Do not resuscitate

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.

See also:

Conversations about death are never easy, but we doctors must have them. Guardian 20.10.2014
What we talk about when we talk about death. A case.

13 responses to “Do not resuscitate

  1. So what if you firmly believes resuscitation would be futile, but the patient asked for “everything possible” to be done?

    Surely in that case resuscitating them is impossible, not in the category of “possible”, and therefore the med reg, sho, ho, nurses and anaesthetist would be better employed making people better elsewhere in the hospital?

    I don’t see how not attempting the impossible runs contrary to the request to do “everything possible”.

  2. Very good comments and put over viewpoint succinctly.

    Did I ever thank you for your mention of my posting re Govt’s Consultation?
    I sent three emails to Steve Field’s Patient Forum – not one was answered.

  3. Very moving story.

    Yes, we do need to talk about death and resus more often and openly. We also need to talk about other aspects of death, such as organ donation. Too frequently, organs are wasted because of difficulties in talking about donation with the families of dying patients.

  4. What a great post. Sometimes it’s better to allow death to come gently. I can remember a few similar sinarios when I was nursing adults. Traumatic for everyone not least the patient!

  5. Excellent post, and frustrating that the discussion is usually left to the most junior members of the team. Working as an orthopaedic registrar, I included it in my consent process for Neck of Femur fractures at the time of admission. Given the mortality rates of NOF patients, its not unlikely that they will deteriorate after surgery (or while waiting for the anaesthetist to OK surgery!) and I think the patients and their families tend to feel that you are “giving up” if you have the DNR chat AFTER ‘complications’ such as pneumonia or MIs arise. I add the inverted commas only because often the problems precede the admisison and the surgery but are only picked up whilst in hospital.

  6. The original story at the head of this blog is an excellent description of the dilemma that all of us face when we are confronted with a person who is dying. The sensitive way in which the author deals with this problem is heart-rending but absolutely true to life. Our problem as doctors is the fear of being seen to be acting with the authority of God against the fear of having missed an opportunity to save meaningful life. We do not solve this dilemma with a piece of paper accompanied by the DNR logo. This DNR tick box culture has more evil within its unwritten innuendos than any of the politically motivated healthcare related rubbish we regularly receive from the Department of Health or the current Lib/Dem Coalition.

    The written DNR statement in the patient’s notes merely shifts the responsibility for the death of the patient to the patient (suicide) or to the “relatives” (manslaughter). Perhaps this all stems from the culture of litigation which haunts our actions. A culture which all too often is a cheap way for a relative or dependant to gain a financial reward from the death of the patient.

    When faced with a “moribund” patient it is almost too late to be asking questions about what we should do if the patient “dies”. In this pre-morbid situation it is our skills of communication both with the patient and their “relatives” that should guide our thoughts and hands when faced with what we assume to be the inevitable outcome of a patient’s illness.

  7. I can’t agree more with the final sentence of the previous comment. I feel the skills in communication are part of the Doctor’s job, with patient and family where there is one. Everyone who goes into hospital should sign something to say whether they wish to be resuscitated or not should the need arise, with the advice of their Doctor. There should be advocates for people without mental capacity. Families/ close friends if there is no family should be consulted sensitively and informed of the patient’s opinion. If the patient wishes it to be private between the Doctor and themselves, it should be part of the written document. Families/ close friends should be informed. My own and my husband’s experience of my mother-in-law’s death was coloured by what happened at the end which was sudden and followed the doctor being very slow in pursuing her illness. No one knew she was dying, even the Doctor who saw her an hour before, although in retrospect I should have realised. My husband and son kissed her and I held her hands, left the room and put her favourite music on. Her eyes were glazing over, I should have realised what was happening: my husband feels she had the peaceful death she wanted, pain free too. I have asked numerous people since and people often say that patients die after relatives have gone. Nevertheless I would have like to be with her to support her as she passed on as we had given her as much support as we could whenever she needed it. The big problem was that in the last few weeks she had almost lost the power of speech. I was the only person who could follow most of what she was trying to say and she used a note book for other people. In her note book she told the GP she didn’t want to go to hospital and he followed this. He could have taken this to mean she didn’t want treatment. He took over and took it out of our hands, took her off her heart medication. Even the manageress of her home was concerned about that. I feel she went to her death just as in life, doing what those in authority told her to do, as well and causing as little trouble to others as possible, such sweet lady. Despite trying to find out, we never really established whether he told her she was terminally ill or not. My understanding is that he doesn’t have to: if he doesn’t have to, how can he get her agreement or other wise on DNR? He was obsessed with putting something vague on the cause of death certificate. When asked we would not agree. This is I agree a matter of nature and I understand the difficulty for Doctors; nevertheless it is their job. We need an officially agreed procedure which everyone understands and which is workable but which respects life and death. I believe strongly in clarifying the procedure at the end of life: getting the patient’s views in writing, to ensure that patients are correctly consulted, families and close friends are not taken advantage of, that patients have the best death possible and Doctors are guided to provide this. We do have to accept the inevitability of death but we do not have to accept hastening of it, whether by having DNR when it shouldn’t be done or not having it when it should be done. Death is not as easy an experience as we might like it to be. We need to find way to improve the current situation for everyone’s sake.

