Month: January 2015

Why did that man receive CPR? – part 3

I rang the family of the 96 year old man, Mr Simpson. I knew I was crossing a boundary, but I had gone as far as I could on the other side of the line – in the hospital, in the GP surgery. I needed to know how much of an offense that futile 6 minute exercise in attempted resuscitation was. Mr Simpson had a younger wife, aged 85, and several children, only one of whom was in the area. He, Dennis, was 65. I held my breath and called. A male voice answered – Dennis.

“Hello.”

“Hello. My name is Dr _____, I am one of the doctors who helped to look after Mr Simpson…”

“Yes.”

“I wondered if I could meet with you, and his wife. There is something about his care in the hospital that I want to discuss with you, as long as it’s not too distressing…”

“Well, we weren’t surprised that he died. He seemed very peaceful when we saw him. My mother is very sanguine about it, upset of course, but I can’t see why she wouldn’t be happy to talk…”

We made an arrangement.

A week later I sat in their lounge; Mrs Simpson, Dennis, and me.

 

Dennis: “How can we help Dr _____?”

Me: “I’ll get to the point. I don’t know if you know what happens when patients die in hospital.”

Dennis: “They go the mortuary don’t they. They are covered up and taken out of the ward…”

Me: “But before that. Have you heard about resuscitation?”

Dennis: “Yes. We’ve seen it on TV. When they try to restart the heart. Very dramatic.”

Me: “It is. Sometimes it works, and the patient comes back to life, but often it does not, especially if the patient is very frail. We tend to assume all patients should have resuscitation if their hearts stop. In fact, unless someone has specifically said it shouldn’t happen, if they die the crash team will be called as an emergency and they will start to perform resuscitation on the patient.”

Dennis: “All patients?”

Me: “Unless a ‘Not for resuscitation’ decision is made, yes.”

Mrs Simpson: “Did they do that to Arthur?”

Me: “Yes, they did. That’s why I’m here. I wasn’t very happy about it when I discovered it.”

Pause. Dennis and Mrs Simpson look at each other.

Me: “How do you feel about that, now you know?”

Mrs Simpson: “It feels very – wasteful. To think  of all those doctors running in, the machines, all the shouting and panic, and Arthur lying there. Did it hurt him?”

Me: “I don’t think so Mrs Simpson. He would have been unconscious. And when they realised that his heart was not going to restart again they stopped.”

Dennis: “After how long?”

Me: “Five or six minutes.”

Dennis: “That long?”

Mrs Simpson: “Was it wrong? Is that what you’re saying Dr ____? Is that what you are here to tell us?”

Me: “I don’t know. I want to ask you. You see, the intention of the system we have is good – to save as many patients as possible – but we can be slow at identifying patients like your husband who really shouldn’t be subjected to resuscitation. It seems wrong, it seems like a mistake, when someone like that is put through such a treatment, but because the patient has died we never know how wrong it is. Is it wrong at all, if the patient passes away and feels nothing?”

Dennis: “Of course it is. To think of him being pushed around like that. It’s not what he would have wanted at all.”

Me: “Do you know that Dennis? Did he ever say that?”

Dennis: “Not specifically. Whoever talks about resuscitation specifically? But he was plain that he didn’t want to spend lots of time in hospital. He told me he wanted to die at home – ‘like in the books’ – he said, he loved the classics. His idea was a clean sheet, a doctor popping in during the morning and leaving instructions with the family, and one of us reading something to him as he became more and more drowsy…”

Me: “That’s… a really strong image. Wow.”

Mrs Simpson: “He didn’t discuss that with me Dennis.”

Dennis: “Perhaps it’s a male thing Mum… he wasn’t one to talk about himself that much…”

Me (uncomfortable) : “Did he, or you, ever consider leaving instructions? Written instructions?”

Dennis: “No. But we should have, I see that now.”

