Two strikes – when the patient ‘Did Not Attend’

The nib of my pen hovers over the ‘outcome’ form*. In the lower third are various options; Follow up x weeks/months, Await results, Discharge, Refer to another consultant, DNA – rebook, and finally, DNA – discharge. DNA. Means Did Not Attend. The patient Did Not Attend their clinic appointment. A stark term behind which there may lie many reasons, some not of the patient’s own making. But the decision to discharge will terminate the patient’s relationship with this clinic, and with me. Responsibility for monitoring them will return to primary care, or may evaporate entirely. Perhaps their symptoms, or the nagging thought that there was unfinished business in the clinic, will draw them back to the GP. The GP will decide whether they need to be seen again by ‘the specialist’, and if so they will need to write a new referral letter. Then they will re-join the waiting list. The process could take months.

NHS Trusts have strict policies on DNAs. After all, 1 in 10 appointments are not kept, and you can’t keep offering them to those who don’t come. The National Audit Office reported that DNAs cost the NHS up to £225 million in 2012/13. Failure to attend means that a slot was wasted. Another patient could have been seen instead. One strike and you’re out, some Trusts dictate. Many consultants are more comfortable with two. The first time could have been an ‘honest mistake’, a slip, a simple oversight. Too harsh then, to strike them from the system on the first occasion. But a second missed appointment must surely mean that either they feel better and do not want to be seen, or they have moved, or they are just too busy and choose not prioritise their health over everyday life.

In a study of 73 patients who had missed appointments, the reasons given were:

  • Forgot to attend or to cancel (30%)*
  • No reason (26%) [I’m guessing they literally said, ‘No reason.’]*
  • Clerical errors (10%)
  • Felt better (8%)*
  • Fearful of being seen by junior doctor (3%)
  • Inpatient in another hospital (3%)
  • Miscellaneous other (20%)

I have asterixed the reasons that seem genuinely to ‘deserve’ a discharge. They make up 64% of the reasons (or ‘no reasons’), so at least a 3rd would be discharged entirely unjustifiably, based on this sample. Those who were subject to clerical error deserve the opposite – a new appointment at their best convenience. I wonder if that happened.

This is Mr Jackson’s 2nd DNA. I know him. He has been coming to the clinic for three years, with a chronic condition that requires regular review by a specialist. Something must be up. We get on well. He may feel healthy, but his condition could be changing beneath the surface. I worry that if I discharge him he will never come back. The pen moves to ‘DNA – re-book’. But… but… why waste another slot when the chances are he won’t come back. The waiting list is long. Every appointment counts. I could call him up to find out why, but to be honest I don’t have time to chase up every DNA. I’ll write a letter to the GP stating that he didn’t attend and asking the GP to keep an eye on things. And another to the patient himself, to keep it personal. So, I’m not exactly severing all connection, but… I will discharge him. Discharges are important. Senior doctors have a duty to keep the lists turning over. And if he develops a complication, a cancer say, it won’t be my fault.

The Medical Defence Union has just published guidance on this subject. Pertinent to Mr Jackson, they say I should,

  • Respect a patient’s decision to refuse an investigation or treatment, even if you consider the patient’s decision to be wrong or irrational.
  • Explain any concerns clearly to the patient, as well as the possible consequences of their decision, and document your discussion in the patient’s clinical records

And that,

  • Previous knowledge of a patient’s circumstances, including the severity of their condition necessitating referral or follow-up, will need to be taken into account.
  • It may fall to a patient’s GP practice to follow up the patient who misses an appointment.

I circle the words, ‘DNA – discharge’. I dictate the brief letter to his GP: “I was sorry not to see Mr Jackson in clinic today. I hope that he remains well. It is important that he attends for regular surveillance. I would be grateful if this can be emphasised to him when you next see him, and I will write separately to him. For now he has been discharged.”

A bridge, a compromise, between bureaucratic imperative and therapeutic relationship. For all I know his family have taken him in to their home up in Yorkshire; or perhaps he has died. I don’t know. Or perhaps he’s decided that these appointments were a bit of a waste of time, as nothing ever seemed to change. He’ll find his way back, if he needs us. I’m sure of it.

Next patient please.

[Fictional patient]


* These forms (either paper or electronic), and the options available, vary between organisations.


5th collection of articles, out now [click image to explore on Amazon]


Introduction to ‘When Windows Become Mirrors’



When Windows Become Mirrors

The 5th collection of articles from Illusions of Autonomy



To the readers of my blog who through their interest have encouraged me to keep writing for 5 years, and especially to those who have helped spread the word on Twitter, that powerful but mercurial invention.


