Like most doctors I have witnessed the deaths of many patients as a result of a cardiopulmonary arrest. The glamorised version of resuscitation attempts portrayed on TV fails to reflect the gruesome reality – most are brutal and unsuccessful. Only about 20 per cent of patients in hospital who have a cardiopulmonary arrest survive to be discharged. Survival does not guarantee a return to full health and many are left with serious complications such as brain damage.
As a trainee I witnessed two deaths that had a profound impact on my practice and taught me the importance of communication between doctors, patients and their families. Both were undignified and predictable. The first occurred when I was a newly qualified doctor. I was urgently called to see Betty, an 87-year-old woman who was found to be unresponsive and without a pulse, lying in her hospital bed.
This was my first cardiac arrest and I was determined to get things right. I asked the nurse to call for the arrest team and to attach a defibrillator. I commenced chest compressions. The team arrived and within minutes Betty had tubes placed in her mouth and both her arms. All the while, chest compressions continued and I thought I heard a rib crack. I looked through the notes to see if there were any clues as to why she had suffered a cardiac arrest. It transpired that she lived in a residential home, had Alzheimer’s and was admitted to hospital due to difficulty with swallowing food. Investigations had revealed advanced cancer of the oesophagus. We all agreed when the registrar wearily suggested we stop resuscitation, and that a “do not attempt cardiopulmonary resuscitation” (DNACPR) decision should have been made earlier.
Later in my career as a trainee cardiologist, I was called to help George, a patient with end-stage heart failure who was admitted with a persistent and life-threatening heart rhythm abnormality. He had an internal cardiac device that had repeatedly delivered defibrillation shocks that day. He begged me to switch the defibrillator off and to let him die. I am still haunted by his look of relief as I held the magnet over his chest in order to deactivate the device. George’s son expected his death as he had been very unwell, but could not understand why doctors had not discussed the issue of turning off the defibrillator with his father before. Both cases highlighted shortcomings in communication between doctors, patients and relatives when discussing death.
In 2011, David Tracey took the Cambridge University Hospitals health care trust and the health secretary to court after his wife had a DNACPR decision made without her knowledge or consultation. The 2014 Tracey judgment means that doctors must involve patients or their legal advocates when making a DNACPR decision, except when circumstances don’t allow.
Reasons cited by doctors for not discussing DNACPR include a wish to avoid upsetting the patient or relatives, and lack of time. It is not always possible to get hold of relatives, and patients may be in denial. For these reasons, many patients have been unnecessarily subjected to CPR, while others have been inappropriately denied it. In reality, older patients usually welcome a frank conversation about which aspects of care they wish to receive. With the advent of internal cardiac devices such as defibrillators, the conversation must be nuanced and should cover a broader range of treatments. It is not uncommon, for example, for some to accept defibrillation for treatable heart rhythm disorders but to refuse intubation and ventilation to support their breathing.
When making a DNACPR decision, I’m always grateful to Betty and George for teaching me the importance of advanced planning and good communication. They could have died with their families around them, possibly at home, but they ended up receiving resuscitation in the clinical environment of a hospital, surrounded by strangers.
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This article appears in the 22 May 2019 issue of the New Statesman, The Brexit earthquake