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