This is the 5th collection of blog posts from Illusions of Autonomy. When I wrote the introduction to the 4th, A Hand In The River, I wondered if that would be the last. The frequency of posts had dropped, due I think to my increasingly specialised role – more interesting on the one hand, but less involving in terms of the everyday human and ethical problems that accompany general medical patients. But then things picked up. There were controversies around under-performing or frankly injurious doctors. Increasingly I reflected on the role of the senior clinician, and how you maintain the skills required to be a good doctor while spending less time on the front line. My perennial interest in resuscitation decisions continued to be prodded by difficult situations in my own hospital, and the frequently lethal nature of the illnesses affecting the patients around me led to reflections on how we (okay, I) communicate in busy and pressurised environments.

Windows into mirrors; reflections. The title of this collection comes from the long walks down dark corridors at three in the morning, when, coming from particularly difficult or stressful clinical situations as a trainee, I used to look in the night-blackened windows and see a haggard doctor who was unsure if he had done a good job. At those times, when our patients’ pathology insists on progressing while the pace of the great machine dials down in the dead of night, there is ample time for self-examination.

Part 1: Night & Day – observations on everyday behaviour in the hospital, good and bad…
Part 2: In Court – arrogance, negligence, and other sins
Part 3: Relating to people near the end of life – how doctors get it right & wrong
Part 4: Resuscitation decisions – not getting any easier
Part 5: Assisted Dying – a true battle of attrition
Part 6: Illustrated essays – on the history of truth in medicine, and how doctors respond after doing harm


Kindle (99p or equivalent), click here

Paperback (£5.99 or equivalent), click here



Junior / Senior


Trainee doctors tend to know more about patients than their consultants, though consultants, by virtue of experience, usually know better how to treat them.  Sometimes however, a peripherally involved consultant will parachute in and give an august opinion, but without adequate knowledge of the person or the problem. For instance, in my field, the insertion of a feeding tube to bypass a blockage in the gut, when a few more questions on the ward round would have revealed that the patient had three similar tubes in the past, each of which was pulled out due to intolerance or discomfort. The plan is sound, but will not work for the patient in question.

Consultants grow increasingly didactic over time, a characteristic deserving of its own article. The daily process of absorbing information and providing timely, confidently articulated answers, can lead to decisions based on pattern recognition, and without sufficient focus being paid to all the variables. As a trainee, the challenge is to receive such answers, but to adapt them to the specifics of the patient. Taking the consultant’s opinion at face value, and acting on it straight away, may not be the best thing to do.

When I was a fairly experienced trainee (medical registrar), my strategies for ‘pausing’ before converting instructions into action, included:


The deflection – ‘That is one option… but I was reading the other day about ______ procedure… do you think that might be better in this situation?’

The prevarication – ‘Right, yes… shall we see how they do on the current treatment, and review again in three days?’

The bureaucratic delay – ‘…there’s an MDT next Thursday, shall we discuss it then…’

The memory slip (high risk, AKA disobedience) – ‘Sorry, we didn’t get around to requesting that scan… do you think they still need it…’

The second opinion – ‘Dr _____ came around, and said she’d seen this before, and we should do x, y and z… is that alright?’

The direct challenge (for senior-senior trainees only) – ‘Actually I’m not sure that would work for this patient, given her underlying x, y and z…’, or, ‘I don’t think he would want that, his wife was saying just the other day that he’s decided not to…’


In fact, all of these are high risk approaches, because when the consultant returns two or three days later and the task has not been pursued, and assuming they remember what they asked for, there could be hell to pay. They are also high risk because they are based on the assumption that the trainee knows best. This is unlikely. But it gets to the essence of the (senior) trainee’s role, that of a coordinator of care, a hub into which results and opinions flow, to be assessed in the light of day-to-day changes that they are best placed to observe. It is not arrogance to presume to challenge a consultant’s opinion, but a necessary part of maturing as a doctor. Don’t accept anything without a critical appraisal of its value. Don’t assume an opinion is right unless it makes sense within the scheme of things. This position is a precarious one, as over-confidence or lack of skill in communication can make you look disrespectful.

