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.

 

three covers

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