Every doctor will recognise the story — it’s played out up and down the country, day and night. The pager goes off, the resuscitation team run to the ward, the doctors and nurses work frantically to bring a patient back to life.
What you do not hear so often is the agonising process of we doctors attempting resuscitation on people when we know we shouldn’t because it’s futile, and all that will be achieved is to rob them of a peaceful death. I remember vividly as a junior doctor belting down a hospital corridor on my way to a cardiac arrest call. On the ward, I was met by a nurse who explained, with a pitying look in her eyes, that it was for a terminally ill, frail, elderly patient.
The nurse had called me only because she was obliged to do so, as the patient’s doctors had failed to complete a Do Not Resuscitate (DNR) form. So I had to attempt cardio-pulmonary resuscitation, wincing as I cracked the elderly lady’s ribs with each compression on her chest, knowing that I was subjecting this dying person to a futile, painful and distressing last few minutes.
I remember the shared look of horror as a colleague jabbed large needles into her arms in a pointless exercise to take blood. That horror stayed with me long after my shift ended.
Resuscitation can be brutal, harrowing — and often unsuccessful. It comes as no surprise to me that a study by Stanford University a few years ago showed that nearly 90 per cent of doctors would choose ‘do not resuscitate’ for themselves if they were terminally ill.
My own experience in this field (I have worked in geriatrics and with dementia patients) has led me reluctantly to the conclusion that ‘do not resuscitate’ orders are a vital tool for doctors and nurses. They ensure that we do not subject patients — when they do not wish it — to unnecessary intervention in the last moments of their lives.
Yet my qualified support for DNR orders does nothing to appease my profound concern about the latest guidelines from the NHS on their use, revealed in yesterday’s Mail.
The guidelines urge GPs to draw up end-of-life plans for all patients over 75, as well as younger patients suffering from cancer, dementia, heart disease or serious lung conditions. They require GPs to ask such patients whether they want doctors to resuscitate them if their health suddenly deteriorates.
Some GP practices have started this already, and nurses have been cold-calling patients to ask if they have ‘thought about resuscitation’.
One elderly patient of mine was called out of the blue last year by his GP asking him to go in to discuss resuscitation.
The patient erroneously assumed his GP was attempting to tell him something was wrong — why else would she be talking about death and terminal illness with him when he had been at yoga only hours earlier? — and both he and his wife called me asking if I knew how long he had left.
I had to reassure them the GP was undertaking nothing more than a box-ticking exercise.
We live at a time when GP/patient relations are deeply strained, with overcrowded surgeries, an A&E crisis, concerns about ‘bed-blocking’ and incessant demands for extra money for an over-stretched NHS.
Can anyone in their right mind really think that it helps to cold-call patients, many of whom are perfectly healthy, to ask them whether they want to die if they fall ill?
Won’t such behaviour not only cause unnecessary confusion and upset — as well as being a huge waste of resources — but also fuel suspicion among patients that they are considered a burden on the NHS, and one it may prefer to be rid of?
Whether these patients’ fears are right or not — and I do not believe the NHS is in the business of deliberately bumping off its charges — this is an appallingly crass and insensitive way of broaching the subject of resuscitation.
There is no doubt in my mind that doctors should discuss the option of resuscitation with patients. But timing and context are everything, which is something the NHS seems completely unaware of.
It is wholly inappropriate for this very important subject to be taken out of the context of a serious medical illness.
Yes, the conversation should take place, but only when it’s necessary and has been prompted by a clinical change or diagnosis that means resuscitation might soon have to be considered.
An arbitrary age of 75 means that many perfectly fit and healthy older people will be faced with being called in by their GP to discuss something they find frightening and alarming.
There’s no clinical reason for choosing the age of 75. It’s just a bureaucratic line in the sand that highlights how the NHS increasingly sees patients in dehumanising terms and ignores personalised care and what is relevant to them.
My concern is that a form filled out in a GP surgery when a patient is fit and well is meaningless. It does not necessarily bear any relevance to the clinical situation a patient may find themselves in later on.
The whole point of a DNR form is that it should be a dynamic document that is reassessed, re-evaluated and reviewed on a regular basis as things change, and one that has been prompted by a clinical situation.
Yet a form sitting on your medical notes is the antithesis of this. People change their minds about things, and I am profoundly worried that this will not be reflected in the DNR form.
I know the pressure and limited time clinicians have, and I worry they will see a form in the medical notes that a patient completed with the GP months or years ago and will not think to check that this still stands.
Shockingly, DNR forms have been filled in by doctors without any discussion with the patient or their family. I have heard of patients sometimes finding out entirely accidentally that their doctor had decided on their behalf that they do not want to be resuscitated. This is appalling and utterly unacceptable.
Another common scenario is that the issue of resuscitation has not been considered at all, meaning people who did not wish to have resuscitation are forced to undergo the process. The problem with the new NHS guidelines is that they fail to address these issues in any meaningful way and, what’s worse, actually introduce additional problems.
The answer is not to get the GP to complete a DNR form in the community, when the patient is well. It’s at the point when patients are admitted that the form should be completed — and then reviewed at regular intervals as things change, to ensure the patient still feels the same. For most patients, the DNR form should be completed in hospital because this is where resuscitation takes place. It should be confined to patients who are seriously ill and for whom resuscitation is something they must actively consider.
When my gran was diagnosed with terminal cancer a few years back, she and her consultant had a frank discussion about whether or not resuscitation was a good idea. The doctor explained exactly what it entailed and that it would be very unlikely to be successful. On balance, realising she was going to die soon anyway, my gran very clearly stated that she did not want to be resuscitated. It was a decision the entire family supported.
When her time came, she slipped away with my sister and me by her bedside. It was a dignified and peaceful end, just as she had wanted. But the key point is that she had made the decision at a time when she had all the facts at her disposal; she had an expert who understood her case and could make an informed decision that was relevant to her immediate care plan.
A box-ticking exercise carried out by a GP just because you happen to have reached your 75th birthday is a travesty — and it does the patient a severe disservice.
Published: 27 April 2015. By
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