On Ending

It can be very hard to stop, even when it would be in the best interests of the patient.

We were called to a new care home that has just opened in the area. Our patient was a man in his late seventies who's heart had stopped.

Our ambulance arrived at the same time as the FRU and we were met by the patient's grandson at the door to the home. We bundled into the lift carrying half the contents of our ambulance and asked the son what had happened.

He told us that our patient was bedbound following a stroke and was unable to eat – so his food was given to him through a tube into his belly. His family had been visiting when he had stopped talking, they called for a carer who had called us.

I often moan about care homes, but in this case the carer was doing excellent CPR on the patient*, there was a large number of the patient's family standing in the room watching.

The first thing that we did was to connect our defibrillator to the patient's chest to see what his heart was doing and to see if if would need a shock to 'restart' it. We looked at the screen and were met with a flatline. People tend not to come back from this type of heart rhythm.

We have a policy in the ambulance service that – if after 20 minutes or so of CPR and drug treatment there is not positive result we can terminate the resuscitation attempt and recognise that the patient has died. Looking at each other we decided that this would probably be the best course of action.

So we started to resuscitate the patient, I was pumping on his chest, my crewmate was trying to secure an airway and the FRU was getting access into a vein so that we could give the patient drugs like adrenaline and atropine.

While doing this I was talking to the family, explaining that it was incredibly unlikely that the patient was going to survive (not the patient to them, to them he was their father, their brother, their granddad). They asked why I wasn't 'shocking his heart' and I explained why it wasn't possible. I told them that they could make a choice, that we could attempt to resuscitate him here in his home – doing all the same things that a hospital would do, or that we could try to get him into hospital, but that due to the distance we were from the ambulance it would be bad for the patient and that the hospital would do exactly the same things that we were doing.

The family asked me a few questions and then they decided that we should remain here and that once we were sure that there was no chance of survival to stop resuscitation.

And then the patient got a pulse back.

Our hearts sank, there was no way that the patient was going to recover – the drugs that we had been giving him had restarted the heart, but this was just a chemical reaction. What this meant was that we would have to take the patient to hospital, and that the family might feel some hope despite there being no chance of survival.

But our protocols say that if we get a pulse we should run to hospital.

His heart stopped at least four more times and each time we got a pulse back with adrenaline and CPR. We got him to the hospital and as we wheeled him through the doors of the hospital his heart stopped again. We explained that we had been resuscitating him for an hour while we stabilised him as best we could and transferred him to the hospital.

I was almost apologising to the consultant as I explained that we had no choice in the decision to keep resuscitating the patient, or to bring him to hospital, or to provide the family with false hope.

I went to the relatives room to explain what the doctors were doing, and to let them know that it was an almost hopeless case – the family told me that they were prepared for his death, and that they were grateful for everything that we had done.

Ten minutes later the doctors at the hospital declared the patient dead.

It always makes me sad to resuscitate people when we know that it isn't going to do any good – I wonder if there is enough brain activitie to feel the pain of us pounding up and down on their chest, to know that we are pulling them about to get them onto a trolley, to be aware of the sirens as we weave through the traffic.

I wonder if it would not be better to accept that some people cannot be saved and that it is their natural end.

Some time ago we moved from written policies for treatment to 'guidelines' – the onus for a patient's care would be placed on us, we would have to decide what was in the patient's best interest, but the policy of terminating a resuscitation is still in effect.

I know that we have these policies in place to protect the patient, and to protect us from being sued, but I wonder if there will ever come a time where we might have more flexibility in deciding the end of someone's life.


On a completely unrelated note, DG hits the nail on the head once more – and writes something that I should have written ages ago.

*Yes, I am writing a letter of thanks for someone knowing how to do their job.

Update:Edited for grammar.

25 thoughts on “On Ending”

  1. We had to do CPR on one of our residents at my care home. It was really upsetting for all of us – the carers, residents (she collapsed in the corridor on the way to the toilet) and her daughter, who was visiting. As soon as the paramedics hooked her up to the defib I knew she was gone, because it flatlined, and sure enough they recognised death and the GP confirmed it. I wish we could just have accepted that she was gone and phoned the GP straight away, but our policy states we have to phone and ambulance, and the call taker in control said we had to commence CPR. The whole time I was pounding on her chest I was praying she wasn't in pain, it was just awful.Is there no way death can be recognised without the need for CPR before the ambulance comes? She was in her 90s and was effectively waiting to die.

