Sergei Brukhonenko (1890-1960), inventor of an early heart-lung machine
In a continuing (but I hope not tiresome) effort to understand why doctors are poor at engaging patients in end of life discussions, I want to explore what makes many doctors tick. This is the opportunity to help someone survive against the odds. For most doctors, especially those in training, the absolute zenith of job satisfaction occurs when a patient arrives in hospital close to death, and with careful attention, timely decision-making and a little luck they recover, take to their feet, and walk out alive. These are the stories one carries through a career, the vignettes one recounts to colleagues when faced with similar scenarios. The memory can help to motivate a team and maintain optimism when the situation appears to be slipping. The ability to grab the smallest chance of life and build on it with all that modern medicine has to offer is one of the most seductive aspects of the vocation. If asked to speak to a room of school children, these are the stories one might tell. The case described by Atul Gawande of the 3 year old girl who slipped into ice cold water and was only found 30 minutes later is a good example. She had drowned; she was dead. But she was transferred to a specialist unit, established on a bypass machine (the ultimate, I think, in life preservation) and survived. This true story typifies the sense of wonder that medicine can inspire. Who wouldn’t want to part of that team? Or part of a team that works in less dramatic circumstances, yet periodically saves lives that would otherwise have been lost?
I can recall a handful of cases in my own career – the highlights. Most of the ‘miracles’ or ‘saves’ were seen during rotations in intensive care, where life support machines and minute attention to detail arrested the descent into death and gave patients time to heal from infection or benefit from definitive surgery, or transplantation. Outside the intensive care unit miracles are less visible. Patients may pass through your hands on the day of admission only to disappear into the operating theatre, thence to intensive care, for a month or more. You may have contributed to their early management, but other patients soon take their place at the forefront of your mind. You may never see them again. If they do leave hospital only a chance mention of their dramatic recovery in the doctors’ mess, or a fleeting glimpse in the corridor as they prepare to stagger into the daylight for the first time, will remind you.
The miracles. These are the what many of us who work in acute medicine live for. But they are rare. Yet, they command a disproportionate influence over our thought processes. They feed the optimism that allows us to meet every new clinical challenge in a positive way, such that we grab the small chance and work on it. The reward for such optimism, for a refusal to give in to nature’s perverse agenda, is the preservation of life. The reward appears to justify the means, however expensive and extensive. Resources, money – very few clinicians give this matter a passing thought as they rush through corridors in response to a trauma call. This is what we do, there is no price for such engrained positivity.
Or is there?
The alternative stories are harder to describe, and would not feature in a school hall lecture. Yet, numerically, the patients in these stories heavily outnumber the ‘saves’; they are the patients who have entered their final days, weeks or months, who will not survive even if they receive the most aggressive forms of treatment. Doctors in a position to offer life saving interventions (intensivists, for example) are good at identifying those who will not benefit, and the best are willing and able to explain to patients or relatives their reasons for denying admission. But there is an even more dramatic intervention that is often offered before the trained eye of an intensivist is brought to bear – cardiopulmonary resuscitation. The decision to offer or withhold this rests primarily with the admitting team. If the patient suffers an unexpected deterioration and cardiac arrest they will receive all that I have described above – the hastily convened team, the application of technology, the grasping of a precious chance that life can be sustained and an acceptable degree of function restored. This is what we want to do. Yet, the truth is we often get it wrong, and choose the wrong patients. We don’t seem to be very good at identifying those who can be brought back from the brink, the ones in whom the glimmer of hope can truly be transformed into a realistic chance of life. Perhaps we are over-influenced by the miracles that have captivated and motivated us before. The thought of reducing a small percentage to zero with the stroke of a pen (and, of course, the agreement of the patient or their relatives) contradicts the learning that has always prioritised salvage, and the instincts that have always made us alert to its possibility.
Does entraining an equal alertness to the possibility that CPR will cause harm, and will be futile, necessarily lead to a less positive, less optimistic approach to patients? I ask myself this question on ward rounds. So much time is spent considering how to protect patients from all that can be done, and how to maximise their comfort as their final illness takes hold, I become paranoid that when a true chance of recovery faces me I will not recognise it. I imagine this concern is more prevalent in those who treat many frail, elderly patients. But all of us involved in general medicine will see a mixture of patients who are near the end of life, and patients who may have entered a hinterland, in which aggressive treatment may bring about an improvement, but may well not. To allow ourselves to veer too far down the path of comfort and early palliation could result in borderline patients being deprived of a fighting chance. Uncertainty is a great challenge, there is very little science. Even the signs of dying are disputed, as shown during the debate about the Liverpool Care Pathway.
I don’t know how to encourage a balanced degree of alertness to the small chance of life and the large chance of unacceptable therapeutic burden on a day-to-day basis. The first instinct should be therapeutic aggression – most would agree with this. But if this instinct is not tempered by a cool appraisal, when all the facts are known, of how realistic survival is after CPR (and intensive care, if offered), then we have allowed our attachment to the romance, to the drama, to the warm feeling of success, to taint the truth. Somehow we need to train our young doctors such that they regard a sensible, appropriate and honest approach to treatment as a success of magnitude to ‘the save’.
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