This month a registered nurse, Nahid Nasiri, was disciplined for failing to initiate basic life support on a collapsed care home resident. Two other charges, relating to failures to attend the deteriorating patient or call an ambulance, were not found proved. The Nursing and Midwifery Council (NMC) hearing, available here, describes the circumstances.
Nasiri was not present at the hearing, having retired and moved permanently to the US. My recreation of how it might have been is therefore pure fiction. The dialogue here demonstrates deep consideration on the part of the nurse. In contrast, the fitness to practise hearing ‘found no evidence before it to suggest that the decision not to attempt CPR was a carefully considered clinical decision’. This may have been different if Nasiri had been there to defend her actions (or omissions), although there is a suggestion, in the transcript of a 111 call, that she was not too familiar with the process:
– – Dr: Was she end of life?
– – Nasiri: Er, No, She unfortunately she hasn’t got this, what’s that, we haven’t got the CPR, we haven’t got it. A doctor was supposed to sign it on Wednesday.
The nurse in this dialogue is highly articulate, and through her I have tried to explore the bind in which healthcare workers who look after the frail and elderly can find themselves. The paragraphs in quotes are taken from the NMC judgement.
Panel member: “…and what did you think, when you recognised that she was pulseless?”
Nurse: “I was thinking for a long time before she collapsed. I had anticipated it.”
“You knew she was deteriorating?”
“Yes. We all did. The doctor did. When Mrs ______ arrived, he called through to tell the duty manager about her. He said she was very frail, had recently been in hospital, and that she should not be for resuscitation. But he hadn’t had a chance to discuss DNACPR with the family.”
“There was an arrangement in place to have that conversation?”
“I’m not sure. But it was the intention.”
“So, she remained ‘for resuscitation’ pending that conversation.”
The Home had in place policies and procedures in relation to Resuscitation. The policy stated that ‘in incidents of sudden or unexpected collapse where a person has clearly not made any living will or indication of their views on resuscitation, best efforts to resuscitate should be undertaken in accordance with the competence and qualification of available staff to offer emergency treatment or first aid. In most cases it will be imperative to summon medical help and the emergency services without delay.
“Her doctor had already decided she shouldn’t be. But that is why we are here, I suppose. To discuss that interval.”
“Indeed. So tell us, what did you, as the most experienced registered nurse on duty, think when she collapsed?”
“My thoughts were very clear. I knew that the paperwork was lagging behind the truth of the situation. I knew that I had a duty to start basic life support and call an ambulance, but I knew also that to do so would be wrong.”
“Wrong it what way?”
“Wrong for her. Mrs _____ was coming to the end of her life. I’m an experienced nurse, and I have seen many patients in their last few weeks or months. I can tell the signs. And I know it is not a true science, predicting death… but sometimes it is clear.”
“What signs did you notice?”
“She was so thin, so frail. She was bedbound, and we knew there was no hope of physical rehabilitation. She communicated in a few words, but did not have mental capacity. That was why her GP hadn’t been able to complete a DNACPR form.”
“I watched her during the morning.”
“And she was getting worse.”
“Getting drowsier, but it was night-time. We don’t do observations, blood pressures…”
“But you can, if you ewish. You have the facilities.”
“I didn’t think it was necessary, in this case.”
“So you were comfortable with the idea that she could deteriorate without medical intervention.”
“That was the spirit of the doctor’s handover. I really felt that he expected it. And I couldn’t be sure this was a true, physical deterioration. She was said to fluctuate. It was in the handover.”
“What time did she become unresponsive?”
“Tell us what you were thinking, at that moment.”
“I had a choice. Do what was expected of me, ‘by the book’, or do what was appropriate, for the patient.”
“Let’s pause there. Isn’t that a large assumption, that you know what is appropriate? There is a system in place, paper-work as you called it, which ensures that next of kin are consulted before DNACPR orders are confirmed. What if the next of kin objected to a DNACPR decision? Don’t they know their relative better than you do?”
“In my experience relatives don’t always understand what resuscitation involves. Sometimes they want us to try even when we tell them it cannot work.”
“So you know better?”
“Medical professionals do know more about resuscitation, and its harms, yes.”
“Don’t you think that relatives should have a say?”
“Yes, they should be involved, if there is time. They should be informed, when the medical assessment is one of clear futility. But that step, if it hasn’t taken place, shouldn’t make us do something to the patient.”
“Have you heard of the Carl Winspear case?”
“Yes. He was a young man. A doctor made a DNACPR decision but didn’t discuss it with his mother.”
“Precisely. The judge in the case found against the Trust. The doctor was legally required to discuss it. Carl Winspear did not have mental capacity. His mother knew him best, she was the only person who could really interpret his best interests.”
“But Mrs _______, she was not like that young man.”
“In the eyes of the law, she was.”
“That’s it then. I broke the law?”
“We’re not saying that. There has been no complaint.”
“Which suggest the family agree, I did do the right thing. They didn’t want her to be rushed into hospital, to be intubated, to get electric shocks.”
“We know that now. Not then.”
The panel acknowledged that Mrs Nasiri was not charged with causing Resident A’s death. The panel also considered the document from the Consultant Histopathologist which states ‘… Resuscitation is unlikely to have been successful’. However the panel considered that Mrs Nasiri could not be aware of the likely outcome of resuscitation at the time Resident A ceased breathing.
“I knew it.”
“You knew it?”
“I knew what was right. I have seen it. So many times. Ask anyone in my role. We are there to care for people like Mrs ______. That care extends to what happens after they die. Every month I clean and make tidy those who have died. We see them move from life to death, we are used to the transition. It is a natural one. Being admitted to a nursing home might be regarded as a step on the way to that transition, I don’t know. But we mustn’t allow what goes on in hospitals to interrupt what is natural. It isn’t right.”
“You seem very confident in your opinion.”
“No, it’s not confidence. It’s experience. You asked me what I was thinking when I found her unresponsive. I’ll tell you. I looked at her, and I new what I ‘should’ do, and I knew what I had to do. I knew I would be criticised. I knew there was a chance I would end up here, being interviewed. In a way, it was a choice between her welfare and mine. This is where we have come – to protect her natural death I had to stand between her body and the ‘rules’. And so here we are. I leave it to you to decide if I should be removed from the register, or if I am fit to do my job.”
The panel is of the view that there is a serious risk of repetition based on the complete lack of insight and complete lack of remediation. The panel therefore decided that a finding of impairment is necessary on the grounds of public protection.
…in light of the above, your fitness to practise is impaired by reason of your misconduct.
Click here to read a pre-publication version of a paper co-written with Dr Iona Heath – ‘The ethical basis for performing CPR only after informed consent in selected patient groups admitted to hospital’. This explores the potential harms of a blanket default ‘for CPR’ policy in healthcare environments.