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Break his sternum. Break some ribs; crack beneath your hands. Push, push, push; one hundred times a minute please. ‘Good compressions’ calls the computerized voice from the defibrillator. Don’t stop, now feel for a pulse; you’ve got it? OK, now leave him to die again. Pillow? There are no pillows in A&E, we will find a blanket and roll it up under his head. He isn’t for intensive care. What’s his name?
I don’t know it.
You could tell that story many ways and it is the story of many. I could paint it rosier, add more details, but when I relive these cases I often don’t. I recall it just like that.
‘Cardiac arrest call ED resus, five minutes; ITU to attend’ the voice crackled over my bleep. I arrived in to resus to receive a woman in her eighties who had choked on her dinner, stopped breathing and then had a cardiac arrest. CPR was started at her care home and an ambulance was called. They arrived, cleared her airway as best they could, continued CPR and brought her in. She had what we call ‘return of spontaneous circulation’.
The patient arrived unconscious with a pulse. We transferred her on to our trolley. She had fluffy white set hair like my grandmother, I used to like to pat my hand gently on top of it and watch her laugh when I told her it felt like a cloud. I looked at the patient’s soft wrinkly skin and her tongue, that lolloped out of the side of her mouth next to the laryngeal mask airway that had been pushed inside.
We knew very little about her, but we set about the basics as a start.
‘This airway isn’t working properly’, I said as I pulled it out of her mouth and discovered a match box sized lump of meat partially clogging the end. Moving on inside, I continued to clear the remainder of her stomach contents that had exploded into her mouth with CPR.
What happened next? The A&E consultant logged onto the computer and gathered what information we could about this patient who arrived without anybody who had ever known her before.
Dementia, diabetes, hypertension, full-time care and previous admissions to hospitals for falls.
I phoned my consultant and we discussed the situation. She would not be escalated to intensive care. Death was inevitable; of course it was, that was true from the first time her heart stopped.
I put down the phone and looked at the monitor. Her circulation was already failing again, so we rolled a blanket under her head and a nurse found a clean gown to place over her broken chest. She was given all the dignity A&E resus could afford her.
Her family came later and the A&E consultant told them about the series of decisions we had made. They understood and recounted many years of their loved one living with dementia and co-morbidities. They agreed they wouldn’t have wanted her to have CPR and they wouldn’t have wanted escalation to intensive care anyway.
They wouldn’t have wanted her to have CPR.
There’s a form for that, I thought, as I remembered standing in a busy resus department looking at her broken, see-saw chest heaving irregularly on front of me.
There is a form for that.
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter
Read our guidance on decisions relating to CPR
Such a sad end to a life. Why can't we discuss death in civilised society as one day it will happen to us all.
This situation could be avoided more often if Discussion of DNACPR could become a routine part of admission to nursing homes and I would argue should be routinely offered as part of an annual review of care in chronic terminal illness, such as dementia.
It is time for us to move the focus from #DNACPR to #GentleCare for fellow human beings who are in fragile clinical health and say #IWantAPeacefulDeath
How we frame the questions shapes people's thinking. Framing #EndOfLife as #DNACPR is a hindrance to #CalmEndOfLife
Time to change from the focus on #DNACPR
www.dropbox.com/.../V2 Time to Change from Do Not Attempt Cardiopulmonary Resuscitation.pdf
TalkCPR videos and resources in Wales, now shown to palliative patients and their loved-ones after first explanatory discussions around CPR and DNACPR http://talkcpr.wales
Also include training videos and tips for healthcare professionals who may have to intiate such discussions.
I do frequently have this discussion...however patients frequently opt for having CPR (however graphically I describe it). I've tried explaining the tiny likelihood of success etc. Until there is a big media campaign on this (rather than the usual daily mail articles on doctors 'signing death warrants ' these situations are not going to end. It doesn't matter particularly that the 'family wouldn't have wanted cpr' - the GP may have had the discussion with the patient any got a different answer (and even with dementia she might have had capacity)
I'm a hospital volunteer and we see things from the other side as non-clinical and not a patient or visitor we have a birds eye view at life, sometimes we are seen as the inbetweeners but we are highly trained to handle most situations calmly and carefully, our drs do a wonderful job at saving lives but not all can be saved and it is a medical judgement that decides the fate of the few.
I wish as a volunteer we were able to help more but we can't we have to stand aside and allow those that know manage the situation, There is a form for everything in a hospital this blog says it all.
I've worked in the ambulance service for over 30 years and have felt sad, ashamed, angry and remorseful after a countless number of resus attempts that just should not have been initiated. It isn't dignified and gives false hope to relatives. There really needs to be a cultural change in how we view death and accept that the time comes when it's inevitable. The debate is long overdue.
I do end of life planning with my patients however many still opt for CPR. One of my patients with multiple co-morbidities felt we were trying to save the NHS money despite education. I wish my patients would allow me to give them a dignified death .
Brings back a conversation with a ward nurse in hospital regarding my mother in law- vascular dementia, cardiomyopathy, uncontrolled diabetes (she'd forgotten that she had diabetes/ needed to avoid the nicer foods in life), arthritis, Barely rousable- "have you considered a DNACPR?" I asked.... "Oh! Do you not want her resuscitated?" Even the poor weekend Dr who unfortunately did not know her was reluctant until we presented our LPA. Which bit of resus would have made her better? Yes she was septic, yes by all means try to reverse this but there was always the chance that the IV antibiotics would not work especially as when they did manage to get a line in she pulled it out...several of them... She lived another 2 years in a lovely residential home and just didn't wake up one morning- pneumonia. The DNACPR form went to the home with her. Her family were around her for the last hour of her life.
P.S- me and my other half are looking at completing advanced directives to refuse treatment
I have a dnacpr form. I've made the decision myself so others don't have to. It was easy just went to see my gp and explained why he filled out the form and that was it
Why does there even need to be a form. You would have to find it first buried in amongst many other crucial and important documents. Whatever happened to clinicians being able to use initiative and make sound clinical decisions based on knowledge, experience and humanity? Perhaps tick box care, directives, guidelines, quality measures, kpi's, targets, clinical governance but above all... fear!
This is what we need as a profession and as a society. We are afraid to discuss death. Every patient with a significant debilitating chronic illness should have this completed prior to discharge from hospital. Every patient on admission to a nursing home should have one completed.
Informed decision making is vital.
I am 46 with COPD & Asthma never smoked and got this due to a rescue as a lifeguard. I now get tachycardia of 150bpm plus when I get a infection. I've decided to get DNACPR. As I know without this they would do CPR as long as possible. I want to die with dignity and respect and pass away on my terms. I only knew I could do this as I've worked in the NHS and feel its still a subject that isn't discussed openly as it could be. One problem is it's A4 piece off paper and is awkward to carry in my wallet. Surely we can have a credit card size card that can have all your details on it.
We need to encourage early conversations and decisions to be made before the acute phase of illness. Up to half our 2222 calls prompt a DNACPR decision after ROSC. We should be holding their hand not cracking ribs and stripping people of a dignified death.