Resus And Culture

Last night I worked out of a different station to normal, although it was still in the same complex of stations, with a team leader assessing my clinical skills. It was an interesting night, and although I was going to nothing except the most serious 'Category A' calls – I still ended up getting called to a drunk.
I had two 'suspended' patients, one of which had been dead some time, and had been found by his relatives deceased in bed. There was nothing we could do for the patient, so the other crew on scene were left to arrange the police to deal with the death.

The second suspended was rather more interesting, in the 'Chinese Curse' fashion.

The call was given as a 90 year old female with difficulty in breathing, and on reaching the scene we were directed into a room with around 15-20 people who were wailing and praying over a very sick old lady.

At first, there was no way I could reach the patient, so I ordered the people out of the room. Some left, although they were quick to return, and I quickly looked at the woman – she was breathing, but her breathing was very poorly. I prepared our equipment to give her oxygen but as I did this, I looked up and saw that she had stopped breathing. A quick pulse check showed that her heart had stopped as well. At this point a lot more of the family came back into the very small room and started to, well, get in the way.

We started CPR, and a second crew turned up. The family were very unhappy that we were attempting to resuscitate their elderly relative, and while I could fully understand this, for resuscitation, is not a pleasant thing for anyone to go through, there was little we could do. If we hadn't attempted to resuscitate her, then we could lose our jobs and, perhaps more importantly, rob this woman of any chance of survival.

So we continued to resuscitate her, and prepared to remove her to hospital – at which point the family became really upset, and adamant that we should leave her alone. It got so bad at one point that my crewmate called for police backup.

There were a lot of angry looks directed to us, and various mumblings that we didn't understand their culture and religion. I can understand this, but still, our hands are tied. If someone suspends in front of you, and they don't have a 'Do Not Resuscitate' order, then we have to attempt a full resuscitation. To do anything else would be to allow someone to die, and therefore a dereliction of our duty of care.

We decided to meet the relatives halfway, in that we would follow our resuscitation protocol, which allows us to cease resuscitation if there is no response after 30 minutes of CPR and drug therapy. This way, the relatives wouldn't have us take the patient to hospital for a (most likely) meaningless attempt at treatment. They seemed somewhat happier that we were doing this, and calmed down a lot.

We treated the patient for 30 minutes and there was no recovery, she was recognised as deceased, and we left the police to deal with the paperwork that follows after someone dies. I think that we handled the situation as sensitively as possible. There is always a worry that what we consider best for a patient, might not be what the family consider in that patient's best interests – but in some circumstances our hands are tied by procedure and protocol.

While I think we did the best we could for everyone concerned, I wouldn't be surprised if a letter of complaint found it's way to the LAS.

But as we weren't nasty to the family, and followed our protocol – I should think we will be alright.

18 thoughts on “Resus And Culture”

  1. “… and various mumblings that we didn't understand their culture and religion”.And they didn't understand yours either, natch.

  2. At least you're allowed to stop. To do what you did, I would have to get a doctor out and get them to request that we stopped. And we all know how easy it is to get a doctor out.

  3. I can't see how anyone can possibly complain about your actions. The relatives, or at least one of them called for an ambulance.

  4. Reynold was spot on in having to resuscitate the patient as the patient's interests (or your perception of the patient's interests) is paramount not the relatives' wishes. However I can appreciate his difficulty as one can sympathise with the relatives as well. I am in agreement that he would have to at least start trying to resuscitate. Relatives not happy? Too bad, just treat the patient and try to calm relatives down.As a junior doctor, I have a few things to add as I think several posters on this aren't aware of some of the aspects of end-of-life decision.

    1) Just because someone calls for an ambulance or for a doctor, it does not mean they want themselves resuscitated. many cancer patients with a 'do not resuscitate' decision already made still need medical care (whether to ease their death or to help prolong life for a few weeks, etc).