So much for trainees. What about consultants? Overnight, you transform from ‘junior’ to ‘boss’. During the early post-transition period you may remain sensitive to the nuances of each patient’s illness. But over time, as you are pulled away from the details and learn to trust your team to micro-manage the bloods and the drugs, the day may come when you formulate and describe a great plan, only for the most senior trainee to pause, look at you quizzically, and say, ‘Yes… that is one option…’


Click image to explore, or go to my Amazon author page

In too deep: privacy on the wards

Ward patients sometimes comment on, or complain about, the fact that they can hear conversations between doctors and other patients through the curtains. When you’re having a conversation with a patient, you may as well imagine that the room is entirely open plan; curtains provide a visual barrier, but are more of a symbol of privacy, like the sheets hung in overcrowded homes of centuries past. Imagining the bay as a small hall with six or eight beds arranged in it makes you think twice about having any conversations at all, yet to conduct every sensitive conversation in a private room would be impractical. David Oliver touched in this in a BMJ piece last year. Patients would need to be wheeled their beds, or helped into wheelchairs and taken around the corner into a private space, with or without their relatives, on each ward round. Nobody expects this to happen. This begs the question: what kind of conversations are acceptable on the ward, and which should be reserved for a truly private space?

We are used to making special arrangements for breaking very bad news, end-of-life or DNA CPR conversations, and for planned conferences where several family members are expected. To gather four or five plastic chairs around a bed in a cramped space and pretend to be comfortable delving into intimate and existentialists details. But other conversations, the majority, are conducted within in earshot of strangers. Sometimes, a ‘routine’ conversation about treatment (which is still, after all, highly personal), can transform into something else.

Recently, in conversation with a jaundiced, alcohol dependent patient, I sensed a complete lack of understanding about the seriousness of his situation. I was standing next to his bed. Other members of the firm, a nurse, and a student, stood nearby, listening or typing into computers of wheels. We had been talking about the next set of tests, progress, plans. Nothing too personal, nothing too sensitive. Then I took the conversation into a darker place, to emphasise the gravity of his illness.

“I’ll be truthful with you Mr ______. And it’s a lot easier for me to say than for you to do, I know, but if you start drinking again after you get home, you will probably die in the next three months.” It took him unawares. His eyes moistened with the realisation of how close to death he was. The visit ended, and the nurse stayed with him to provide comfort and make our disappearance from the bedside less abrupt. As I drew the curtain back I looked across to the patient opposite, who had of course heard everything. Now he knew as much about the alcoholic patient’s poor prognosis as the patient himself. As patient 2 looked across at patient 1, there was shared, highly personal knowledge. Patient 1 was left totally exposed. It felt wrong. It was wrong. Yet, how could I have done this better? Perhaps I should have paused the conversation and said, “We really need to talk about the future, in private… how about I come back later…” But there was no ‘later’ that day. I could have delegated the task to a very capable registrar, but that also felt wrong. And the conversation just went in that direction, naturally.

Hospital, I have observed over the years, is a harsh leveller. It is difficult for the great machine to tailor and modulate its processes to the individual sensitivities of each patient. What one patient would regard as unacceptable in terms of privacy, another will have no problems with. As doctors and nurses, we tend to apply our own standard to everyone. Yet that standard has probably been lowered by brutal shifts in A&E where people display their vulnerability to all and sundry in waiting rooms and scream in pain or cry inches from strangers. It is easy, as a doctor, to think ‘The priority here is treatment, this is a busy environment, dignity comes second…’

Nurses are the guardians of dignity. Yet doctors can with an irritated scowl or a quick glance at their watch, overrule the gentle suggestion that ‘it might be better to have this conversation away from the bedside…’ I know I have done that. A conversation that I think is ‘ward appropriate’ might, in a nursing colleague’s mind, touch on a subject that no other patient should be allowed to hear. Who decides? Does the acuity of the ward, or the incessant flow of humanity through an Acute Medical Unit, justify a reduction in privacy thresholds?

There is no list of topics that should be explored in true privacy. The patient should, in theory, be in control. To discover a patient’s level of sensitivity, it is necessary to ask at the beginning, ‘I’d like to talk about x, y and z, would you rather we did this somewhere else?’ The danger, perhaps, is that they will say yes! Then it will be necessary to move everyone. Universal provision of side rooms would make this all easier, and it is actually a relief to see people in that environment, on haem-oncology wards for instance.

My advice? As ever, it starts with a patient-centred view, and empathy. What would you feel if you were told you have three months to live in a room where five other patients could, if they were alert enough and unable to switch off their ears, hear every word? Like all things in medicine, quality takes more time, more patience… it requires the machine to slow down. That is not always easy.



New booklet, 4 interactive ward scenarios – you decide how they turn out! Click image to explore…

or see Amazon author page

The edge

There isn’t time to go into every complaint in a typical clinic. There just isn’t. So, however open my initial question (‘How are things?’), I narrow down to the important matter quickly. Most patients understand this, and tacitly agree to drop other concerns. It sounds like bad medicine; it is certainly non-holistic, but it is real life. If symptoms unconnected to the condition that brings a patient to the clinic are explored for too long, less time will be spent pursuing the potentially dangerous diagnosis. Therefore, patients receive little more than sympathy and a recommendation that they had ‘better see your GP about that.’

