^™) Data Center. Of these calls coded on Protocol 9, 54% are determined as 9-E-1 (Not breathing at all) from the Case Entry Protocol. In these situations of suspected workable arrest (often from a just-witnessed or recent incident), the Emergency Medical Dispatcher (EMD) is directed to begin providing CPR instructions immediately without further interrogation.

Protocol 9 also addresses a very different scenario of callers reporting a fatality, sometimes discovered well after it occurred. The report of an OBVIOUS DEATH (9-B-1) comprises about 18.85% of Protocol 9 calls, indicating that the patient cannot be revived, unquestionably.

OBVIOUS DEATH is locally defined but may include the patient conditions listed as the following suffixes:
• a—Cold and stiff in a warm environment
• b—Decapitation
• c—Decomposition
• d—Incineration
• e—NON-RECENT death (defined as “six or more hours have passed”)
• f—Severe injuries obviously incompatible with life
• g and h—Medical Director-approved additions (Typically, they are assigned a similar limited, non-emergent response.)

The Key Question “Please tell me, why does it look like s/he’s dead?” is meant to confirm the caller’s qualifying observations of the patient, while carefully avoiding leading the caller. If the patient’s described conditions match any of those defined in the OBVIOUS DEATH definition, the EMD asks, “Do you think s/he is beyond any help (resuscitation/CPR)?” This is done specifically to confirm the caller’s impression. If any question exists, the EMD is directed to begin providing CPR instructions to the caller.

Suffix descriptions
Collecting effective descriptions during a reported death can be a difficult process due to the caller’s shock, emotion, or simple lack of words. Sometimes callers will provide a partial description to an OBVIOUS DEATH qualifier, such as “He’s cold and stiff,” without offering “in a warm environment.”

The EMD may be confused about how to elicit a complete description while staying compliant to the protocol. Bryon Schultz, IAED Medical Academics & Standards Expert, says that common sense plays a role in these situations.

“I’ve heard some EMDs ask the caller if they are in a normal, room-temperature environment,” Schultz said. “This would be considered a clarification, which is compliant. Keep in mind that if a patient is found outside lying in the snow, hypothermic cardiac arrest is possible. However, if the caller has already described that the patient is in their bed at home, we can usually be confident that the temperature is not a factor in the patient’s condition.”

Schultz said the OBVIOUS DEATH suffix that is not often utilized is “NONRECENT death” because it’s uncommon to quantify whether 6 hours or more have passed since the patient’s demise. “It’s possible a neighbor last saw the patient on Monday, and the patient has now been found reading Tuesday’s newspaper on a Thursday,” Schultz said. “Most often, however, the caller doesn’t know the timing definitively.”

When the conditions of OBVIOUS DEATH are met, the resources sent can also be dependably decreased. “Initially, some agencies may be reluctant to send fewer resources to these codes,” said Brett Patterson, IAED Medical Council of Standards Chair. “They may fear that the patient may not actually be dead, but studies reviewing the criteria and the outcome for these codes prove the protocol to be very reliable.”

A 12-month retrospective study done in three centers in 2015 showed compelling evidence that “overall, unquestionable death in the priority response classifications of BRAVO and OMEGA-level codes were coded correctly by the EMD in 98.5% of all cases, as indicated by the paramedics’ decision not to transport upon arrival.”¹

EXPECTED DEATH
Protocol 9 also addresses reports of EXPECTED DEATH, typically where the caller has been caring for a critically ill patient who has a terminal illness. These Determinant Codes include 9-D-2 “OBVIOUS or EXPECTED DEATH questionable (a through h; x through z)” and 9-Ω-1 “EXPECTED DEATH unquestionable (x through z)” with suffixes x—Terminal illness, y—DNR (Do Not Resuscitate) Order, and z—Medical Director-approved additions.

Often these patients have a physician signed DNR order to prevent attempting to extend the patient’s life through extraordinary means. The presence of a DNR order can be indicated with an additional y suffix.

Though these callers have anticipated the patient’s death and are primarily focused on making them comfortable, they may require reassurance when the patient demonstrates signs of dying, such as agonal respirations.

In these cases, the EMD asks the caller, “Are you certain we should not try to resuscitate her/him?” As stated in the Protocol 9 Rules: “If the caller believes the DNR should be ignored or is uncertain if the DNR is valid or in place, an appropriate response and resuscitation attempt should be made.”

Additionally, EMDs should be aware that in some cases, the patient’s current condition may not be related to the specifics of the DNR. For instance, a patient may be experiencing an acute condition unrelated to his or her terminal illness (e.g., a cancer patient currently suffering from pneumonia) and may be treated aggressively in the interest of patient comfort. For this and other important reasons, EMDs should not attempt to validate or interpret the specifics of a given DNR. Ultimately, the resuscitation choice is left to the caller.

Caller refused to provide CPR
A new “Caller Refusing CPR” ProQA^® pathway has recently been added as both a Key Question answer choice on Protocol 9 (prior to Pre-Arrival Instructions) and as a pathway option on Protocol C, Panels C-2 and C-20. Often as the EMD begins instructing the caller to position the patient, this can be a pivotal moment for the caller to confidently express their desire otherwise.

There are varying reasons a caller may refuse to provide CPR. They may feel fear of misinterpreting the situation, worry about performing CPR incorrectly, have concern over contamination (where compressions-only CPR may be appropriate), or experience discomfort over responsibility for the patient. caller refusal pathway directs the EMD to the appropriate PDI-a (also used for OBVIOUS DEATH): “I’m sending someone to assist you. Please leave everything as you found it. Is there anything else we can do for you (or your family)?”

Compassionate support
“Sometimes callers report that an EXPECTED DEATH patient is in the throes of dying, but they’re not dead yet,” Patterson said. “The caller doesn’t want to begin CPR or intervene, but they’re calling 911 anyway, often due to their own discomfort in seeing their loved one’s struggling final breaths.”

This scenario can confuse the EMD on how to help. If the caller doesn’t need lifesaving instructions or resources at the ready, why are they dialing for emergency services? During these moments, compassion becomes the driving force behind the call.

“From a customer service point of view, these are some of the most difficult calls to deal with, even as field responders,” Schultz said. “Over the phone, all you have is your voice to convey empathy for what they’re facing.” Much like utilizing repetitive persistence to focus the caller, you may use reassuring phrases between protocol questions and instructions: “I’m here with you,” “I can hear that this is so hard for you,” and “Help is on the way.” The goal is to convey a sense of calm while allowing room for the caller to connect.

Conclusion
Though both OBVIOUS and EXPECTED DEATH situations are clearly defined, the EMD still must consider each situation individually, review and follow the protocol, and determine the best course of action to support the caller.

“You have to be a person and not just a protocol in these moments,” Patterson said. “That’s why they’re talking to you and not an automated system telling them to ‘press one if you’re choking.’” Even when the patient is already gone, your influence can make a difference in the way the caller feels heard and understood.

Source 
1. Whitaker I, Olola C, Toxopeus C, Scott G, Clawson J, Schultz B, Robinson D, Calabro C, Gardett I, Patterson B. “Emergency Medical Dispatchers’ Ability to Determine Obvious or Expected Death Outcomes Using a Medical Priority Dispatch Protocol.” Annals of Emergency Dispatch and Response. 2015;3(2):5-10.