    2) Cultural sensitivities are a big part in death issues, and by and large, one follows the wishes of the patient first and then the will of the relatives. The grey area in this case is that Reynolds did not know if the patient had expressed any wishes, the relatives aren't clear about the laws about this (as most people aren't) and the fact that there wasn't anyone able to make that decision not to resuscitate.

    As a doctor, I rarely encounter this problem as I just make the decision to either not resuscitate or to stop an ongoing one. So I got a question for for Reynold: Who else other than doctors are allowed to make 'we shall stop this resuscitation because it is pointless' decision? I had the impression anyone who is leading the resuscitation is allowed to make that decision (even if they aren't medically or even paramedically trained).

    So… in this particular case, I am curious why Reynolds felt that 30 minutes was a realistic timeframe. 30 minutes is far too long. I have never seen anyone make it out from >20 minutes (if not hypothermic), and most of those 10-20 minutes don't make it past the next few days. And all these figures are of young to junior-geriatrics (<75 years). I have never successfully revived a 90 year old (or seen revived). In view of this, I would have only gone for 2-3 cycles of advanced life support (ALS), ie. 6-9 minutes even in my most optimistic mood. That is certainly a more tolerable duration for the relatives than 30 minutes! It would certainly make any complaints less likely and reassure all parties that it was not just a transient easily reversible episode.

    Perhaps your ambulance trust has a policy on how long to conduct a resuscitation attempt for in a cardiac arrest of unknown duration. Perhaps that is the guideline to use when negotiating with the relatives?

    If I was in your shoes as an EMT, I would have told the relatives, “I have no choice but to proceed as I have never met the patient before this and I don't know if this is something which could be easily reversed. However as her prospect of recovery is slim and you are not happy with resuscitating her, I would only proceed for a realistic period”. If pushed on what this period is, I would say “it depends on her response but if there is no response, 10-15 minutes.” If asked about if she would be transfered to hospital, I would say “if there is any response, she would be”.

    And to top it off, I would apologise: “I am sorry but I have no choice”. If they remained obstructionist, I would add “I would rather not have to go against your wishes and your culture, but as I was called here, I am required by the ambulance trust to attempt to revive her.”

    PS. I am chinese as well.

    PPS. I think that if I was >80, I would only want for the leads to be placed on my chest to ascertain if I was shockable or not. If I was, I would only want 3 shocks.

    PPPS. I sympathise with the relatives as if I didn't know anything about healthcare, most people have the idea that the relatives would have the final call after the patient.

  5. i'm not going to enter the debate on the whys and wherefores of resusbut you can never trust “relatives”

    as a studnet nurse, many years ago, when relatives could decide that their father/mother shouldn't be told they had cancer and were dying…. we had a “family” in to discuss a DNR ( Do Not Resusitate) order being placed on their relative, as it was, this was probably the best thing, judging by their past and present medical history etc, this “family” were quite positive this was the right thing to do,

    a few days later more “family” turned up, family we didn't know about – it turns out the quicker he died the quicker the 1st set of “family” could get their hands on the estate…… all hell broke out.

    but i learn't never to trust relatives, especially when it came to death and decisions made about DNR orders

  6. Yeah this is all great and everything but is it possible to eat a cadbury's cream egg without looking like a pervert?

  7. Hi Grushnik,You make some good points there, and although I didn't pad out my post with too many details it seems that we think pretty much alike.

    We checked to see if there was any advance directives about not resuscitating the patient, and there wasn't any – we got the best history of the patient from the District nursing notes that we found at the home. When I worked in hospitals I was often involved in a DNR order, the NHS likes teamwork because it means not one person can get the blame.

    You are right about cultural issues, and that in a pre-hospital setting, you often don't have the time to 'deviant from the norm' of resuscitation. I think that we did the right thing to resuscitate, but to terminate the attempt at home. That way I think that they could see how we were taking their wishes into account.