Sometimes patients insist though. When this happens, it is necessary to find the language that combines genuine interest (after all, to dismiss something that causes anxiety is just rude) and skilful management of the time-limited interaction. However, if despite the nuanced nods, silences and redirections, the primary issue continues to be relegated to the background, less subtle tactics are required. Perhaps, ‘Sorry Mr ______, we really should concentrate on what your GP wrote to me about,’ Or, ‘I can tell that’s causing you some real problems, but I’ll have to ask your GP to refer you to another clinic…’

Recently, I found myself in this situation. I had finished examining the patient and was sitting at the desk, looking at x-rays and blood results, trying to work out what tests to arrange next. From the couch my patient returned for the third time to an irrelevant (to my mind trivial) complaint. Filtering his words ruthlessly while I concentrated on the most efficient path to a final diagnosis, I mumbled something half-hearted and non-committal. There was a pause. He rose from the couch and said,

‘Oh, forget about it then.’

The sharp edge to his words pulled me out from the clinical, impersonal space into which I had fallen. One rarely hears such a tone. I saw that I had been rude. I turned in the swivel chair and back-pedalled desperately,

‘No, it’s important! Sorry! Have a seat. We need to think about how you can get it sorted…’

Gradually, the consultation was retrieved. Left as it was, the encounter would have gone the way of many hospital appointments – into the ‘he/she barely listened to me’ category. We discussed the other matter, and I promised to do something. He left content (I think, I hope). The appointment overran. But I owed that, for losing sight of what mattered to him, and steering too close to the edge of a precipice down which trust can easily be lost.

Click image to explore books

In my day

Reading about the situation at Derriford hospital, where two doctors found themselves responsible for over 400 people, I thought about my own training in the 1990s. Before you slap the computer shut or throw down the phone, I should say that although there is a fair amount of ‘in my day’ reflection here, it is not my intention to promote a ‘just get on with it’ attitude.

Back in the 90’s few if any junior doctors thought about challenging potentially dangerous staffing levels. If we turned up to the hospital on a Saturday morning to find that we were one doctor down, we steeled ourselves for a nightmare and hit the wards determined to fight the fires as they arose. If people died, we attributed their demise to disease, not to a paucity of doctors. Overnight, in the large hospital where I started work, two JHO’s and one SHO* managed all the medical wards and all medical admissions after seven o’clock. The Registrar went home at ten. The consultant was not seen until the 8AM post-take round. That was just how things were. It seemed hard, it felt threadbare, but we did not complain.

Our perspective was centred on our own experience, not that of the patients. As the sun rose to brighten the night-blackened windows after a non-stop night, and the nurses handed over to the early shift, we congratulated ourselves for having responded to the many calls, requests and emergencies that had arisen. The euphoria of finishing the shift counteracted any misgivings we may have had about sailing too close to the wind at times. We felt like heroes. In the pub, we spoke about working in ‘warzones’.  We weren’t happy with it, and the hours before a series of weekend on-call shifts could become heavy with foreboding, but we managed.

If a patient deteriorates during a period of sub-optimal staffing, it is very hard to link their outcome with the number of doctors available. The sick get sick, that is why they are in hospital. Doctors are good at focusing their time and energy on those who need it most, so of those 400 and more patients in Derriford, perhaps twenty will have required urgent medical assessment and a new management decision over an eight or twelve-hour period. The stable majority were looked after by nurses, who could alert the doctors to any signs of deterioration if they developed. It is rare for two or three patients to get acutely ill simultaneously, such that a doctor cannot physically be with a patient during an emergency.

But what if that does happen? A doctor might have to run away from one patient before he or she has sorted them out, to see another one who was just deteriorated. If there are only two doctors, and six simultaneously sick patients, it would appear that a difficult choice has to be made, and the least deserving will go neglected. This is extremely rare. When the alarm goes up, other colleagues (anaesthetists, outreach teams, even orthopods) emerge from the ether. The system stretches. The need is met. So at the end of the day, nobody seems to suffer. There are no ‘serious incidents in which the root cause is felt to be under-staffing. And the patients… they would have had no idea the team was a doctor or two down. So what exactly is the problem?

