Don’t tell me the odds

I survived the war…the odds were long for prisoners like me, but I managed it. Luck played a part, but so did resilience, and, though it I can’t prove it, my ‘survival gene’. I won’t tell you exactly what I went through but I was in Singapore when it fell in 1942, I was captured and imprisoned, and I was starved. I saw friends and fellow soldiers swell with malnutrition, vitamin deficiencies and heart failure, and a good number fell to the ground on the building works. There was cruelty. The chances were that I would not survive, but I did.

Since that time I have dodged a few bullets: a car accident on the M1 in 1975 (‘a miracle you survived’ said the intensive care nurse when I came back to thank them for all they had done), and the bad bout of influenza in ’92 nearly did for me. I was on a ventilator for two weeks, and developed kidney failure as well. The family were brought in, and they heard that I was ‘very, very unlikely’ to survive. But I did. I’m a survivor.

So now I come to this week. I’ve not been right for months, but 5 days ago I got properly sick. It looks like the heart is catching up with me because suddenly, just like the chaps in the prison camp with wet beriberi, my legs started swelling and I got desperately short of breath. Apparently my chest x-ray shows that my heart is hugely enlarged, and after the echo test I overheard someone say that it was pumping like an old carrier bag. I get the meaning. I’ve got bad heart failure, from the fags I’m sure, and two of the valves are shot. But I’m what…born in ’24…I’m just shy of 90, I’ve done pretty well.

So one of the random doctors came along this morning and did the usual checks, crossed some things off the drug chart and added some more, then looked at me, all sensitive in the eyes, and sat on the bed. He said,

“Eric, I’d like to ask you something that you may not have thought about before.”

“Yes.”

“It’s about what we should do if your heart were to suddenly stop. If you were to have a heart attack, a cardiac arrest.”

“I know what you mean. But I haven’t thought about it.”

“As you might know, we often call the emergency team to try to restart hearts with chest compressions or electric shocks, but we have to be sure that there is a good chance that it will work. Sometimes, if the heart is already very weak, the chance of it working is very small indeed, and the damage that those attempts can do is quite significant.”

“So what are you saying?”

“Well, in your case, I don’t think it would be a good idea. We know your heart has become very weak over the last few years, without you knowing it, and if it were to stop – and I’m not anticipating that it will, you’re quite stable – the chance of getting it going again, strongly enough for you wake up and be close to how you are now, is unlikely.”

“How unlikely?”

“I can’t give you a definite number.”

“Don’t they know?”

“Well, I did read a study that found for every 30 people in their nineties who were resuscitated only 1 left the hospital. But everyone is different, it’s a decision that needs to be made on an individual basis.”

“But from where you’re standing the odds are bad.”

“Yes.”

I really hadn’t considered all this before. Perhaps I should have. You see, I enjoy my life, and I have confidence in my ability to survive. I’ve proven it, after all, time and again. But yes, I am older now, the floppy bag in my chest is on its last set of batteries, so I suppose I need to listen. But I wasn’t prepared to say – ‘OK, mark me down for no resuscitation.’ I’m sure it’s awful, being compressed and shocked, I’m sure the machines you have to go on are uncomfortable, but I’ve had worse. They way he spoke, I’m not sure he’ll agree to put me down for resuscitation anyway, it sounds like it’s his decision. But he did ask me. Didn’t he? Or did he tell me. I don’t know. So I’ve left it for now. I want to think about it.

 

The doctor sits in the canteen with his team. His junior colleague asks,

“So, the old chap with the bad heart. Do I do a DNAR form?”

The senior doctor replies,

“Tricky, tricky. In my opinion he has next to zero chance of surviving a crash call. I made that pretty clear didn’t I, within the bounds of compassion.”

“I think so.”

“Would you give chemotherapy to a cancer patient if there was, say, a 2% chance of it working?”

“No, of course not.”

“In fact, you wouldn’t even discuss it. It wouldn’t be on the agenda. So you could argue, why are we even discussing resuscitation with this man? Statistically, medically, it’s an irrelevance. It won’t work.”

“You don’t know that. And you’re talking about the end of his life. The moment of death. He’s bound to have an opinion. You didn’t say it was guaranteed not to work.”

“Trust me, it won’t. He might get a pulse back but he wouldn’t get off inotropes afterwards. And his kidneys are already working at 20% capacity. They will fail too. And will intensive care take him? No. If he stays for resus we’re holding out a false hope. It’s dishonest.”

“So I should do the form shouldn’t I? It’s the weekend, we can’t leave it.”

“I’ll need to go back to him, see if he agrees. He wanted more time, so be it.”

 

Back on the ward.

“Hello again Eric.”

“Hello.”

“I wondered if you had thought any more about our conversation.”

He sat down again, carefully addressed the subject. He made a good case. And you know what I said? Well, I didn’t say much. I didn’t have the energy. I couldn’t be bothered to tell this doctor about my scrapes with death, about the commitment I made to myself back in ’42 never to give in, never to accept fate without a fight…because that’s what got me through it, and that’s what got me off the ventilator in ’92. It was survivability. I’m still the same man, mentally, if not physically. Call me stubborn, but his statistics don’t apply to me. I’ve proved that. I’m going for it.

 

The doctors’ mess

“Did he agree?” asks the junior.

“No.”

“What do we do?”

“Respect it.”

“It’s crazy…it’s not the right decision?”

“Well I’m not signing it.”

“I’ll talk to him some more. Do you mind if I try?”

“And coerce him?”

“Persuade him.”

“He’s made up his mind. It’s not a rational thing. It’s about not letting go of 90 years of life without an argument. I understand it. I don’t agree, but I understand.”

“And if he arrests, we’ll look pretty silly, leaving a 90 year old with severe heart disease for resuscitation.”

“So be it.”

 

fall of singapore painting

 

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5 comments

  1. First up – autonomy. Patient expresses his wishes, need to respect them

    Next up – realism. I want a pony for Xmas. Doesn’t mean I’m going to get one.

    But you know what? I’ve had this conversation many many times. And mostly these old soldiers know the score. They’ve fought and fought. But they know when to give in gracefully. All have said “that wouldn;t be the kind of life I’d want doc, just let me go peacefully if it comes to that”

    The MOST important thing? to have these conversations. Not just on the acute medical wards, but in our primary care clinics, in the ED…way way before we get to ICU…

    Good post, well done.

    1. So right, earlier the better when before the heat is on the situation and before unfamiliar hospital doctors approach. BUT…it’s also hard to explore the subject fully before the nature of the acute medical problem has been established. The early views on end of life care need to be modified and confirmed in the light of any new information.

      Thanks for your comment!

  2. This could be my dad. Eighty-eight years old, Normandy veteran. Before my mum died, I did get him to agree that resuscitation would be cruel, and we should just let her go. But he loves life. I don’t think he would want me to give up on him so easily…

  3. Exactly what I thought myself straight after I’d hit ‘post comment’! The hospital my mum was in did resuscitate her even though we asked them not to – we approached them, rather than the other way around. After multiple GAs, Mum was far too confused to make the decision herself. Because it was Christmas Eve, there was no one available to discuss it with us or make the decision, so they had nothing in writing. She arrested that evening. The positive was that the crash team kept her alive for long enough for us to get to the hospital to see her before she died. We immediately told them to stop resuscitation and she passed away about half an hour later. I don’t know whether the experience of actually seeing my mum being resuscitated would colour my dad’s view of what he wants for himself.

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