I don’t like Outreach shifts much.
On paper they seem great – just sit and wait for calls from ward doctors or the CCOT (Critical Care Outreach Team) nurses about very sick patients. Walk to the ward briskly when the call comes, but meander the last few steps to the scene of the crime – it wouldn’t do for any ambassador of ITU to appear hurried. The locals are on hand to handover any information or help I’d need, and hope that I’ll whisk their problem away like a rabbit into a hat. At that point it’s just a question of making the right decisions and either fixing the patient, or declaring ‘Not for ITU’ and providing some departing advice.
But it’s never that simple in reality. Compared to the unit, the wards are an unfamiliar cacophony of noise and unknown colleagues. I don’t know where any of the equipment is, the skillsets of the people I’m working with (although often exceptional), or the history of the patient. When Judith, one of our outstanding CCOT nurses calls me and asks for help on one of the Care of the Elderly wards, I know there’s going to be a problem.
I can’t help but frown as the ward doctor hands over the history. 76-year-old female, COVID positive, significant past medical history including ischaemic heart disease, type two diabetes, obesity, possible dementia, and previous breast cancer treated with chemotherapy. Mrs. P lives in a bungalow with her husband and gets help once a day from carers. She’s sat upright in bed, sweaty and clammy and gasping for air, although after Judith and I fiddle with her CPAP settings she looks a little better.
“Well she’s certainly not for ITU. I’ll document a plan, let’s keep non-invasive ventilation as our ceiling of care. If she doesn’t respond within the next day or two, then probably consider alternative treatment goals.”
‘Alternative treatment goals’ is my way of saying ‘switch focus toward end of life care’. Cases like this make me extraordinarily grateful to not work in one of the many countries with conservative positions on palliative care. Colleagues from Italy, a profoundly Catholic country, tell me of wards lined with slowly irreversibly dying patients. The concept of a doctor there is one that tries to prolong life, no matter how futile the endeavour may be; a concept I fundamentally disagree with. It is my own deficiency that prevents me from returning my thinking to that childhood naivete, from those innocent days in the kingdom of youth where everyone lived forever, and death was an unknown concept. Because of that, and my own experiences, I cannot easily empathise with the adults that still maintain the fear of, and inability to accept dying as the natural end of living.
“Erm, there’s something else you should know… She’s for CPR.”
“Are you joking? Change it to DNACPR and call the family.”
“That’s just it, the daughter is some kind of lawyer and threatened to sue when we phoned her.”
“Rubbish, it’s a medical decision. What did your consultant say?”
“He didn’t want to get involved, and said to leave it. I think he had a similar case before, and it was a massive headache.”
“And the patient definitely doesn’t have capacity?”
“She doesn’t, we’ve tried speaking to her a few times, so we’re obligated to inform the next of kin. Actually… We were really hoping you might be able to speak to her? She might listen to an ICU opinion.”
It’s really not my problem, this isn’t my patient and I don’t want to get in the middle of what sounds like a potentially volatile situation. But I look over at Mrs. P and sigh. If she arrests in the middle of the night I’ll be the one having to run a pointless call, putting the whole team at risk and probably traumatising some of them. Worse still, to subject a patient like Mrs. P to the agony of cardio-pulmonary resuscitation with negligible chances of success challenges my very oath to ‘Do No Harm’.
“Fine, let me read the notes.”
I call the daughter, Tina. I figure it’s best to start with the facts, and inform her about her mother having a deterioration. Her tone is frosty, and she asks a lot of questions – but I don’t mind. If my own mum was sick in hospital, and I wasn’t allowed to visit her, I’d probably interrogate every person that ever picked up a phone.
I answer all her questions, and shift topic towards ‘The Talk’. The resuscitation variation specifically. Everyone’s got their own method, I always start off by checking if they have an understanding of what the term means in a medical context. I always explain that we would continue to treat to the very best of our ability, just like we would for any other patient, because some people have the funny idea that being ‘not for resuscitation’ means we’re going to just give up on making them better. But I tell them if the worst were to happen and their heart were to stop, we wouldn’t use electric shocks and invasive breathing tubes down the windpipe to try and restart it. I’m always honest and say that in their case, it’s very unlikely to work.
Most patients who have capacity are very understanding of this, and are in full agreement saying they’d prefer to just die peacefully and painlessly. Sometimes patients don’t have capacity, so we inform their next of kin of our medical decision. Given the difficult nature of the conversation, and no matter how it’s explained, there are rare cases where the next of kin disagrees. In which case I can only apologise, but inform them it’s a medical decision – doctors are not obligated to provide treatments that we feel are futile or not in the patient’s best interest. Some people mistakenly counterargue with the idea of ‘my body, my choice’, a valid concept that medical ethics fully agrees with. Every patient of sound mind has the right to refuse treatments that are offered, self-discharge from hospital against medical advice, and otherwise harm themselves – it is, as they say, their body. However, patients cannot force us to inject crushed diamonds into their veins to cure their cancer, or keep their brainstem-dead body alive indefinitely with machines. In this case, patients cannot demand that we attempt resuscitation if they were to die, if we feel it to be inappropriate. The confusion between ‘my body, my choice’ and the autonomy of evidence-based medicine has led to many high profile and terribly sad court cases – often brought by parents traumatised and unable to accept the idea that their child is going to pass away.