Me: “The difficulty is, now that you know what happened to him, to work out how wrong it was to try to keep him alive. Mrs Simpson, what do you think?”

Mrs Simpson: “Until you told us, we didn’t know. We assumed he had stopped breathing and that he had just passed away on the ward. I was not surprised, even though he was not that unwell when he went in. At his age it could have happened at any time. It could happen to me at any time! His death I can accept. And now you come and – forgive me – you come and complicate it. I don’t know what to think. I trust the hospital to have given him the right and the best treatment. If you tell me it didn’t, then I am upset. I don’t know enough about it to have a strong opinion – was it right or wrong. If that is what you do in the hospital, as long as he did not suffer I am not angry. Dennis?”

Dennis: “I’m upset. His death, as I now imagine it, is the opposite of what he would have wanted. The exact, diametric opposite. So that makes me angry.”

Me: “Would you rather I hadn’t told you though?”

Dennis: “In one way, yes. We were getting along fine after his death. This has sullied our memories… but if it happened it happened, and it’s better for us to know. The only good that can come of it though is if you go back to the hospital and make sure it doesn’t happen again, to another nearly hundred year old.”

Me: “That is a real problem for us. You see, if a patient looks OK, not to unwell, and if they don’t bring the subject up, doctors don’t always raise the subject. If it is not discussed openly with the patient, or with the family, they are not allowed to make a patient ‘Not For Resuscitation’.

Mrs Simpson: “Absurd. It was obvious he wouldn’t want such a thing.”

Dennis: “But you’ve had complaints I guess. Legal cases. I’ve read about them. But surely if your doctors bring a 96 year old into hospital, they should have to raise the subject. Not to do it is just avoiding the issue. They can’t just pretend it might not happen.”

Me: “I agree with you. But it gets lost, I’m afraid. And we can’t have a rule that says over a certain age you should not have resuscitation. It has to be on a case-by-case, individual basis.”

Mrs Simpson: “Then go back, please Dr _____, and tell them, all your colleagues and students, to think about it. And to talk about it. Please.”

Me: “I will. Thank you.”

 

Part 1

Part 2

oOo

 

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Why did that man receive CPR? – Part 2

In Part 1  of this imaginary inquiry I asked several doctors why a 96 year old man was subjected to two cycles of cardiopulmonary resuscitation. My search for accountability was not successful. The AMU consultant led me down a path I hadn’t explored before – into a half-lit world of philosophical uncertainty. Was it wrong, after all, to perform a violent and futile act on a patient if they felt no pain and suffered no indignity? Moreover, was that apparent violation of nature not a reasonable price to pay for the safety of others who might well benefit from resuscitation? An efficient crash team asks no questions initially – it gets on with the job on the assumption that it is appropriate. It is swift to act, and by virtue of its unquestioning approach, maximises its chances of success. A hesitant approach to life support would fail the majority who might benefit – it would not be safe.

I concluded that an inquiry limited to decisions made after the patient had entered the hospital was bound to fail. So I rang the GP, Doctor K – the doctor who, I assumed, knew the patient better than anybody else. He asked me to drop in to the surgery. I sensed that he was feeling defensive about it. It went like this…

 

Dr K: So you want to know why I never discussed resuscitation with him?

Me: I am interested, in your view. I don’t see what you do on a day-to-day basis.

Dr K: The problem is… I hadn’t seen this man for 6 months.

Me: What did you need to see him for?

Dr K: A chest infection. We managed to keep him out of hospital. That was the last thing he wanted.

Me: That’s interesting.

Dr K: What is?

Me: That you picked up on his general wishes… his goals, as Atul Gawande would say. He gave you an insight into his attitude towards hospitalisation. He had thought about it.

Dr K: Of course. It came up in the discussion.  I said if he wasn’t feeling better in 48 hours he’d probably need to be admitted.

Me: And yet… you did not take the conversation further. You did not open it up to a discussion about end of life care.

Dr K: He wasn’t that ill!