  2. Those protocols are there for the one in a thousand patient who actually WILL recover. You doing your job well shouldn't make you feel bad….

  3. What you did was totally correct in more than one sense.If you had just looked at the patient and just declared death without much fuss, the family may have been questioning whether you could have tried more.But by trying to resuscitate for an hour – and more in the hospital – it is more likely they would feel that everyone tried their best to save him. It doesn't ease their grief, but in time they will realise the hopelessness of the situation and take solace that you all did all you could.

  4. I entirely agree with you on this post (and 99% of the others!). I work as a nurse on a Medical Admissions Unit and we regularly have to point out to the doctors the futility and potential cruelty of leaving patients for resus, and sometimes its a real battle. For example, on Sunday night a 92yr old man was admitted with haematuria, previous history was advanced dementia and prostate cancer with metastases among other things. His diagnosis was a severe UTI but it took me over 10 minutes to convince the SpR that he shouldn't be for resus, his comment being 'Why, do you think he's going to arrest overnight, he's not that ill'. My argument was that someone with terminal cancer and dementia, and being the age he was, I didn't feel it wasn't in his best interests and would in the event be cruel. I also had to point out that people can die in their sleep wherever they are, the fact he is in hospital might make no difference! Eventually he agreed with me but it struck me that Drs need to be more willing to say 'yay or nay' regarding resus, but it seems a lot of them are scared to make the decision without someone there to hold their hand, which I find worrying since they are either SpR's or consultants! I'm glad that in your case they had the sense to stop, although as you say, it was sort of a shame you had to try in the first place.On a different note, I love your blog, keep up the hard work and when is the new book out??

  5. When I read about the Tories wanting to cut regulations on care homes I always think about your blog.(Although you make it hard for comments as someone who reads this on LJ – I hate having to register and generally don't)

  6. > “…that it was incredibly unlikely that the patient was unlikely to survive…”I hope you didn't phrase it that way to the family!

  7. After watching an ambulance crew trying to resucitate my Dad after he had a massive heart attack I can fully sympathise with your view. My Sister and I both realized that to all intents our Dad had died and we wanted the resucitation to stop, however, our Step-Mum was hysterical and begged them to keep trying which they did for about anouther 20 minutes – so I guess you just have to “play it by ear” in each individual case so that the people left behind feel that you have done everything possible for their loved one.

  8. Hi Reynolds, have you seen this. Sure to make your blood boil ;)http://www.thesun.co.uk/mysun/comment/view.page?storyId=2007400974&submissionId=136649

  9. Getting Do Not Resuscitate tattooed across my sternum, all advance directives updated regularly, whoever is still around when I get up there will know to tell them to stop, don't touch me, let me go. Yup. Done enough on this side of it not to want to be on that side. Glad I got pummeled when I just choked and lost consciousness, at 45. But when I'm 70+ and my heart flails, enough is enough. Regulations to avoid lawsuit may ease some uninformed observers, but cause a great deal of pain, and burdensome expense.

  10. I know ambulance people who would rather get a heart attack out in the wild somewhere, far from anyone else, so that they wouldn't be resuscitated if something happen.I'm glad someone has the sence to stop when the treatment does more harm than good. I very much agree with you.

    (On a sidenote: Did you have a chance to read the Norwegian ambulance case news story? I'm sure you would find it very interesting)

  11. Okay – having had serious concussion (in bed, ears bleeding, knowing nothing) can I suggest that a person in those liminal states doesn't share our everyday sharp personal awareness of what's going on?Let's look at the two views on this:

    If you believe in the soul (as, I confess, I do) it is not there for that pummelling – it has already migrated. If it can come back it will, if not, it will be fine elsewhere. Oversimplified (google psychopomp) but basically true.

    If you don't, the consciousness is already degraded, diminished, and your pounding won't do it any more harm than a hard delivery via vaginal/caesarian birth did when it entered.

    Either way, you are working hard to try to get that person able to change their favourite type of frickin' biscuit, or not, should they choose.

    And the relatives will feel better long term than if they'd seen a “DNR” slapped on that person they loved, who watched telly with them, who enjoyed hearing one station on the radio.

    The dead either move on, or don't exist – the living matter in that they can be scarred by thinking they should have done more. Guilt is common in bereavement and anything you can do about that, 2 – 3 years on, sets them free.

    JMO.

  12. Oh… Good… Grief…The comments are…painful.

    'Churchill would spin in his grave' – well considering that Bevan (who set up the NHS) and Churchill were rivals, I somehow doubt it…

    *This* is what ambulances are for, for people who can't be bothered to wait to be seen – damn this 'on demand' culture.