Well, there was risk. There was probably delay in seeing patients, and perhaps some associated morbidity – but none that could be measured or proven. And the doctors, for all their coping ability, were strung out, and felt vulnerable. The price to pay for a system running at full stretch is the potential for disaster, stress, a poor learning environment, disillusionment and ultimately burnout. Yet many of us saw this during our training, and said nothing. We were in the problem so deeply, we didn’t see it as a problem. Or perhaps we didn’t have the ability a look up and gain a broader perspective.

Today junior doctors are more vociferous, and, in certain circumstances, more militant. The industrial action that took place last year was the clear example of this. Unsatisfactory staffing levels and training opportunities are now challenged. They do not regard those difficult shifts as a heroic challenge, but as failures of the system which they, the doctors, have a responsibility to highlight. This involves informing management and pressing for locum cover, providing feedback freely and without fear through GMC surveys and empowering their BMA representatives.

Why the change? I think junior doctors are more mature nowadays. Many have competed degrees before entering medicine, or have pursued different careers. They may be more independently minded. As a 24-year old in my first teaching hospital, I was grateful to have been selected for a ‘good’ post. I saw the challenges ahead in terms of my ability to meet them, to avoid failure however steep the learning curve… not to question the organisation itself, or the wider political environment. Therefore, during those years when I worked to the limits of my ability in understaffed areas, I did not complain. I did not seek to improve patient safety by making a fuss. I was, in a way, complicit.

Old attitudes don’t fall away easily. When I hear about an understaffed shift now I worry, and I sympathise, but a hard part of me thinks, ‘They’ll manage. They always manage…You know, back in the 90’s…” etc., etc,, yawn, yawn.

The future requires doctors like me, who appear to have grown older and perhaps a little cantankerous, to recognize that what was once acceptable is no more, and that without fuss, there is no change.

*JHO, junior house officer – first year post-qualificiation; SHO – senior house officer – 2nd or 3rd year post qualification


Think like me

Last week I delivered a lecture about resuscitation decisions. Part of it was a scenario, carefully thought out with my co-presenting colleague. We described a lady in the 80s, living in a residential home, with a degree of heart failure and some other co-morbidities, who had been admitted with pneumonia. There were markers of severity indicating a 20% risk of death. In this scenario she deteriorated overnight, and was found ‘barely conscious’ and in respiratory failure.

We asked the audience to put up their hands if they thought the patient should have a ‘do not attempt resuscitation’ (DNACPR) notice. I was amazed to see only around 15% of the audience put their hand up. Then we asked if they would consider a ceiling of care, for instance non-invasive ventilation or, all the way to intensive care and mechanical ventilation. Most felt that non-invasive ventilation on HDU would be the appropriate limit of intervention. But I couldn’t get over the small number who would have started to discuss resuscitation status at this stage. Why didn’t they think like me?

This scenario was deliberately “grey”. We didn’t want to make it obvious that the patient was dying, for instance with terminal cancer or end-stage heart failure. But we wanted to describe a patient who was not improving. In my mind, having considered the case carefully before the lecture, the fact that she was to deteriorating despite antibiotics meant that if her heart did suddenly stop, the chance of surviving would be very small indeed. Advanced life support might temporarily restart the heart, but would not reverse the problem, which was pneumonia. It seems clear to me. Why not to my colleagues?

Could it be that I was wrong?

Probably not, in terms of the evidence base around prognosis and resuscitation. My colleague and I had reviewed the studies. We could show that a successful outcome was unlikely. So I came away asking myself, why the discrepancy?

I had had the benefit of thinking about this case in detail, for a few days. Those who had just heard the scenario were like doctors in the acute medical units, who are presented with a new patient’s details and required to make big decisions a few minutes later. It doesn’t feel comfortable, or right. Perhaps that was the issue. How can you make what seems like a ‘life limiting’ when you’ve only spent 10 minutes with the patient?

Or perhaps they judged that the hypothetical patient had more of a chance than I did. Perhaps, if the heart was restarted (assuming too that they would then be admitted to ITU for ongoing ventilatory support), continued antibiotics would overcome the infection and she would recover. That seemed like wishful thinking… but who would criticise a doctor for grasping at that possibility, however small?

Or perhaps, I reflected, I have developed too gloomy outlook. I am too ‘realistic’. So interested have I become in identifying futility and ensuring that patients do not undergo CPR needlessly, I am unable to recognise therapeutic opportunities anymore. How else could my opinion different from the majority so starkly?

But I know that this is not the case. I am careful always to make sure that I have not overlooked an opportunity for improvement, or cure. So is the problem me or them?

The answer can only be – neither. They are good doctors; I think I’m a good doctor. We disagree. And in this disagreement is revealed the essence of uncertainty, the unknown quantity that doctors deal with every day. If a room of individuals interested enough in resuscitation to attend a lecture cannot agree on the right course of action, how can we expect patients or their family to offer a firm opinion, or agree with our suggestions?

