Resuscitation orders “DNACPR” “Not for resus”

Bighospital, like many other hospitals is seeing something of a change in how we manage end of life care. In my working life we have gone from simply telling the nurses that a patient is not for resus, to writing it in the notes; usually in capital shouty letters with stars around it to a formal form that is filled and filed in the notes.

Death is a relatively frequent occurrence on the surgical wards, we probably have one a week across the various units, most of which can be predicted in advance of the event.

In light of the court of appeal’s ruling last week that all patients must be consulted about all not for resuscitation orders we had a huge fiasco last weekend with a dying man. The man had advanced cancer, quite recently diagnosed and was not fit for a curative operation. Following a small procedure to diagnose the extent of his disease he developed pneumonia and developed respiratory failure. Over the course of a day he went from talking and being well and to almost comatose and at death’s door.

The family were distressed, son’s were being called from up North, the wife was utterly distraught and they all wanted something to be done. My junior’s were out of their depth with the situation and so, rightly, I was called. A bit of frusemide, some higher flow oxygen and sitting him up a bit improved the situation temporarily. This man was not a candidate for ICU, I knew they would say no, he had weeks to live and his lungs were severely emphysematous. However, this is not just my call and because of that and for the inevitable complaint that I could see coming (“My husband walked into Bighospital a well man and 4 days later he was dead: bungling surgeons cause pneumonia in man who was playing golf last week”) I phoned my friend in ICU for a ward consultation, even though I thought he would say “no” over the phone. The ICU doctor took one look at the man, the notes and the X-Ray and spoke to the wife, there would be no ICU.

Now, for those of you who don’t know, no ICU used to mean an automatic not for resuscitation as following a successful resus, you go to ICU as you may be alive again but it isn’t like on TV. Post arrest you are still in a bad way and are heavily reliant on drugs and medical care. It was for me to speak to the wife to say that we wouldn’t recommend CPR as it was no longer in his interest, would likely not be successful, we were not going to ICU etc. I rang the consultant involved as I didn’t really know the man well and wanted to let him know what was happening and confirm he was happy with the plan. He was happy, but he reminded me that because of this new ruling by the court of appeal, I had to ask the man himself.

Man said “I don’t want to die, you have to save me.” I explained that there would be no ICU post arrest, that this was not going to prolong his life by very much and was likely to cause him significant distress at the end of his life. “Don’t let me die” he said. He arrested an hour later and we were called, it was a respiratory arrest and we got him breathing again, most unexpectedly.

The wife was distraught, an arrest is a traumatic and horrific thing to witness. Organised chaos is the best way to describe it. She wanted to stay in the room whilst we bagged and masked him. His heart did not stop beating this time, we got him breathing again, reassessed the not for ICU status and all agreed that this was the correct course of action.

I spoke to his wife, perhaps we should now consider a not for resus order? “I can’t decide that”she said, “he doesn’t want to die, I don’t know what to do, I need my son here”. I was heading for my evening meal in the canteen when the call came again, an arrest on blue ward. This time it was a cardiac arrest, with the chest compressions the F1 broke rib after rib on the frail man’s chest. His cancer ravaged body was bashed and battered, though not for very long as we decided that this was a futile exercise and that we were not going to continue.

My ICU colleague asked me why we were in this situation, why had I asked the man if he wanted resuscitated or not? He put it in a somewhat stronger way, along the lines of “What the fuck? Are you insane? Why was he still for resus?”. The man didn’t want to die, he wanted to live, but we had decided that he was not for ICU (without any need for his consent) and so had effectively decided he would be allowed to die naturally without anyone trying to stop this process. He had to consent to the not for CPR though, even though CPR for those not going to ICU is crazy.

It was a shit situation, I suppose at least his wife and sons can console themselves that their loved one fought to the end and that we tried to save him, even if it was partly an empty gesture with the ICU doors firmly closed.

This is the situation that we are facing, asking patients if it is ok that we aren’t going to jump on their chest if their heart stops beating. What a question, usually we involve people in this in a gentle and pleasant way, we explain palliative care, keeping comfortable, a quiet and dignified death, slipping away, your breathing slowing down and stopping, there are a hundred euphemisms.

A few days later and I have a 92 year old from a nursing home sent in moribund and not fit for a haircut with some massive intra-abdominal catastrophe. We kept her comfortable, we let her drink and eat what she could, checked she was in no pain and held her hand and watched her die a day later with her family around her. Nobody asked her if she wanted resuscitated.

The first situation felt wrong to me and the second one felt right. That’s not how the court of appeal would see it of course. For the Court of Appeal ruling see this handy summary.

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PDSA…plan, do study, act….What a load of sh*t

PDSA…plan, do study, act….What a load of sh*t

When you become a consultant surgeon you seem to very quickly get bored (within 5 years) and need a sideline. This can be private practice (lucrative and enjoyable), royal college stuff (prestigious and enjoyable), academia and research (allegedly enjoyable for some, not lucrative, moderately prestigious), NHS management (allegedly enjoyable, some extra cash) or you become a complete asshole.

