5 days: a tale of escalation creep

escalation

Day 1 A 90 year old lady, Mrs V, is admitted to hospital with symptoms of pneumonia. She was managing at home 6 months ago but has become increasingly dependent on her family; the plan was to employ or arrange carers soon. She always said she never wanted strangers around – the words ‘fiercely independent’ are used a lot. She saw her husband die on an intensive care five years ago – it was very unpleasant, and her son makes it clear from the outset that she would never want to be put on a ventilator. Treatment begins, and her son actively engages the consultant in a DNAR conversation during the post-take ward round. All are agreed she should not be subjected to it should her heart stop. But the consultant explains that the pneumonia is not that severe, and says she is optimistic that Mrs V will improve. The son was due to go on a business trip for three days – he asks if that is wise. The consultant says,

“Well, nothing is ever certain, but her oxygen levels are not too bad, and she has no other illnesses. I can’t tell you what you should do, but she doesn’t seem to be in imminent danger.”

He leaves.

Day 2: Mrs V appears confused to the registrar who does the daily ward round. He notes that her oxygen level is borderline. The oxygen flow is turned up, the level improves. But later that day it dips again (saturation 83% on an oxygen mask). The registrar calls the consultant,

“I was thinking about some non-invasive ventilation on the medical HDU.”

“That would be reasonable. Her son was keen not to medicalise too much…”

“I think she just needs a couple of days of support.”

“I agree. She was pretty good before, the antibiotics haven’t really kicked in yet. Any positive microbiology?”

“Streptococcal antigen positive.”

“Ah. Well at least we know. But it could be aggressive. I’m happy for you to arrange transfer.”

Day 3: Mrs V has spent the night on a tight fitting mask which allows oxygen to enter the lungs under pressure. She struggles with the mask periodically, but settles eventually. Her oxygen levels are better, but she is still confused. The team put this down to delirium, an acute confusional state. A blood sample is drawn from the wrist, and it shows that her carbon dioxide levels have risen. The HDU nurse asks if the team could arrange an arterial line, a cannula inserted into the radial (wrist) artery, to allow more frequent blood sampling. This will avoid repeated needles. The registrar agrees, the SHO volunteers. He can feel the artery easily, and is confident. The ward round moves on and the SHO stays behind, but 40 minutes later he calls the registrar.

“I couldn’t get it in.”

“How many attempts?”

“Just three…but it bled and she has a big bruise.”

“Leave it for now. I’ll do it.”

Day 4: The consultant does a ward round in the morning.

“How come she’s got a nasogastric tube?” she asks of the charge nurse.

“She was sick overnight. Her stomach filled with gas because of the positive pressure. She’s a lot more comfortable now.”

“Is she eating?”

“Not much. She has some sips during breaks off the mask.”

The team look at the arterial blood sample results. Gradually, with the eye of faith, the respiratory failure is improving. Mrs V cries out. She has pleurisy, intense pain at the edge of the lungs. Simple pain killers are not enough, and she is prescribed morphine. As the consultant walks away she notices the urinary catheter bag hanging from a stand.

“Why the catheter?” she asks. The charge nurse replies,

“She couldn’t manage with the commode, not on the mask. She’s high risk for pressure sores. We put it in yesterday.”

Day 5: Mrs V deteriorates. A repeat x-ray shows that the pneumonia has spread further through the right lung. The registrar calls the consultant.

“I’ve got quite a bad feeling about her now. I think her age is beginning to tell, I know she didn’t have any other illnesses but…”

“You’re right. Once things begin to go downhill it’s hard to see her getting better.”

“I understand her son didn’t want her to go to intensive care.”

“I don’t think they would take her to be honest. But yes, he told me that she wouldn’t want that. In fact he needs to know what’s going on. He’s supposed to be coming back today.”

“The nurse called him this morning. He arrived back in the country in the early hours apparently. He’s on his way in.”

“I’ll speak to him. We need to discuss de-escalation.”