This point was brought up by someone in the audience. He said that we should not be surprised when families disagree with our assessments, if a group of ‘experts’ cannot be certain of what the outcome is likely to be. And faced with disagreement, we must not allow ourselves to see them as opponents in a debate whom we must win over. However sure we are of our opinion (having had the benefit of dwelling over the results of investigations, the output of prognostic models, or just plain experience), to walk into a room and bring around an anxious family to that point of view is probably naïve. The situation is being revealed to them with the same suddenness that it was revealed to the colleagues on that lecture theatre. The natural instinct is to defer judgement; to assume that there is a chance of survival that should be pursued with active treatment. Only in the most clear-cut cases, where death is visibly progressing or an underlying disease has clearly reached its culmination, can we be fully didactic.

So at the end of it all, I remain confident that I can identify patients for whom CPR would be futile, but at the same time I realise, if I had not before, that opinions will frequently differ. For both doctors and families, time is needed for the facts to be explained, for their implications to sink in, and for the resulting reaction to mature. This cannot always be done in ten minutes, or on Day 1.


Click picture to explore stories, books and other projects


Batteries are low: the work of engaging in DNACPR discussions

During a talk I gave to an audience of palliative care specialists two weeks ago (St Barnabas Hospice, Worthing, thank you for having me), I wondered how they found the energy to engage patients in discussions about dying all day, every day. The comment was undoubtedly naïve, because that’s not what they do, and the many positives that come from managing dying well must recharge the batteries. But for those like me who work in the acute hospital setting, and whose job it is to recognise the approach of dying, a form of exhaustion can occur. Sometimes this leads to missed opportunities.

Imagine a typical ward round in general medicine, or even within a narrow area like my own (liver disease): there might be three new patients with clinical features to suggest that rapid deterioration could occur at any time, which on a background of chronic disease or frailty indicates that resuscitation would be futile. It is my job to start a discussion about the place of CPR and escalation of care. Three conversations. Take a deep breath.

In the ideal world, where patients with chronic disease talk about their wishes well before admission to hospital, the door would already be ajar. Perhaps a documented plan (eg. ReSPECT, described in this week’s BMJ, UFTO, or UP*) would be produced from an overnight bag, or from a relative’s pocket. This paper, a symbol of prior reflection, would allow us to compare their goals with the facts of the situation.

It’s 9.15AM. The team is full of energy and caffeine. We have X patients to see, some of whom are on the road to recovery, some of whom have already been recognised as dying, some of whom have uncertain futures.

The trainees are attentive. They are learning how to do this (aren’t we all?). First patient. I complete my assessment, pause, then open the discussion. I won’t rehearse the words here – my version is not perfect, and it varies. If it does not vary then it shows I am just repeating some learned lines – an impression that it is important to avoid. (Interestingly, a patient involved in the BMJ’s article commented, in reference to a particular form of words, it was ‘as if this is what they had all been taught to say.’)

So I open the patient’s mind to the possibility of dying (be it suddenly or gradually). Perhaps their next of kin is present. They react in their own way. A faraway look is not uncommon. Sometimes a film develops over the eyes, glistening in the morning light of the nearby window. Poetry has no place here, but as a human, I am affected by the impact of my words. We reach an understanding – we agree – CPR is not the right thing to do. If the patient or a relative disagrees, we park it, and arrange to speak about it again, later. I walk away, unsure how to close the interaction. A hand on the arm, a swish of the curtain (‘or would you like me to keep it closed?’). There is no comfortable way, to be honest.

Outside the bay we complete the DNACPR form – put the bureaucratic stamp on it, for the benefit of others who might be called to see the patient in an emergency.

“Ok. Where to next?”

We see a couple more patients. Then the registrar says, “We probably need to discuss escalation with the next one, she’s —–.” We review the history, the data, and agree, yes, we need to anticipate the worst, even if, crossing fingers, it doesn’t happen during this admission.

I use subtly different words, but move in the same direction. This time there is a more overt reaction. And a longer discussion. The thought of dying has never crossed her mind. Nor her husband’s. Part of me brims with anger – she has an incurable, gradually worsening condition, she has been seen by her GP and in specialist clinics umpteen times over the last year; why has no-one brought this up? Why does it have to be me, now? I could just leave it. She might not deteriorate after all. Why not leave it until she does… but if that is at 3AM, and a foundation year doctor is asked to see her, and she refers to a registrar who has never met the patient, there will be hurried decision making, the patient will probably not be conscious enough to express their wishes, an ICU consultant will be asked to make a call based on scanty information…  bad medicine. It must be done now.

