It’s the cracking of her ribs as I started the compressions I remember most vividly. “Keep going”, the medical registrar calmly instructed, “not quite so hard”. Compared to the Annie the resuscitation doll, Annie the 92 year old woman was made of porcelain, osteoporosis had made her bones brittle and fragile. One junior doctor was struggling to find a vein in her left arm to set up an intravenous infusion while another was trying to take an arterial sample from her right arm and an anaesthetist ventilated her with a bag and mask. The medical registrar calmly conducted as Annie shed blood and the young doctors, sweat and tears. Thready veins collapsed as one attempt after another to get venous access failed. Cotton wool balls were hastily taped over her bruised and bleeding arms. Annie’s ribs crunched loudly with every compression. The defibrillator arrived, we stuck patches on her chest and gave electric shocks. The protocol was followed to the joule, but Annie’s heart didn’t beat again.
As a schoolboy I spent 2 summers working as a nursing assistant on an elderly care ward at Winchester Hospital. After a few weeks the ward sister asked me to spend my night shift with an elderly woman who was expected to die. She had advanced dementia and had suffered a stroke so that she was paralysed down her left side. She slept peacefully, occasionally moaning when she moved. As the night went on the ward sister bought me cups of tea so I wouldn’t have to leave my patient. At about 4.30 her breathing began to change, it slowed and became irregular. I called the sister who came over and drew the curtains around. I held the old lady’s hand and watched her silently and intently. She had no family, no friends left alive with whom to share her last night on earth. Her breaths were so quiet, I hardly dared breathe myself. At about 6am she stopped breathing. With the ward sister’s help we washed her and wrapped her in a sheet before the porters came to take her to the morgue. It was one of the most formative experiences of my life.
Death is in danger of being defined as a consequence of medicine’s failing rather than as an integral and necessary part of its business. By separating off palliative care as the speciality that cares for dying patients, there is a risk that the rest of us consider the survival of the living our business and fail in our duty to our patients at the end of their lives.
Resuscitation attempts are always brutal and for frail nonogenarians almost always futile. Annie’s reuscitation was, for me as a newly qualified doctor, an awful experience, violent, bloody and futile. But it was for Annie that I was most upset. She deserved a more dignified death.
As doctors we have a duty to ask patients whether they wish to be resuscitated in the event of a cardiac arrest. Like every intervention we have a duty to explain what the intervention involves, the risks including the potential disability due to damage incurred by your vital organs being deprived of oxygen in the time between your heart stopping and starting again.
It is terribly hard finding the right time to have this conversation when someone is admitted sick and afraid to hospital. Recently I asked two patients. One was very sick and emaciated from chronic bronchiectasis, “doc, I don’t think there’s anything left to resuscitate” she said. The other, equally sick with heart and lung disease said, “Doctor, I want everything possible done”.
I don’t think we can guess what our patients want at the end of their lives, but I do think we need to have more conversations about it, and if we can reassure our patients that when their time comes we won’t desert them it will be better for all of us.