The Right Choice

There is a road on our patch that I'd never been to before, there are only thirty or so houses in it. However, in the past two weeks I've been there on four occasions.
Last night I was there because someone had slipped and fallen on the floor. Last week I was there for an ill child, but it was the first two times I went there that will stick in my mind. They were both on the same day.

It was the first call of the evening, a 'difficulty in breathing' for an elderly woman. We entered the house to be surrounded by a large number of relatives, this isn't unusual it was an Indian family and they tend to be large. The patient herself was a very frail and bedbound elderly woman, she had had many strokes in the past and was dependant on her family for her care.. It didn't need the FRU paramedic to tell us that she was extremely unwell. The patient was unresponsive and had laboured breathing. She had a sheen of sweat on her, a sign that her body was struggling and she was completely unresponsive.

It soon became obvious that the patient had pneumonia and wasn't shifting enough air to keep alive. We loaded her and one of her relatives onto our ambulance and 'blued' her into hospital. The relative seemed resigned to our patient dying, we couldn't disagree with them.

By the time we took our next patient into the same hospital, all the relatives had arrived. They had spoken with the doctors and it was decided that it was in the best interests of the patient to not pursue any active treatment, and instead to let her die. The relatives had asked if they could take her home, and the hospital was in the process of arranging transport for her.

It must have been a hard decision to make – having seen many, many futile attempts to save someone's life, it always seems to involve pain and suffering as needles are pushed through skin, drugs with nasty side effects are given and breathing tubes are inserted. It was brave of the patient's relatives to make that choice that this moment was the end of their loved one's life and that it should be as undistressing for the patient as possible.

It was less than an hour later that we were called back to the same address, the job was given as 'patient deceased'.

What had happened was that the hospital transport had taken the patient home and, before they left, the patient died. They then advised the relatives to call for an ambulance.

So we arrived and everyone decided that it was for the best not to resuscitate her. We offered our sympathies and arranged for a GP to come out to certify the death.

The family were lovely, they offered us tea and thanked both us and the hospital for what we had done. We hadn't saved her life, but we had allowed her to die with some dignity at home, rather than being treated futilely on a hospital trolley.

When I went back to the same address a couple of days later (for the sick child), I saw the funeral notice on their front door. Last night when I went back to the same street for the woman who'd fallen over, one of the family came out and thanked us again.

Four times to one small street, and with a family and a 'job' that I'll remember for a very long time.

21 thoughts on “The Right Choice”

  1. This is something that my mum and I discuss sometimes… my main worries are about the legal issues surrounding “not intervening” ie not calling an ambulance or attempting CPR. I mean, would a court of law take my word for it that the deceased “told me” (prior to their death) not to call an ambulance in certain situations? Or would I, in failing to call an ambulance, be guilty of manslaughter?

  2. Dear Goodgrief,Mine has the signatures of two independent witnesses; and the wording is simple and tried. But, you're right – you can only do your best, no system is perfect.

    Re the ambulance crew thing:- been there, and, unfortunately, bought the T-shirt. The sudden death of a loved one precipitates confusion; neighbours or friends are contacted in the bereaved's panic, and 999 is dialled (and an ambulance activated) as a simple, normal reaction to an emergency. As the inevitable tea is being made, the bereaved suddenly recalls that the deceased had insisted that no attempt be made to resuscitate him, and we bounce into a hell's kitchen of weeping people begging us to do nothing.

    There are situations in which “sense”, “discretion”, “humanity”, and “experience” are better bywords than “procedures” and “protocol” – despite which, I can honestly say that I have never actually broken any of the rules. As to my own case, well, I live alone, and can always pin my Living Will to the living room door – but I'll still have to take my chances.

  3. Actually, what we are “officially” supposed to do, is to fill out a form with the firm's crest on, hand it to the bereaved, and whizz off back to the front line (ambulances are for the living not the dead).Not only is the form utterly soul-less, it is tactless, thoughtless, and badly written. I'll admit it stops short of “(Delete as appropriate) Dear Sir/Madam, Please accept our condolences on the death of your huband/wife/father/mother/son/daughter,” but not much.