At 2pm her son arrives on the ward. He finds his mother lying on her bed, barely conscious now. She is muttering words but he cannot understand them. A monitor pings and alarms insistently above her head. Trailing from her body are a urinary catheter, an arterial line transducer, two intravenous infusion lines and the wide oxygen tube attached to the mask at her face. The air and oxygen in the mask whistles. Cardiac monitoring leads trail out of her gown into the machine that is alarming. He sees the bruise on her forearm that has now developed into a 4-inch haematoma that sits proud to the skin. He pushes the curtain aside, tears in his eyes, storms out of the cubicle and shouts in the direction of the nurses’ station,

WHO DID THIS? SHE NEVER WANTED THIS!”

She dies later in the day, the mask having been removed and the monitor having been turned off. Six weeks later her son writes to complain about the inappropriate, overly intensive treatment to which she was subjected during her final illness.

What happened here?

*

I wrote this to explain how, as the cliché goes, the ‘road to hell is paved with good intentions’. Looking back, Mrs V’s treatment seems misguided. How could her consultant have allowed a frail 90 year old lady with (what proved to be) severe pneumonia undergo multiple, potentially painful and distressing procedures to no avail? Didn’t she hear the son when he explained how Mrs V had witnessed her husband undergo a similar ordeal? Why didn’t she put a brake on the system and stop the medical rollercoaster in its tracks?

But then, let’s go back to beginning and follow these events step by step. The infection didn’t look that bad at the beginning, there was little reason to expect Mrs V’s death. So, when Mrs V’s oxygen levels fell, a judgment was made that a short period of assisted ventilation would help. But then, to avoid repeated blood tests, an arterial line was required – a procedure that proved harder than it looked. The gastric tube had to be passed, the nurses couldn’t just stand by as her stomach filled with gas. The catheter was routine. Every step was justified.

How could this have been avoided? Well, if the son had been there every day he may have called a halt to things, but I’m not sure he would have felt able to question each procedure in the face of enthusiasm and almost routine pattern following on the part of junior doctors and nurses. So to stop this we need to go back further…to the initial conversation. It needed to focus on the ‘ceiling of care’.

Perhaps the consultant should have made a decision, in discussion with the son, that whatever happened Mrs V would remain on the basic medical ward…even if she deteriorated. In that way there would be no danger of being prescribed the mask, and no danger of having to endure the paraphernalia that can goes with it. The son would have returned (perhaps a day or too earlier if he had been contacted about the deterioration) to find his mother being treated on the original ward, in relative comfort. Knowing how things turned out in the end, that decision would have been right. But no-one knew how things were going to go. The consultant thought there was a chance of survival. She decided that the burden of treatment was reasonable in this case, despite the caution that the patient’s son had expressed. She made the wrong call.

I have no right answer here. I wish only to highlight that, as Soren Kierkegaard said, ‘Life can only be understood backwards; but it must be lived forwards.’

The case description is entirely fictional.

cover to tweet

Click icon to explore e-book

Click here for paperback details

Advertisements

5 comments

  1. Thanks for another thought-provoking piece underlying the complexities of seemingly simple decisions made in hospitals.

    Working in an advisory palliative care service we are often involved days to weeks after admission has happened. The narrative provided by casenotes is really important to make sense of what is happening, doubly so when complaints or questions come in at the bereavement point of view. Sometimes this narrative is clear, sometimes it is quite obtuse and potentially this is increasing with increased specialisation and altered working patterns.

    The challenge as you point out is how you marry the overall thrust of care with the individual components that up, particularly where these components have equivocal or seemingly innocuous outcomes.

    Considering values, considering the risk/likelihood that someone may not survive this episode and -if that’s the case- what care would look like if that happened is important (and part of what makes up AMBER care bundles etc).

    Ultimately it comes down to how we as doctors think when almost all decisions in hospitals are quick decisions. And how we put the right shakes to tramline thinking into our way of working.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s