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58 JULY 2016 | EMSWORLD.com THE MIDLIFE MEDIC By Tracey Loscar, NRP, FP-C It's an ironic par t of our profession that we install people into a system we do not our selves trust. J u s t S o We A r e C l e a r Interactions with healthcare providers require plain talking M y mother is dying. My relationship with her is complex and painful due to drug and alcohol addiction. My father's sudden death in 2013 thrust us back together after many years of self-imposed estrangement. My younger brother had already drunk himself to death and the rest of her fam - ily had distanced themselves long ago. I was the last one left. When I came to Alaska from New Jersey to start the next chapter in my professional life, what we were going to do with her provided a huge challenge. We decided to bring her out here, as managing households on opposite ends of a continent was just too much. Two months after she arrived she started complaining of a sore throat. With a two-pack-a-day habit, this is not unusual. At first it was manageable with OTC pain meds. Eventually it became painful to swallow, then difficult to swallow mechanically. When she began losing weight, we knew what we might be facing. The last couple of weeks have been full of appoint- ments and tests. This once-vibrant, brilliant nurse is now tiny and frail, crying quietly as they insert needle after needle into the mass in her neck. She tries to control her shivering as they put her in the CT machine, as she's always so cold. She wants to eat, but cannot swallow. Three days ago, we got the preliminary results—meta- static squamous cell neck cancer. (Author's note: As with any cancer, Google is NOT your friend.) From there we made plans for an ENT consult, and the very real fact that my mother's fragile health probably will not toler- ate much in the way of surgical or medical intervention. I asked for a hospice consult as soon as possible, the doctor agreed. It did not hit my mother until later that night just what the doctor was saying, and her anxiety went off the chart. She exacerbated to the point where we ended up in the emergency room. I have a fear of hospitals and so does she, for the same reason that I know a lot of you do too—it's an ironic part of our profession that we install people into a system we do not ourselves trust. Why was I afraid? Because they do not listen. They hear the report or the alarm on the monitor, but they do not listen fully. Sometimes it takes extraordinary measures to get caregivers to understand the depth and breadth of the problem or the need. A few hours after she's in the emergency room the phone rang; the intensivist initiating her care after they admit her is alarmed about the CT results from her neck. He was calling me to see if I was willing to transfer her to Anchorage because of her precarious airway status. I told him she's a Comfort One patient and that won't be necessary, there's no need to transfer her. Doctor: "I just want to really highlight one line from this CT report for you, 'Impending airway obstruction.'" Me: "No tube, no trach, no vent." Doctor: "Just so we are clear, if I transfer your mom to the floor and say, five minutes later her airway closes, you are OK with your mom suffocating to death?" Me: "Of course I am not, but what I am OK with is the fact that she is a Comfort One patient, which is in accordance with her wishes. Trust me, she and I know what 'impending airway obstruction' implies. Make her comfortable. Just so we are clear—no tube, no trach and no vent." My parents had advanced directives and medical proxy orders drawn up before it was cool to do so. Once we got her into the Alaska health system the first thing we did was request "Comfort One" status, which is the state's DNR program and recognized statewide from EMS to hospital. This forced confrontation with mortality so close to home is an excellent lesson. Midlife may not mean end- of-life but it does put us at the generational range where we must change our working relationship with death. Our parents are aging, we are aging. If we do not make our wishes known then we leave ourselves at the mercy of the healthcare system and face the necessary brutality of resuscitation. Is someone able to speak for you? Are you strong enough to speak for someone else? Make a plan, do it now. As of this writing, my mother is still in the hospital and we are waiting for a consult with hospice. Every shift change I contact the oncoming nurse to make sure that we are on the same page: "No tube, no trach, no vent." Just so we are clear. A B O U T T H E A U T H O R Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska- Susitna (Mat-Su) Borough EMS in Wasilla, AK. Her adventures started on the East Coast, where she spent the last 27 years serving as a paramedic, educator and supervisor in Newark, NJ. She is also a member of the EMS World editorial advisory board. Contact her at taloscar@gmail.com or www.taloscar.com.