I’m aware I write about death a lot. I can’t help it, if there is one thing I have learned about death since I became a doctor it is this: it happens.
At night, I am often called to the ward when death is already certain, like I’m supposed to give permission ‘you may allow them to die now’. It’s an odd thing to consider is part of your day-to-day life, in retrospect. In these cases, it’s usually 6am when the crackly voice summons you from your bleep. You run-walk to the ward and arrive at the end of the bed like some sort of arbitrator.
You become adept at scanning through notes, picking out the salient points and when it is clear that this patient is in the 94 per cent of people who will not survive a PEA arrest to discharge you give that opinion; will not benefit from escalation to intensive care.
So it was 6am and I was standing at the end of another bed. Compressions had been stopped and the patient heaved what would be her final minutes of agonal breaths. Her circulation was adrenaline dependent and her pulse was barely palpable in the clammy creases of her groin.
I had already spoken with my consultant and advised the team that we felt escalation would not be appropriate. I could have walked away then, because I had done what they had called me there to do, but I didn’t because that’s not the doctor I would want at the foot of my bed.
I did what I thought I could do, which is try and make her look like she is about to die peacefully in her bed. I helped the night sisters lift her back up from where she had crumpled down into the middle of the bed. I asked my SHO to get the pillow back from where it had been thrown aside on a chair. I wiped her mouth. I put my hand on her forehead for a couple of seconds and I don’t know what that meant, but I always feel obliged to do it. I think it makes me feel like I am paying them some respect. Maybe it’s an apology.
Then as I turned to leave, I realised the medical registrar and his SHO were preparing get a venous blood sample from her groin.
I knew I was partially responsible for this predicament. When I arrived at the tail-end of the resus it felt already abundantly clear we weren’t going to be successful. The FY1 was trying desperately to get some blood from her shut-down peripheries, but they already had a cannula and enough for a blood gas sample so I told her to stop. It seemed like the pain inflicted that I could immediately control.
I didn’t know this medical registrar, but I looked at the night sister who also appeared perturbed, so I suggested calmly, that it wasn’t necessary.
‘We haven’t got one.’
‘She is dying, it won’t change her management, you don’t need it.’
‘She isn’t dead yet, maybe we should still get one?’
‘Well it is not what I’d want for my grandmother, is it what you would want for yours?’
I moved from calm enquiry to firm direction to exasperation.
He didn’t answer me.
I walked away.
By the Secret Doctor
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did you apologise to the junior for talking to him like that? he probably didn't know what else to do at that point. seems like he didn't deserve that tone of voice and as a result probably felt awful.
Whoever the current Secret Doctor is: your writing is amazing. Always so spot on and moving.
How have we got to this point? It sounds tragic that CPR was even attempted in this case- this should have been decided by seniors/GPs long before the middle of the night and we can't blame the juniors who have to make difficult decisions in the middle of the night . Thankfully the number of inappropriate resus calls in the hospital where I work is decreasing, but we have a long way to go..........
This is so true. In our junior doctor years and in Nursing we are so hide-bound by protocols and wary of deviating from them in case we are taken to task by colleagues, relatives or lawyers.
Having the guts to see a dying person's perspective takes maturity and experience. Seeing it through is becoming increasingly difficult due to the strait-jacket approach to the practice of medicine.
It is a great misfortune for the patient to be left entirely in the hands of the less experienced for long periods. During a recent admission I sat opposite a 99year old who was admitted on a Friday night. She was troubled by thirst and left crying out for some water to wet her lips. I do not know what her underlying condition was, but the protocol said nil by mouth until swallowing is assessed. The speech and language therapist was the only person authorised to do this and there was no service over weekends.
The patient did not have the wherewithal to discharge herself. The nursing home she came from did not have the courage to look after her. She must have felt the helplessness of a prisoner and yet she had the child like faith in the NHS that she had grown up with , nor did she or most other patients have an alternative. As being virtually the monopoly provider of healthcare at the time of need we should take great care to remember that being slaves to protocols and the exclusion of common sense and experience can very rapidly change the patient's experience to a negative one and render staff to being merely technically adept.
Unfortunately the patient died weeping and sobbing in the middle of Monday morning.
Secret Doctor, I'm glad you stayed and did what you could, but... if you're getting called to a lot of these scenarios as urgent middle-of-the-night decisions, then that suggests that your hospital desperately needs to revamp their procedures for reviewing treatment escalation.
Sure, circumstances change, so with the best system in the world you're going to have to make a middle-of-the-night decision change in some cases. But I strongly suspect that a lot of these were actually scenarios where it was obvious from a much earlier stage that escalation was inappropriate, and that that decision could have been in place far earlier in the patient's stay.
Thank you for trying. I had to "strongly discourage" a well-meaning junior doctor from taking an arterial blood gas from my dying mother (the protocol said it was necessary as her obs had deteriorated!). Common sense AND compassion - God bless you!
Really excellent little piece - and it shows us at our best - caring, compassionate and sensitive. Someone with a modicum of experience will "know" when something is futile and to hide behind "she needs bloods" is just plain crazy (and not caring/compassionate and certainly insensitive!). As the secret doctor says - death happens and again one of our roles (seniors?) is to ensure that we stand back and let nature takes it's course. It was the Henry Marsh - the neurosurgeon in his recent book who said the art of surgery was to know when NOT to operate just as much as to when.
I like to remind the juniors in my (GP) surgery that the first rule of medical Ethics is "first do no harm".
Articles like this need more discussion.