  8. Thanks for this, it was a very moving article and I find it heartening that there are people like you working as doctors. I wish that conversations like this had taken place with my family when my granddad was finally dying of dementia this time last year. Each time he got an illness that he could have died of naturally he was pumped full of antibiotics and kept going for a bit longer, in such a state that had he been able to make the decision, I don’t think he would have chosen to be alive.

    Families understandably don’t want to have these conversations, but it would be worth giving medical professionals some kind of training in how to sensitively broach the topic of what they think the wishes of the dying patient would be. Or, better would be to ask the patient when they are still alive, which is not always possible, but would be in the case of drawn-out illnesses such as dementia. As ever, it’s a matter of looking at each patient’s circumstances individually.

  9. Excellent post, and equally excellent comments.
    I cannot help but think that my answer to this question will seem offensive and tactless to many people.
    Death is still the last great taboo in our society. However, it has almost been elevated to the status of a celebrity in its own right, the most obvious public outpouring of grief (for someone that 99.9% of the screaming wailing people didn’t even KNOW) being Princess Diana.
    Our health service and its incredible staff, also seems to have been elevated to the status of life-giving ‘Gods’ – and when someone in their care dies, they have failed. The system has failed.
    I work in health care for the elderly, home based domiciliary mainly, and the thing i notice most is that health care now seems to be for the benefit of the relatives and not the patient. All too often elderly people become the embalmed living, totally dependent on those around them to keep living, sparing the relatives the pain of loss, whilst losing almost all of their dignity. (incontinent, peg-fed, wailing, flailing arms). When, perhaps, just perhaps, if society actually dealt with its fears a little better instead of medicating them, these people could die with dignity, peacefully some years before. SO many home care situations cause family feuds (“who looks after Mummy the most?!”) and so many of the carers are locked into the caring role that their lives are put on hold, sometimes for decades.
    Transversely, re-sus has had innumerate extraordinary successes. Young people in horrendous RTAs brought back form the brink, and live a full healthy life.
    What about those involved in horrendous accidents (of any kind), brought back from the brink, by tireless gifted health professionals, only to spend the rest of their lives being fed through a tube, breath only with a ventilator, no speech, and a whole family’s life on hold, again, for decades. Who does that serve?
    Its an endless debate. And one that I don’t think will ever be solved. But its one worth having.

  10. Thank you to all of those who allowed my father a peaceful death this week. They know when the time has come and its cruel to end it traumatically. However it means that there needs to be some honest and upsetting discussions in preparation, not necessarily unkind but helping the family to understand the situation and what would be kinder. It was easier for me as a doctor to recognise that my fathers time had come, and to let him go peacefully. I am still very sad, but know it was what he wanted.

  11. Do we deal with the death of a pet more humanely than the death of a close relative?

    Do we know why?

  12. Sometimes everything possible may not be enough. But with most patients in the present day, they have their mind made up on getting a DNR order on their records so they can just let nature take its course. However I do agree that you can never know what is going on in the mind of the patient, but just give them the respect and attention they request for or deserve. As doctors, respecting patients wills is needed more.

  13. my wife and myself have now been asked 18 times about agreeing to a dnr she has copd have pleaded with them not to ask any more but to no avai we feel as though we are being pressured to agree this cant be right

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