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.