A dying man, a doctor who wanted him treated and a paramedic who didn’t

“He’s not even going to make it to hospital,” Brian said. “He’s going to die in the back of the truck.”

An ambulance is driven through snow and sleet as it travels along the A34 road near Chievely, in Berkshire, west of London, on February 1, 2019. - Snowfall and icy conditions were expected Friday to cause travel disruption after temperatures overnight reached as low as minus 15.4C. An amber snow warning has been issued for an area west of London including parts of Oxfordshire, Hampshire and Buckinghamshire, after as much as 14cm of snow fell on south-west England. (Photo by Adrian DENNIS / AFP) (Photo credit should read ADRIAN DENNIS/AFP/Getty Images)

It was the second call that evening from Brian, a paramedic. Before ringing him back, I checked the previous notes. He’d spoken to another doctor in the out-of-hours service just 15 minutes earlier – a Dr Fussell, not someone I knew – having been blue-lighted by NHS 111 to an 86-year-old man in a dementia care home. Ned Harris was evidently dying from a fulminant bronchopneumonia: in the space of a few hours he’d become semi-comatose, with reduced oxygen saturation, rapid pulse and breathing rate, high fever and markedly low blood pressure.

His son and daughter had been summoned by the care-home staff, and they’d met Brian there. Rapid conversations had ensued. Brian had explained the prognosis, and family and staff had agreed that it wasn’t in Ned’s best interests to spend his final hours on a trolley in a chaotic, strip-lit A&E corridor. His quality of life was poor, with dementia, arthritis and frailty; it was best to accept that this was the natural end, and to allow him to die in calm, familiar surroundings with his children at his side.

In such circumstances, a paramedic needs the agreement of a doctor not to admit the patient to hospital – hence Brian’s call to Dr Fussell. As well as taking details of Ned’s condition, Dr Fussell had also established that neither son nor daughter had power of attorney, a legal category enabling someone to take health-care decisions on behalf of a patient without mental capacity. Ned’s care-home file contained a treatment escalation plan (TEP) stating that in the event of serious infection he wanted admission and intravenous antibiotic therapy. Having ascertained this, Dr Fussell had been explicit: no one present had the right to override Ned’s TEP. Brian must convey him to hospital forthwith.

I rang Brian’s number. He explained neither the family nor care-home staff were happy with Dr Fussell’s decision. He gave me the latest observations; Ned’s condition had further deteriorated. “He’s not even going to make it to hospital,” Brian said. “He’s going to die in the back of the truck.”

I’d never spoken to Brian before, but I quickly formed the impression of a seasoned and sensible practitioner. And there was an edge to his voice; what he was being told to do was the worst thing you could do to a dying man, and I could detect the suppressed outrage of a professional feeling forced into something they knew to be wrong.

I got Brian to run me through the history again, as much to buy me thinking time as anything. In a strictly legal sense, Dr Fussell might be justified in his decision: Ned’s condition was grave, and his TEP specified what should be done. And I am all too familiar with the kind of pressure Dr Fussell would have been under. Triage calls are unrelenting: new urgent cases being added faster than they can be dealt with; patients with less pressing problems frequently waiting hours on end for a callback. It would have seemed clear-cut and quick to him: just do what the TEP says.

Yet at the top of the TEP form is an explicit statement that they do not override clinical judgement. It is impossible for any of us to anticipate our future circumstances so exactly; a TEP is only a guide to our wishes. And every instinct told me that Brian was making the correct call, as were Ned’s family and the carers who knew him well. A lot of out-of-hours work is undertaken by young, relatively inexperienced doctors, who may not have been around long enough to have developed surefootedness in the complex dilemmas medical practice sometimes involves.

“Leave him there, Brian,” I said. “I’ll send someone round to visit.”

Once again, Brian’s tone told me all I needed to know: relief underscored his words of thanks. The visit was superfluous – Ned passed away peacefully long before the mobile GP arrived. Its importance lay in supporting Brian in the tough but patient-centred decision he’d had to make.