  13. (On a sidenote: Did you have a chance to read the Norwegian ambulance case news story? I'm sure you would find it very interesting)No, which story is that?

    (Or more likely, 'yes', but I've forgotten it…)

  14. Nope – because I hadn't just woken up and was trying to make sense pre-'Red Bull'.But I shall edit the post so that none shall know of my idiocy (unless, you know, they read the comments or something…).

  15. Well Tom, you know the old saying: “If you put enough epi in, they'll get up and dance” It's a fact that a lot of cardiac arrests are continued in futility because of epinephrine and it's effect. Maybe we should ban epi? Just kidding!I'm sure you did your best under the circumstances. I know how difficult this situation can be. I once had a colleague tell a woman that her husband was already dead when suddenly the Lifepak 12 went….bleep, bleep,bleep. I'm sure you know the rest of the story……….

    Oh, and I bought your book in a fit madness yesterday. Talk about a busman's holiday…

    Take care and keep up the good work,

    WM

  16. Nice thought Tom, to thank the member of staff; doing 'bystander' CPR, is so far out of peoples 'comfort zone' it's bound to leave them a bit shaken, I say 'bystander' because from what you tell us about most care homes, being a care worker doesn't always mean you staff are ready willing or able to to do it.I suppose this is a situation where there is no easy, clear cut answer, and with the clock ticking, no time for debate or deliberation.

    All rather sad really

  17. What always defeats me is when the nursing homes (note nursing not care homes) call us to patients who are dying. I don't miind when they've had some kind of incident unrelated to their admission to the nursing home, but when they call us because they're passing away as a part of the natural progression of their chronic condition it utterly defeats me.We arrive. There's no current DNR order so we assault them with all our medical skills can throw at them and remove any last vestiges of hope they had of a dignified death.

    Now I may be incredibly stupid, but don't people go into a nursing home so they CAN die in a dignified manner?

  18. What always defeats me is when the nursing homes (note nursing not care homes) call us to patients who are dying. I don't miind when they've had some kind of incident unrelated to their admission to the nursing home, but when they call us because they're passing away as a part of the natural progression of their chronic condition it utterly defeats me.We arrive. There's no current DNR order so we assault them with all our medical skills can throw at them and remove any last vestiges of hope they had of a dignified death.

    Now I may be incredibly stupid, but don't people go into a nursing home so they CAN die in a dignified manner?

  19. What always defeats me is when the nursing homes (note nursing not care homes) call us to patients who are dying. I don't miind when they've had some kind of incident unrelated to their admission to the nursing home, but when they call us because they're passing away as a part of the natural progression of their chronic condition it utterly defeats me.We arrive. There's no current DNR order so we assault them with all our medical skills can throw at them and remove any last vestiges of hope they had of a dignified death.

    Now I may be incredibly stupid, but don't people go into a nursing home so they CAN die in a dignified manner?

  20. What always defeats me is when the nursing homes (note nursing not care homes) call us to patients who are dying. I don't miind when they've had some kind of incident unrelated to their admission to the nursing home which requires our assistance, but when they call us because they're passing away as a part of the natural progression of their chronic condition it utterly defeats me.We arrive. There's no current DNR order so we are compelled, against all our instincts to assault them with all our medical skills can throw at them and remove any last vestiges of hope they had of a dignified death.

    Now I may be incredibly stupid, but don't people go into a nursing home so they CAN die in a dignified manner?

  21. You've been there before. Either, he's an immortal soul about to get birthed into a new body (the 3-month mark I'm told) or he's so zoned out, he's feeling no pain. Has had a good life, this is just the grotty postscript.The very idea of a “dignified death” implies:

    A: the person treating the flesh:

    knows it can't come back, therefore tries to sign it off with dignity, while at the same time trying everything possible to bring them back – and in medicine, some of these things won't be pretty:

    B: the soul, if you allow for that, doesn't care about a tube up the nose and an electroshock heart thing;

    That soul goes on and views the flesh as a vehicle:

    C: either of these matter – if the person is dying, and nothing remains, you did your best and they cannot stand back afterwards and criticise: I happen to think something remains, and if it does, how does anything you do harm them?

    Hope you don't mind me posting all this waffle.

  22. hello friend thank for sharing this information and this excellent story about this patient was a man in his late seventies who's heart had stopped My father is too old but he take Generic Cialis but he died the last year for problems in his heart

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