We finish. It took half an hour. Not long in the life of the patient, relative to the magnitude of the subject under discussion. But very long in the context of a ward round. Never mind. The time must be taken.

We see some more patients.

Then we come to the third.

I enter the bed space. The visit proceeds along routine lines while I make a general assessment. Then I reach a fork in the path. Now is the time to level with them. But I am not up to it. I have left two patients in mute distress (possibly; how could it be otherwise?). I have re-formulated the words to keep them fresh and sincere and specific to them. I have struck a balance between brutal realism (I’m not one for drawing a vivid picture of CPR, but the act has to be mentioned) and sensitivity. I have asked myself, as we continued our progress along the ward, ‘am I bring too pessimistic here? If the other doctors they saw didn’t bring up dying, perhaps I shouldn’t either…’) – and I make a decision. Not today. Another day. Let’s talk about it on Wednesday. I haven’t got the energy. Or I’ll ask to the registrar to do it, she’s good.

“So are they still for resus?” asks the nurse.


“What if they deteriorate?”

“We’ll cross that bridge when we come to it. Sorry.”

And so we move on, hoping that the worst doesn’t happen before we find the time and the energy – a very specific form of energy – to broach the subject.



* ReSPECT = Recommended Summary Plan for Emergency Care & Treatment; UFTO = Universal Form of Treatment Options; UP = Unwell and Potentially Deteriorating Patient Plan. According to the BMJ this week, In Torbay, where Treatment Escalation Plans were introduced to replace DNACPR forms in 2006, ‘30% of elderly patients now arrive [at the hospital] with a TEP.’



Books! Click to explore…

When death is not the end


This week’s report about a nurse being disciplined for failing to ‘revive’ a clearly deceased nursing home resident, has caused consternation. According to the description given, the woman was ‘yellow, waxy, almost cold’. But a rule mandated that the nurse on duty should commence basic life support and call an ambulance. For her to be punished seems perverse*.

The big fail here is not so much the rule (which is to maximise safety and ensure that no opportunities are lost to reverse acute deterioration), but the fact that the woman did not have a community DNACPR order. Such an oversight could be written about at length, and the difficulties doctors, families and patients have discussing the subject have been explored on this blog.

The other problem this case reveals is our general confusion about the transition between life and death. There is a phase in dying, perhaps fifteen minutes (longer if hypothermic – I am happy to be corrected) where vigorous efforts to restart the heart might result in more life and acceptable cerebral function. For this to happen, the heart and other organs need to be in reasonable condition. If death was sudden, re-opening a coronary artery might be all that is required. But if the patient had been ailing for a year, or succumbed to a spreading cancer, nothing will work.

So, when a nurse or a member of the public comes across a seemingly dead person, what tells them whether it is right to start basic life support, or respectfully cover their face? If the situation is at all unclear, it seems there is only one defensible answer – try to resuscitate.

When I did Advanced Cardiac Life Support training years ago I was fascinated (and disgusted) by a paragraph in the manual that described situations where resuscitation was clearly inappropriate. These included decapitation and separation of the body into two halves (sorry to make you queasy, that’s what it said; I’m not sure if the current version still includes this). It may have mentioned rigor mortis. But it did not talk about the ‘waxy’ or ‘almost cold’ person.

Faced with such ambiguity, people are quick to refer back to earlier times, when community doctors or wise neighbours were called to see people in their homes, whereupon they calmly observed that the patient had died and that there was nothing more to be done. Now, such acceptance can only occur if, prior to death, there has been a series of clear discussions and agreements (all documented) regarding resuscitation, transfer to hospital, or escalation of care.

This has come about because modern medical techniques can do much to delay death. The burden of heroic interventions has to be considered of course, hence the need to think about such things before they happen. However, the medical reflex is to treat and save. The reflex applies to all people by default, even those who appear too frail to benefit. Thus, the nursing home has a ‘reflex’ that patients found unconscious and without a pulse should be rushed to hospital unless there is a DNACPR order in place.

This evolution in our ability to preserve life has diminished the validity of the experienced nurse’s, or lay-person’s, impression. He or she is no longer trusted to recognise established death. In the case reported this week, the diagnosis of death was, presumably, only valid if made by paramedics, or by the A&E doctors who might have received her (intubated, cannulated, perhaps with intraosseous access lines protruding from both shins).

There is an argument that only those who have been trained to certify death should be allowed to bear the responsibility, and it is interesting to note that the nurse in this report has subsequently received such training. However, a part of me wonders how it is that death, which has been part of our experience since homo sapiens began spread across the globe, is still such a mystery that one needs to go on a course to recognise it.