Me: But he became ill, 6 months later. With the same problem. And he died, albeit unexpectedly. When he saw he was 95.

Dr K: He walked in with his shopping! He walked out with a prescription for penicillin.

Me: Yet 6 months later not only was he admitted to hospital, he was subjected to a form of treatment that he almost certainly would have rejected if given the opportunity to consider it. As you know, we in the hospital did not cover ourselves with glory by failing to start that conversation, yet there was an earlier opportunity, with you.

Dr K: You’re asking me to start end of life discussions with every patient in their nineties?

Me: Not based on age. General physical fitness. Reserve. Survivability.

Dr K: You say that, but I have told you that when I last saw him he looked OK. It’s his age that you focussed on. 95 when I saw him. You cannot believe that any 95 or 96 year old would have a good outcome from CPR – that’s my reading of what you’re saying.

Me: Probably not, but setting an age threshold above which a discussion about CPR should happen does isn’t feasible.

Dr K: So help me. What threshold should I use. End-stage organ disease, lungs, heart, liver – easy. Terminal cancer – straightforward. Nursing home resident, completely physically dependent on others – yes, I can do that. Previous severe illness or ICU admission, unlikely to survive another – yes, possibly, I can note that and be reminded to start a conversation. A bit frail looking, commensurate with living into one’s tenth decade – not easy at all. How do I start it? ‘Have you thought about what might happen if…’ Easy words, but they wouldn’t be relevant to the problem they came to see me about in the first place. It would shock them. It might undermine their confidence in me. It’s not my role to continually remind people of their mortality. I don’t have the emotional  capacity to do that. You see? The same arguments apply to me, and to my colleagues here in the surgery, as to your colleagues in the hospital. We are human.

Me: Can you imagine a situation where you would have that conversation with a patient who did not have an obvious life-limiting condition.

Dr K: If they raised it, yes. And if I had a bad feeling about them, yes.

Me: A ‘bad feeling’. What is that?

Dr K: A gradual decline, a move into care… a change.

Me: And the 96, sorry, 95 year old –  you didn’t have a ‘bad feeling’ about him?

Dr K:  No. Things are unpredictable aren’t they. But can I expected to anticipate and plan for the worst case scenario every time? I can’t. You know something – this inquiry, this interrogation, is focussed entirely on what happened during a series of short interaction with doctors. I think you should look elsewhere.

Me: But I thought you of all people…

Dr K: You though I would know everything about him, as his GP. It’s not like that. He was always quite well, there was no reason for us to have built up a close relationship. The odd thing, but no chronic condition, no depression, no reason

Me: Where do you suggest I look?

Dr K: At him. At Mr Simpson. His family. That’s where the truth probably lies, don’t you think? That’s where he lived his life – around his family. Not around me.

 

Coming soon – Part 3, the family

See Part 1 here

oOo

Why did that man receive CPR? – an imaginary inquiry

Reviewing the notes of a frail 90-something patient who had undergone an unsuccessful resuscitation attempt, I imagined touring the hospital and asking each doctor involved in his care why they had not thought to make a DNACPR decision. It went like this…

 

The Emergency Department SHO:

‘We don’t really think about DNR decisions unless they are clearly deteriorating or unstable in the department. Or established palliative care patients. I was only with him for fifteen minutes, it was a pretty mild chest infection, CURB 1… I think the medical team would usually get into that.’

 

The clerking medical SHO:

‘It was a busy one. And he wasn’t that bad. I mean, there isn’t time to go into it unless the patient is obviously unstable… And don’t the guidelines say you only need to do it if there is a risk of cardiac arrest? I didn’t think he was at risk.’

Me: ‘But people this old can arrest any time, without warning, don’t you think?’

‘They might. But if they’re not that unwell – and he wasn’t, I remember him – it’s not what they’re expecting is it. You can’t go into a cubicle while a man is having a cup of tea, getting ready to go to the ward, and start talking about death! Well you can, but it’s a bit of a jump.’