    We seem to have lost all of ours.

  4. i work in NICU, and i have to say i get the most satisfaction out of making sure a withdrawl of care is done how the family want – you never get a second chance to do anything you say or do, and that family will remember every one of your words and actions for the rest of their lives.I'm sure it will be the same with this family when they remember their relative. its the 1 situation/job like this that makes up for the 100's of – abusive, ungrateful people you meet

  5. They sound like a wonderful caring family.You can plan a birth with the to have as few medical interventions as possible, so that you can be aware of and make informed choices. Its a shame the same sort of ethos seems to be missing at the end of life in this country. Maybe this is because our culture seems to be keen to treat death as a taboo subject.

    Perhaps what is needed is a sort of National Dying Trust (as opposed to the National Child birth Trust!)

    Maybe we should all give it a bit of thought before we are up against a deadline (no pun intended!) For readers of a non medical persuasion try having a read of Esther Rantzens book How to Have a Good Death. Its not a morbid thing to do its empowering.

  6. i have seen in a friends family one of it members slowly die. the desision making on what to do in the best intrests of a old and dieing member was long and painfull and sad.The out come was for active pain management and let nature take its course. in the end he died in his favour arm chair, with his family around him. he smiled and his last works where” i love you all, have a good life”.

    I was there, when into the back room to let them to say good bye in peace. and i have the feeling that i would want to do CPR on him.

    My friend asked me to come in, most of the family had gone. he asked me to check he was dead. then to help him to sleep more peacefully.

    Gently we moved him into his wheelchair and took him to his bed, laided him down and said goodnight. we both thought that we could see the smile on his face.

    it was sad, but satifing to know we did what he wished.

  7. A couple of things that spring to mind after your post Tom:It's not often you are given heartfelt thanks by a family, often makes the job worth doing.

    I find it often find me struggling with my feelings over dragging patients who are obviously deceased from their homes, denying them the dignified death that they often want. I know the procedures e.g. ROLE are there to protect both staff and patients, but I often ask myself it is acting in the patients best interest. This is re-enforced by the fact that a lot of patients receive one loop of ALS before calling it.

    There needs to be some kind of guidance for people so they know their rights, and take into mind their quality of life, so they or their family can make an informed decision. A few months ago wen went to a nursing home (doubtful use of the word nursing here), a patient with advanced dementia who was also blind was found unconscious. By the time we got there she had arrested and was in a PEA, she had recieved no CPR. We took this poor patient into hospital because we had no choice (CPR was ceased on arrival at hospital), but denied her the dignity of dying in peace in bed…and why? Because someone had not been brave enough or sensible enough to discuss with the relatives prior to the event what would be best for the patient.

    It is a very hard issue to discuss and there are many pros and cons to each and every argument, but the fact is i think on this issue unless there is a terminal illness we all tend to act reactively rather than proactively that could help maintian the dignity of those most vunerable.

  8. My Father lived in Australia towards the end of his life, and on realising that he had the last stages of lung cancer, he was directed to a book (obtainable from the Post Ofice) that explained the legal/medico requirements that needed to be fulfilled, along with advice and some minor medical details. In the final section (Set out in a fill-in-the-blanks & multiple choice format) you could enter EXACTLY what levels of care and medical intervention you did and didnt want. It made him a bit more content (and us as well it must be said). We thought this was such a good idea I brought back a copy back to the UK for myself.

  9. I'll never forget the GP who came out the night my Dad died. He was in the final stages of terminal cancer (so widespread they weren't sure of the primary, but probably lung). He wasn't really concious, but was obviously in pain, so we called the on call GP out.He took me, my mum and brothers into the kitchen (the dining room had been turned into a bedroom for Dad) ad said he could ease his pain a little, or he could give him a large injection of morphine, that would ease his pain greatly, but would also hasten death. We all went for the morphine with little thought.

