Picture the scene, in the emergency department:
“…and if your heart stops…”
“Eh?” [pained groans emanate from the adjoining cubicle] “What’s that you said doctor?”
“I mean if your heart were to stop beating, would you want us to try to restart it?”
“My heart? But I thought you said I had a chest infection.”
“I know, I know, but we always like to ask…sorry…” [nurse enters cubicle with casualty card and asks how long until Miss X is seen] “…tell her twenty minutes…yes, just in case the worse were to happen I mean.”
“I guess so. Is it that bad?”
“No. Not at all…I’m sure it won’t come to that, but, you know, your heart has been through a lot…it’s not as strong as it once was.”
“So what do you think?”
“Can I think about it, talk it over with my daughter when she comes in?”
“When is that?”
“Of course, of course…[aside] but please don’t arrest tonight.”
Bill is seventy five and has come to casualty because he has been coughing up blood and getting more short of breath. He has been smoking since he joined the army in 1940, and his lungs resemble a blackened sponge, the air sacs coalescing into overlarge, inefficient holes. He can barely walk from the lounge to the kitchen. He does not look particularly unwell and if all goes well he’ll be home in a week. But he might die. It’s possible. So, in anticipation of that misfortune, I must discuss the subject of resuscitation with him. It could wait of course, until tomorrow when his daughter comes in, but…time is of the essence – I want to know how to respond if he arrests tonight. As it stands, we will try to resuscitate him. We will have to.
In response to the concern caused by evidence that the elderly and those with cancer were being ‘written off’, the Secretary of State for Health stated in September 2000; “Decisions on non-resuscitation should only be made following a discussion with patients and their families.” This has been emphasised time and again, in hospital protocols, in national guidelines. But that requirement means the DNR form will remain incomplete until a discussion has taken place. If relatives are not in the hospital, or not contactable by phone, or ambivalent themselves, only the very senior, very confident doctor will fill out that form. If they can make a firm case for not resuscitating they will go ahead, ready to defend themselves should the family choose to complain after their loved one’s death. If the doctor is not minded to take that risk, the patient will be subjected to a resuscitation attempt.
The chances of getting Bill’s heart going again, should he arrest, are small. In 1992, when the BRESUS investigato
rs counted up the number of people who had had cardiac arrests on the general medical wards of 12 hospitals, they found that only 11% were still alive a year later. This included all age groups. The over seventy-fives stood even less chance; those with pneumonia even less. Quality of life was not investigated, but many of those who died within a year never left hospital. Should I tell Bill this when I see him in casualty?
And what of the mechanics of an arrest call? Should I give even a sanitised version of the events that take place during cardiopulmonary resuscitation; the cracking of brittle ribs, the rivulets of black blood resulting from the desperate search for vascular access, the tube down the trachea, the muttered consensus between nurses and doctors that precedes the final release? If I do I will be making my own views on the matter very clear.
A fine balance must be achieved, between ensuring that patients are acquainted with the depressing reality of resuscitation, and the avoidance of brutality. It is not easy bringing up the subject of death, steering the conversation towards mortality having focussed, during the preceding thirty minutes, on the measures that you are planning to avoid it. It requires a thick skin, a form of words, a knack – an iron hand in a kid glove if you like. Casualty departments and admission wards are not conducive to such subtlety of communication. Given the gravity of the discussion, it is not surprising that the presence of family members is required. The logistical and emotional difficulties presented by this plunge into the deepest fears of a patient or a family means that the discussion may not take place at all. The resuscitation status will therefore remain positive, by default. However small the chance of success, however strong the feelings of the doctor, resuscitation must be commenced, for to do otherwise would be to ‘watch the patient die’. Doctors transgress guidelines at their own peril in this litigious age.
What then is the answer? The answer is…pragmatism.
“What if he arrests? He’s still for resus. There’ll be a crash call.” the junior doctor enquires.
“Well…look, use your common sense…if you don’t get him back straight away don’t go on…” has been the traditional instruction. This is not a casual statement. It is an attempt to match the chance of success with the burden of treatment. If it looks like it will work, sure, push on, go all the way, that’s what we are here for, to save life. But if the patient is clearly not responding, pull out. Don’t commit the patient to a prolonged death.
So the team follow the resuscitation algorithm, give the drugs, deliver the shocks, but they will not persevere for more than a few minutes, for they know that even if the attempt is ‘successful’ (ie. the heart is restarted) the end result will probably be ultimately disastrous for the patient. So the medical profession has found a compromise. Doctors will attempt a resuscitation in any circumstance, in order to abide by the guidelines that have been set down, but they will not subject a patient who has obviously ‘died’ to endless cycles of massage, shocks and injections, even if a small chance remains that the heart can be kicked into action. Indeed, repeated administrations of adrenaline, a drug powerful enough to squeeze another hour’s activity out of the most tired and damaged of hearts, are often avoided. A tidy, unambiguous death is preferable; better that than not being able to tell the waiting relatives that their loved one is dead just because the heart has not yet ceased its fitful, useless contractions.
This circumstance has come about because the ineffectiveness of resuscitation in the elderly population is not understood by the public. Doctors, who know how harmful a resuscitation attempt can be, are not trusted to make a unilateral decision as to whether it is right or not, when the discussion has not taken place. The pendulum has swung away from the medical paternalism of yesteryear, but in this area the opinion of an experienced doctor is trumped by caution. Cardiac arrest is the only situation in which a doctor has no choice as to whether or not to give a particular treatment to a patient…the most unpleasant, and in some cases, the most ineffective ‘treatment’ of all.