    As for terminating a resuscitation – I spoke a little about it here, in that a paramedic can terminate a resuscitation attempt after five cycles of CPR + Medication.

    The reason why it didn't take 20 minutes, but instead took 30 minutes is partly due to being unable to get IV access, and the first two ET (breathing tubes) that we put down had a punctured cuff (meaning that they were next to useless) I know that in a hospital setting you check the cuff – but it's something that sometimes goes undone when out on the road, dealing with an arrest, surrounded by angry relatives.

    Personally I agree that it was too long to continue a resuscitation in those circumstances – If it were up to me I would have done 2-3 cycles and then stopped, but unfortunately we have to follow the protocol. The LAS and government give us leeway in a lot of things, but unfortunately this isn't one of those cases. I also may have rounded up the time a little – timekeeping tends to go out the window when someone dies in front of you, and everyone in the room is busy doing other things. A lot of our times are 'guesstimated' sometime after the job.

    (Fear of being sued, methinks)

    As for what you would say…are you sure you weren't one of the people in the room? As that is pretty much exactly what we said and did (with the exception of 'following protocol' instead of 'realistic period'). I think that it worked, as it seemed to calm the room down a lot.

    Agreed that most relatives think that they can 'call the shots', and we do sometimes find ourselves bargaining – something that had my ethics described as a 'Serbian war criminal' when I suggested this during a nursing course…

    And when I find I can't walk upright, am in pain or otherwise am generally fed up of life – I'll have DNR tattooed on my chest

  8. Its all fine and good to say what you would do in a similar situation and that you have the luxury to make decisions based on your optimistic mood, but as EMTs and Paramedics, we function under protocols set by the systems we work in. Other than our frequent flyers, we usually dont have prior contact with patients to know what their personal or cultural wishes are. Especially regarding end-of-life decisions. I think the superior EMS systems are the ones that allow EMS to stop resuscitation after a set period of time (30 minutes being reasonable) thereby sparing family members some of the trauma associated with treatment and transport out of the home. I dont think it serves any purpose to extricate an obviously unsavable patient, sometimes overweight and off of a second or third floor. The patients are half dressed, while CPR is being performed and they end up being displayed to all of their neighbors. They get driven expeditiously through traffic, putting the public at risk and all of this just so the ER Doctor can pronounce the patient dead thirty seconds after you arrive at the hospital.Your point regarding a patient not wanting to be resuscitated, even though they called for an ambulance, is true. A lot of misconceptions surround, Do Not Resuscitate (DNR) orders . Nurses in nursing homes often think that a DNR means Do Not Treat the patient. There is no reason to have simple treatments withheld because a DNR exists. It may be a simple condition such as hypoglycemia that is causing the distress. Give them some Dextrose and they are good to go. But if that same patient goes into cardiac arrest, EMS is not allowed to decide whether or not they are going to resuscitate or not. Thats where a DNR order comes in.

    Family and patient confusion comes from Doctors writing orders for a DNR and never educating them on what to expect when they call for an ambulance. In the system I work for in the US, we are required to resuscitate if the DNR order isnt present. This sometimes causes tension between family members and EMS. At certain times I would like to honor the familys wishes of not doing anything, but like Reynolds, we are bound to perform our duty. Its not a pleasant position to be in. If a resuscitation is to have any chance for success, it must be initiated immediately. If the first ten minutes after arriving at the patient are spent trying to decipher if a DNR exists, we are clearly decreasing any chance of survival.

  9. When I was in training I was told that I should look for a DNR order, and then phone the GP to make sure it is legal……to be fair I think the protocol has changed since then, but I can just imagine sitting on the phone trying to get past a receptionist to talk to the doctor while rigor mortis is setting in…

  10. Anonymous – Class comment.You must work for “da Firm” with a cynicism as finely honed as my own.

    Interesting blog-entry and enlightening replys.

    I'll endeavour to research the “egg” question first hand.

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