    The next two hours, while he gently slipped away were peaceful, and he died with true dignity. I will be thankful for that for ever.

  10. Both my parents have made “living wills” which state their wish not not be resuccitated if the circumstances do not warrant it; no “heroic” measures to be taken to preserve life unnecessarily. As their eldest son and of the executors I hope this will be of help for me and the medical / emergency staff in attendance should it come to pass that I have to make the same difficult decision this family did. Loving someone and yet allowing them to die – with dignity – is a tough one; I hope I am up to the challenge.AFAIK Dad drafted them himself – I will check and let you know if it is otherwise.

  11. Do you have the equivalent of a DNR (Do Not Resuscitate) order in the UK ? Here in the US it's a pretty unequivocal legal document that defines what measures a patient wants taken in the event of a life threatening event. They can be fairly specific (i.e. CPR but not defib, AED but not intubation etc. etc.). These help a lot in this kind of situation and help protect everyone (including the patient) from misunderstanding. Dying with dignity is very hard…..

  12. Yes we do mate…but it's poorly explained to patients and relatives as are living wills. People get very mixed up about who is able to sign what and what is valid.The only time i have seen a written DNAR was a hospital to hospice transfer. The DNAR was thankfully handed to us by a doctor with a full explanation, which had already been explained to the relatives.

    There is also a query with my Trust of what means Do Not Attempt Resus. Do you intervene to prevent the patient going into cardiac arrest? Or do you just let them deteriorate. It's the same with living wills, if there is any doubt to their validity we have to start resus… the whole thing is one very big mess with many grey areas…a living minefield if nothing else.

  13. Try googling with dnr, tattoo and nurse. I don't know about its legality here in the UK but I'm coming up to 44, give it 30 years or so and I'll probably do the same myself, at that age if my heart stops it's probably time to go. I've been wiping my own arse, feeding and dressing myself for most of my life, I don't want to go out dribbling in a corner.Yup, getting senile scares the shit out of me.

  14. Dear Batsgirl,In Britain, you commit no offence simply by allowing a person to die. Even where there is a clear duty of care (eg, ambulance crews) it is a disciplinary matter rather than a matter of the law. This is a fact which – from time to time – puzzles one of my colleagues who is from Berlin. In Germany, if you “pass by on the other side”, you may be charged with an offence and have to justify your actions – eg, the victim was drowning, but you couldn't swim. Rest assured that if your mum has expressed a wish to die peacefully with you holding her hand, then you are doing nothing wrong by granting her wish.

    Some years back, I was on a night shift, and we were passed an emergency call which had originated with NHS24; when we arrived at the house, the man who opened the door was quite surprised to see us. His wife was terminally ill with cancer and was nearing the end; she had been made as comfortable as possible and the GP had said to call at any time. The lady had become briefly restive, and her husband had rung the doctor, but, because of the time of day, the call had gone to NHS24, and they had sent us; in the meantime, though, the patient had settled down again.

    We said that – in that case – we would just quietly leave; however, he asked us to come in and see the patient; he did not want her to suffer in any way, and wanted to know whether we thought she might need further pain relief.

    The lady was deeply sedated, and obviously well cared for; we took a brief ECG, BP, etc, and it was clear from the readings that death was not far away; we took the equipment back to the vehicle and filled in a patient report form. In view of the unusual circumstances, we thought it a good idea to ask the lady's husband to countersign the form, which he happily did. Whilst he was doing so, my colleague took another look at the patient, and did some serious eyebrow waggling and silent talking to catch my attention; I confirmed what my colleague had noted, and told the husband that his wife had died. “Oh dear,” he said, “I'll need to phone my sons”, and his eyes filled with tears. We told him that we would stay as long as necessary, called the EMDC to tell them what had happened, and asked for an Out of Hours doctor to attend to certify death; we also put the kettle on. (This is Britain – you always put the kettle on).

    His family started to arrive within a few minutes, and we quietly left.