Becoming an asshole means you start using acronyms like the one above. It’s the current buzz in groups like the institute for healthcare improvement. It isn’t really a new idea, it’s been around for a while now, but we should all be glad we can get on with improving healthcare now that we have a less tricky name for doing a fucking audit.

To help you make sure that you ask the right people about your audit, sorry, PDSA methodology research project, there is the easy to remember “9 C’s”

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I have no idea what they are talking about. The 9 C’s don’t roll as easily over the tongue as “oh, oh, oh to touch and feel a virgin girls vagina ah heaven” does for the cranial nerves (olfactory, optic, occulomotor, trochlear, trigeminal, abducens, facial, vestibular, glossopharyngeal, vagus, accessory, hypoglossal). And anybody who uses the word brainstorm after 1992 should expect to be laughed at.

All over Bighospital in the last few weeks posters have been appearing featuring management’s latest ideas for saving money, using less staff and using cheaper equipment (and thus improving care) based not on boring old audit with it’s inherent problem of closing the loop; reauditing the change and confirming the effectiveness of the intervention, but on PDSA.

The other PDSA I am familiar with is the People’s Dispensary for a Sick Animals, a charity that cares for bewildered donkeys and the such like. Next time I am asked to do a PDSA cycle I am going to do 150k,
get sponsorship from all my colleagues and give the money to the donkey sanctuary. That will quite possibly be the most useful PDSA cycle Bighospital has ever seen.

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A memorable patient

Some patients stay with you, some for good reasons and some for bad. You carry them around with you in your head and use them for anecdotes, teaching cases, reminders of complications or pitfalls or things you would have done differently. There are others that stay with you because they touched you personally, which is to say you carry them in your heart. This number is small as these really are the special moments that occur infrequently.

The ward round on the admissions unit is a business like affair, we have 30 or so admissions to review and assess and make a plan for and then we need get to theatre to operate. Very little gets in the way of this process, few patients interrupt the flow.

Mr Smith (not his real name) was scheduled for a laparotomy, I had consented him and he was ready to go. We were popping in to say good
morning and to check he was ready for theatre.

What happened next has never happened to me before in a relatively long career of managing the sick and dying. He asked my consultant if he could pray, “of course, you don’t need my permission” she replied, turning to leave the room.

Mr S closed his eyes and bowed his head. “Dear God, bless this team that are here today and are going to operate on me this morning. Guide their hands and help them do their best. Take all the spirits of evil and death from the room and bind and banish them. Keep me safe in your care and love and help me face the coming difficult days with strength and courage. Thank you God for giving me the chance today to have this surgery and for the chance to cure me, thank you for these two women who you have given those skills and that gift to. Amen”.

The two of us had tears in our eyes, we had expected him to pray in silent when we had left the room. I couldn’t look at anyone, the nurse was openly crying, my boss managed to thank him whilst she choked back the tears and we all shuffled from the room.

I spoke into the dictaphone “Mr S is for a laparotomy this morning. He is consented and an HDU bed is available.”

Sometimes you think your job is shit and you don’t make a difference and nobody cares. Other days you stop and remember what a privilege it is and why you do it and how lucky you are.

BMA News….from 1963

I know I go on about the same stuff over and over. Today’s BMJ is not particularly annoying, nothing too controversial unless you are in Northern Ireland and have strong views on termination of pregnancy. The accompanying BMA news is however quite annoying. The BMA have a new series of articles about what it is like being married to a medic. “Doctors, do you know what your partners really think of you? Ask them to tell us the best and worst things about living with a medic.” Write to news@bma.org.uk

Can you believe this is of interest? There is some lovely girl in today’s BMA news telling us all about life being married to her wonderful A&E trainee husband who doesn’t “talk in acronyms and seven-syllable words, like some medics we know”. Nothing like alienating your audience!

She is lovely and super sweet and gives an account of life with her husband that wouldn’t be out of place in Chat magazine or The People’s Friend. She clearly adores her husband who works (gasp) 12 hour shifts and then comes home to a house with 2 kids and a wife who try and give him peace so Daddy can study and write papers.

I have nothing against this lovely woman and her lovely life with her husband that she adores but what the fuck are the BMA news editors doing putting this stuff in a magazine for doctors?

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Then they have more advice from an F1 on how to make nurses like you if you are a girl junior doctor;
1. Become an expert with the kettle
2. Make sure you watch the length of your skirt hemline
3. Tie your long hair back. “Imagine how annoying it must be to have your long hair scraped back into a bun while the junior doctor’s long blonde locks are flowing” . Imagine indeed, or instead imagine how it must feel to earn a quarter of the money that Dr Goldilocks earns..
4. Bake the odd Victoria sponge
5. Read Heat, OK or Now magazine so you can talk to the nurses.
What a patronising wee cow, I read Heat magazine anyway because I like it, I read The Sun (because I like Dear Deidre) and I talk to the nurses and porters like people because I am a person.

BMA News this is fucking terrible. Am I the only person who reads it? I am going to have to write to you and stop ranting about it here. This is a magazine for doctors, we know how to talk to nurses and get along just great with them and we know what it is like being married to one because we get told by our partners. Cut the damn thing down to one sheet of paper and stop publishing shitty filler pieces. I’m tempted to see if I can get published posing as a dopey wife!