Me: ‘But he arrested, didn’t he?’

‘Unexpectedly.’

Me: ‘By definition. If it’s expected they just call it dying.’

‘So you think I should have asked him?’

Me: ‘It would have been appropriate, to bring it up. He was 96, he was being admitted as an emergency… even if you did grade it as a ‘mild’ chest infection.’

‘Well what about the consultant? He was seen by the consultant. Didn’t she bring it up?’

 

The consultant on the post-take ward round

Me: ‘Can I have a minute?’

‘Of course.’

Me: ‘It’s about that chap, Mr Simpson. 96. He arrested on the Acute Medical Unit last week and was still for resuscitation. They gave him two cycles.’

‘Oh.’

Me: ‘I wondered, if you had a chance to consider making him DNAR on the ward round?’

‘It crossed my mind. But he looked very well. I estimated he’d be out in 48 hours. That’s a shame…’

Me: ‘It crossed your mind. What stopped you from discussing it?’

‘Time. Circumstance. It just didn’t seem relevant. And – I remember now – he’d woken up rather confused. That was a change, according to how the notes described him the day before. He wasn’t up to having a sensible discussion.’

Me: ‘Were the family there?’

‘No. Definitely not.’

Me: ‘So he had deteriorated.’

‘Barely. Look, I would have had to have the family there if I wanted to make him DNACPR. He wouldn’t have been able to focus on the discussion. And to be honest, it didn’t seem like a situation where I needed to do that. He wasn’t that bad. Would you? Would you have signed the form in case he did arrest?’

Me: ‘I might have asked him… tested his mental capacity. He might have looked up and said ‘No way. That’s not what I want. I don’t want to be resuscitated.’ He might have made it easy for you.’

‘Perhaps. But it’s not always as straightforward as that, is it? He might have got upset.’

Me: ‘Death, or the thought of death, is upsetting. We can’t escape that.’

‘Well I didn’t think it was an occasion deserving of upset. In retrospect, I agree, he shouldn’t have been resuscitated, obviously. I’m not averse to asking patients, but this time… I just didn’t.’

 

The crash team registrar:

‘He looked dead. But they were already doing basic life support, and the nurse had brought over the resus trolley. I knew nothing about him. We started the algorithm, obviously.’

Me: ‘Obviously?’

‘Well that’s what we do, isn’t it. You have to start. We arrive completely in the dark. I asked for the notes as I recognised that he was frail, very old and frail. There was no DNR in the notes, so we carried on… until it was obvious he wasn’t coming back. Why, don’t you think we  should have started?’

Me: ‘No, no, I’m not saying that. You have to don’t you.’

‘I knew it was inappropriate though. He should have been ‘not for’. I didn’t feel good, looking at him afterwards. He was very thin, I know we broke something.’

Me: ‘Don’t blame yourself.’

 

Later… the AMU consultant catches me in the corridor:

‘I was thinking, about the premise of your questions. From a philosophical point of view. What is the problem with that man being subjected to a resuscitation attempt?’

Me: ‘It’s cruel. It’s violent and undignified. And useless.’

‘But is it cruel?’

Me: ‘We’ve all seen it. How can it be justified if a man is nearly a 100 years old and cannot realistically survive the attempt.’

‘Ah! That’s futility, not cruelty. You see, he was unconscious. He was dead.’

Me: ‘By definition…’

‘… and unfeeling. He was not hurt.’

Me: ‘And what of dignity?’

‘We, the hospital, treated him as we would anybody else. Without discrimination or favour. At no point did he tell us he didn’t want it.’

Me: ‘He didn’t have a chance to express that.’

‘No, but I’ve spoken to a lot of people in their 90’s about resuscitation, and many – most – have never even thought about it. It’s not an issue for them.’

Me: ‘Until it happens.’

‘And when it does, they don’t feel it, you see! They are unconscious.’