These fine lines and in-between spaces of the debate around medicolegal ethics and philosophy are also home to the argument around euthanasia. If a patient has autonomy of their own body, and has the right to make decisions that harm themselves, then logically should they not be able to desire an end to their life? Patients cannot force doctors to perform interventions that we feel are inappropriate, but what if there were a doctor that looked at a tragic case of terminal ALS, Locked-In Syndrome, or Huntington’s Disease, and felt the patient’s requested intervention was understandable? My own family has a terrible history of advanced dementia, and I know that if I should ever follow that road toward losing myself and becoming a burden to my children, I would wish for a managed, painless, comfortable end to my own life. Like many of my colleagues, medicine has taught me to fear the loss of quality of life, not death; but I fear society will be too obdurate to take a brave, rational approach toward these issues, and people will suffer for it.
As if to prove the point, the rarest instances of ‘The Talk’ are when relatives, like Tina, inform me in no uncertain terms that she’s seen the news and knows that we’re killing off the elderly in hospitals. She tells me how disgusting it is, and that if anything happens to her mum she’ll fight in court until my colleagues and I are all jailed.
I really want to have a go, and ask her to explain exactly what she means. Why she thinks my colleagues are exhausted, putting their lives at risk – some having died already, putting their families at risk, going through traumatic situations and crying at work day in and day out, and everything else, if we’re just ‘killing off the elderly.’ But I choke back the undercurrent of anger in my voice, and fall back to old schoolboy training. I tell her as politely as I can manage that we’ll continue doing our very best for Mrs. P, and finish the conversation.
It takes a few minutes before my hands stop shaking and I can document the conversation. My colleague, the ward doctor, reads the entry over my shoulder and makes sympathetic sounds.
I don’t know what the right thing to do is. Maybe I shouldn’t have even gotten involved. Mrs. P isn’t my patient, and the consultant in charge of her care has washed his hands of the issue because… What exactly? He’s afraid of a frivolous lawsuit that would surely get thrown out by any sane judge? But then it’s easy for me to say, I wouldn’t be the one facing the stress of having to go to court or sit in those ghastly meetings with the Trust’s lawyers.
I leave the ward feeling like a fool – much less the mighty ambassador from ICU. Knowing that the patient remains for resuscitation hangs over my head like a Sword of Damocles. Every time the alarm tone sounds from my bleep with the words ‘cardiac arrest’, I keep expecting the location announcement to be Mrs. P’s ward.
My feet of their own accord carry me to Dr. Jay’s office. He must have seen the look on my face, because he gestures for me to sit down and offers up a fairly archaeological packet of biscuits. I present the case while he chews thoughtfully on a chocolate digestive.
“You’re right that it’s a clinical decision, even if the daughter disagrees. But since we’re not accepting the patient, we shouldn’t really get involved – it should be her parent team that makes and documents resus decisions.”
“Couldn’t I do it boss? I’ve seen the patient just now, and I’m technically the ‘second opinion’. CPR for her would pretty much be torture.”
“Yeah, you could… but worst case, you’d have to waste a lot of time and energy responding to frivolous complaints. Even if they threw it out straight away you’ll need to declare it at your career progression panel and on your revalidation. I know how you feel son, but I’d leave it alone.”
I leave his office feeling more uncertain than when I went in.
“Cardiac Arrest, 6E Ward”
A number of less than pleasant sounds exist in the world of medicine. It’s to be expected, when dealing with pain and suffering, disease and bodily fluids. The piercing wail of a mother that’s lost her child, the screaming anguish of a man with a cluster headache, the guttural viscous flow of air through choking bronchopneumonia-riddled lungs – but to my mind none are as horrifying as the orchestra of CPR in progress.
“Oxygen away please, everyone away. Stand clear. Shocking.”
A violent thud, and the dead patient arches off the bed as electricity rushes through his body.
“Back on the chest please.”
Cracking as shards of broken and bruised ribs are repeatedly mashed together by the exhausted, but still highly capable alternating nurses.
“Let’s get a definitive airway in, please.”
Sucking as the plastic tube is forced down into the windpipe, accompanied by the hiss of oxygen forced into the lungs 10 times a minute.
We get ROSC (return of spontaneous circulation) after about 17 minutes of CPR. The patient, a forty-something man, looks in a bad way. Post-arrest patients like this come to ICU to try to keep them alive, often the lack of oxygen for a period of time has caused severe injury to the brain and other organs. In this case, the patient arrests again a few minutes later, and this time we don’t get him back.
As I log into the computer system to certify the death, the echoes of the arrest still ringing in my ears, I make my decision.
One of my bad habits is scrolling through social media before bed. I wonder if it’s fate that #DNACPR is trending on Twitter – some sensationalist headlines from the usual rags are getting traction, and the armchair doctors and lawyers are out in full force. It never ceases to amaze me how confident people can be in talking about things they have absolutely zero knowledge of. But then, we are living in a post-truth era nowadays. One GP has apparently made some of their comorbid, elderly patients not for CPR and informed them by letter; a rather proactive practice during a crisis that would prevent paramedics having to attempt futile resuscitation in the event of a death and 999 call in the community. But naturally deliberate misinformation-for-clicks is rife, and the mob are pushing a nasty false narrative that DNACPR implies consigning sick vulnerable older patients to die without treatment in any capacity. The comments are endless:
“It’s against the Geneva convention. It’s a form of euthanasia.”
“What kind of doctor would even think about doing that kind of thing?! Shipman?”
“Seems the GMC/BMA are trying to slip in euthanasia by the back door without any of the responsibility and failing in their DUTY OF CARE”
“Euthanasia by deliberate neglect”
“It is morally wrong. How dare they do this.”
“The name Shipman comes to mind. They locked him up?”
“COVID 2020 Act = Genocide”
Even after I cast my phone away in disgust, it takes a while to fall asleep.
Two days later, breathing easily with medication and oxygen, Mrs. P’s heart stops.
Her chart reads “DNACPR”. I believe she dies a comfortable, dignified death.