    Sometimes we help just by being there; and, no, you do not commit any offence if you simply let someone die. As for the ambulance service's duty of care – nobody argued that we had not discharged it properly; the lady's family were our patients too.

  15. Oh dear; I'm 58 and creaking. I made out a Living Will so long ago that one of the witnesses has since died. I have one copy with all of my other documents, and one copy is on my file with my GP. Living Wills – made and witnessed when you are healthy and compos mentis – make it clear to your family and health professionals your wishes regarding the REFUSAL of intervention and procedures; such refusal is binding on doctors. You can also use them to REQUEST particular courses of action which – though in no way binding on the medical team – can be a useful guide as to the direction you would prefer them to take.You can buy Living Will kits cheaply enough on the internet.

    PS, re becoming senile – a thought for the day. “If, when you're mad, you don't know that you're mad, how do you know that you're not?”

  16. Thanks – beautifully written and exactly the point of my posts, sometimes we simply have to be there, just to witness.

  17. Living wills as far as I know have to be witnessed by an independent person e.g. solicitor. Have had issues with living wills that have been signed by family members before.As for it being with the GP, the ambulance crew who come and collect you from home won't have access to it, so they will be duty bound to treat you!

  18. Well said Tom, unfortunately some in our control seem to think patient care stops with the patient, not with the wife who has just seen her life long partner pass away…the dreaded ORCON speaks again!

  19. Thank you very much for such a clear and reassuring response. That helps a lot.It's also good to know that ambulance crews observe the protocol of the Healing Kettle. 😉

  20. Actually, “pin it to the living room door” reminds me. Someone I know with a number of conditions and a metric f**kload of medications has this emergency kit in the fridge.There's a green and white sticker on the outside of the front door frame and a matching one on the door of the fridge, and then inside the fridge is a pot containing a form that gives details of his conditions/medications, and a single dose of any meds which might be needed in an emergency (eg one of the things that is up is diabetes, and there's a thingy of insulin in there).

    Apparently (this has yet to be tested) any medical responder (St Johns, doctor, paramedic, EMT, etc) will see the sticker and know that they should check the fridge. Why the fridge? Because it's easy to find, it keeps meds cool, and it's the thing in a house most likely to survive a fire.

    IF it is genuine and works, and wasn't just some obscure thing made up to give people like him some peace of mind, that might be a handy place for a DNAR order or a Living Will.

    /waffles on

  21. I've seen them; also, some years ago, the local papers included a leaflet explaining what these things were, and telling you how to get one. The “thing” was (is) quite simple – a couple of stickers, and a plastic sample bottle with a green and white label. The scheme was (is) called “Message in a Bottle”, and the idea is that you put just information in the tube – medical details, DNR wishes, contact numbers etc. Your explanation (above) about the fridge is pretty much what the leaflets said; additionally “ICE” (In Case of Emergency) goes handily with “fridge”.As to whether it works – ah. In the kind of cases under discussion here, we are generally called by someone other than the patient. This implies that that there is some kind of care network about them – paid carers ,neighbours, relatives, community nurses, carecall systems etc; even cantankerous, misanthropic, elderly alcoholics tend to have someone who notices their absence from the local scene (often thankfully!), and raises the alarm. Here, in rural, small town Scotland, folk still take an interest in their neighbours (for one reason or another – real life can be so much more entertaining than Corrie!), so we seldom go short of information. The old besom (handy Scots word – it actually means a broomstick – figure it out ) next door ,who is always poking her nose in where it doesn't belong, is also the guardian angel who calls us and the police when she spots that you're not around.

    I don't work in the big city, so I don't know how effective these things would be there. You certainly wouldn't do any harm by putting info in an easily-recognised container in the fridge, and devising a way of drawing attention to it. Also, re the I.C.E. thing above: Another wheeze is that you should enter “ICE” into your mobile phone, followed by a terribly handy number for helpers to ring; OK if you haven't locked your phone with a PIN! Far better would just be to write all of the relevant stuff on a small piece of card, have it laminated, and keep it in your purse, handbag, or wallet.

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