Me: ‘Until we get them back. And then they are condemned to a grim few days in hospital, dying slowly. The statistics confirm it, for the vast majority.’

‘If we do get them back and they are clearly not going to bounce out of hospital we look after them and palliate them. We recognise what is happening and do not persevere with disproportionate levels of care. So give us a break! It’s not always a crime to try to resuscitate someone who in retrospect didn’t really have a chance. I respect what you’re saying, but we don’t need an inquiry.’

 

I shuffled off. Point taken. But that’s the beauty of imaginary conversations. No offense given or received.

 

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Two weeks in January

crisis

 

What a fortnight.

During what has been described by some (not all) as a ‘crisis’, hospitals around the country have found themselves full to the brim. Patients (and nurses to look after them) have been moved into ‘escalation areas’, meaning that doors which usually open onto sleepy corners or waiting rooms now reveal eccentric looking wards buzzing with activity. Queues of trolleys, a rare scene in most Emergency Departments nowadays, have stretched into corridors. The ideal (arbitrary but for the most part admirable) of being seen, assessed, treated and moved into a bed within four hours has been denied an increasing, though not enormous, proportion of patients. Papers have latched onto the rather dated idea that people who have suffered neither ‘an accident’ nor ‘an emergency’ should not be there. The sense that something exceptional is happening has spread, and even without a major internal incident being formally announced many doctors and nurses changed their usual routine.

It is strangely exhilarating to work through a crisis. People pull together and up their game. You begin to wonder, ‘Shouldn’t we work like this all the time?’ But the energy that a crisis releases is finite. Doctors and nurses can extend themselves for so long, but they cannot maintain a heightened level of activity for too long. Cracks begin to appear. As I paced the wards repeatedly over the last two weeks I observed, in myself and others, some subtle but unwelcome consequences of ‘crisis’ psychology.

‘Crisis’ communicates itself to patients. Those who are aware of what is going on outside the building know that the system in which they find themselves is under pressure. Occasionally this pollutes the patient-doctor relationship. A frail patient awaiting placement [MFFD in the current parlance, Medically Fit For Discharge] looked up at me and said, “I know you need this bed, sorry…” to which the only response could be, “No, this is your bed, and you will be in it as long as you need it. Please don’t worry about that.” However, having just left a bed meeting in which the vital importance of ‘flow’ was again emphasized, I thought privately, ‘Yes, but we do need your bed, for someone waiting in the ED who is acutely ill’. The frustration that we feel in this situation cannot be allowed to communicate itself to the patient. If it does, they will feel as though they have become a burden to the system, and trust will begin to dissolve. We have been there before – it was only a year ago that the idea of ‘death pathways’ being used to free up beds was seriously entertained in the press.

With younger and more robust patients one can be more open about the pressures. During another ward round intended to identify possible discharge I said to several patients, “I saw you this morning, I know, but I’ve come back to see if there is any possibility that we can look after you at home with this chest infection/pain/cellulitis/diarrhoea etc.” A common response was “I would much rather be at home doctor, but I just don’t think I can manage.” Without such a frank approach extra discharges will not be achieved, but the question, once asked, skews the dynamic. It leaves behind the feeling that behind every interaction lies a subtext – how quickly can we get you out? On the one hand we listen and respond to the pressures around us, trying to effect every discharge that we can. At the same time we must maintain the perception and the reality that business – the provision of good care centred around an individual’s needs and no others – continues as usual.

Patients must believe that their best interests are uppermost in our minds, even as we balance the need of the community with the need of the individuals in front of us. Senior doctors have a managerial responsibility to improve the situation and help with patient flow. They cannot bunker down and adopt a wholly myopic view. But they are also the last bastion of defence if and when those pressures threaten to detract from the care that is given. When it comes to crunch, the welfare of the patient in front of you must trump the needs of those queuing to come in. This is what crisis does – it creates hard choices and does not permit right answers.

 

oOo

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