Most ward nurses, or trainee doctors who have led a crash team, will have been in a similar situation. From a doctor’s point of view – the crash call goes out, you run to the ward, and observe nursing colleagues performing basic life support. Collateral information soon paints a fuller picture – the patient was last seen alive four hours ago; they were ‘stone cold’ when the nurse came to routine observations at 6AM; clearly, the patient died peacefully in their sleep. But, in the absence of a DNACPR order, a crash call had to go out. As the medical registrar you must now decide whether to call the resuscitation attempt off immediately, or continue for a few minutes just to make sure that there is no return of spontaneous circulation (a heartbeat and a pulse). Most doctors in this situation continue until they are sure the patient is truly dead, as they will not have known the patient and do not feel confident in stopping the attempt immediately. Some of the reasoning here is defensive. You could be criticised for saying ‘stop’ without having gone through the algorithm.

It seems to me that there is still a place for the healthcare worker’s common sense opinion, especially if they know the patient – ‘She has died, let’s ring the next of kin… no, don’t call the ambulance, don’t start compressions. They have died.’

Recent BMA/resuscitation council guidelines do, to some extent, take such ‘common sense’ into account –

…there will be cases where healthcare professionals discover patients with features of irreversible death – for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies’. [see previous post on this here]

Despite this, and even with the support of medical colleagues, while nurses feel vulnerable to censure, only those with great confidence will risk not calling the crash team when they find a dead patient.


* We have very few details, so the arguments and conclusions drawn from the case here are generalised






The unknown quantity

What determines if and when patients ‘turn the corner’? I have never understood.

In my world of acute-on-chronic disease, where patients suffer sudden and life threatening reverses, there are numerous stories of unexpected turnarounds. Our efforts to prognosticate accurately have led to many scoring systems, all of which have been ‘validated’, but when applied to individual patients who surprise you with twists and turns, their relevance appears diminished. However bad the numbers, we treat, we support, we try to save… unless the presentation comes at the end of a long and well recognised decline, and we (the patient, the family, the team) are thoroughly ‘signed up’ to palliation. That circumstance remains a rare one, despite the increasing value we give to conversations about death.

So we are guided by experience – that fickle teacher.

Last year a very sick patient came in. He struggled, we struggled; he responded to intensive care support, we felt satisfied that our decision to advocate for aggressive treatment was the right one. He deteriorated, we isolated the infection. We talked the family through it, and suggested that not give up yet. He fluctuated, weakening a little with each reverse, until… weeks later, he died. All that hope. All that work. The ‘numbers’, at one stage, had looked better. But that is the nature of the disease. Unexpected complications. Hidden infections. Sudden ruptures.

The grim picture joined the file of failures that I, and all doctors, compile in their memories from day 1. It is called experience. But the way such memories absorb the light colours our view of the present. That is the whole point of experience, of course; to change the way we approach similar circumstances in the future.

The shapes and lines of that patient’s clinical course remained etched in my mind when, months later, I recognised an almost identical scenario. Her liver function looked the same during the first week. Her slide into an intensive care bed occurred over similar interval. I was ‘guarded’ in my prognosis, but I knew what was going to happen here. I knew. The road home presented too many traps and potholes for her body to negotiate, given the advanced nature of her disease. Any and each of them could kill her in a few hours. As time passed, her clinical course described the usual sinusoidal curve. The downslopes were not catastrophic enough to justify withdrawal, and the upward gradients were not sufficiently sustained to launch a bid for convalescence.

We reacted to each complication with urgency. Our policy was unchanged – treat, support, save. But my heart was not really in it. I did not have hope. I know I communicated that to trainees. Those muttered opinions as we walked out of intensive care. But at no point did we hesitate or withhold. And time passed.

Until… she returned to the ward. She turned the corner. She had climbed far enough up the hill for the swirling, sucking mists of death to no longer have a hold on her. Then she went home.

A trainee asked, “You know _____? I thought you said the chances of her surviving were…” I stopped her there, and turned the case into a occasion to teach on the subject of uncertainty. 

Is it a ‘survival gene’? Poor science. Then what? We do not know. Probably, luck is involved. When such large unknowns are involved, when the rules that underlie our attempted predictions appear unfixed, pattern recognition can lead to erroneous conclusions. Sometimes it’s better just to treat, support, stand back, and try not to outthink the disease… hoping that they turn the corner.


See also, Patterns and pride: diary of a medical anecdote




Click image to explore all the author’s writing projects.