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.