Anyone who has worked for the ambulance service for even the shortest period of time will have experienced the following situation. Someone with a serious medical condition unexpectedly deteriorates and a panicked family call 999 to summon ambulance staff to resuscitate their loved one.
Recently I had one such call. An elderly lady had been given a diagnosis of cancer a few weeks earlier. Plans were being made and a package of care was being put in to place that would support her through the inevitable decline that would ultimately lead to her death. However, her condition suddenly took a down turn and the desperately worried family, not knowing where else to turn, dialled 999. Despite her diagnosis of terminal cancer there was no ‘Do not resuscitate’ (DNR) order in place and we were obliged to attempt to resuscitate her. This means compressing her chest to squeeze oxygen around the body, placing a tube into her throat to allow ventilation of the lungs and placing a cannula into a large vein in her arm to provide a route for drugs. We moved her from her home to the ambulance during this procedure and her family were in a state of flux as they prepared themselves to follow us to the hospital. It all proved futile (as we knew it would) and efforts were finally stopped shortly after arrival at hospital.
Sadly, I have been called to many patients in the last stages of cancer, emphysema or other long-term or terminal conditions who have suffered a cardiac arrest. Usually the family’s expectation is that we begin cardio-respiratory resuscitation (CPR). Shocked and distressed, they want the best for their relative; they want them brought back to life and so we commence CPR. Sadly their expectations are often misguided and unrealistic.
CPR is definitely not a panacea for all. It should be considered a targeted treatment to be reserved for those for whom there is a reasonable expectation of survival. Importantly age should not be an influencing factor when deciding who receives CPR because the elderly can do just as well as the younger population – provided that there are no co-existing serious diseases. CPR is unlikely to be successful in those patients who already have a disease such as emphysema, advanced cancer or pneumonia. Even if we do bring them back to life, they will still have the disease that caused the cardiac arrest and quite possible they will now additionally have brain damage through the lack of oxygen as a result of the episode.
Personally I blame television for much of the problem when it comes to expectations. On a weekly basis we see CPR used in hospital soaps. One after another sick patient is resurrected, still miraculously in full possession of their faculties. They then skip off into the sunset with their grateful families in tow. This inaccurate portrayal does little to give a balanced perspective to families or aid reasonable and honest discussion on the matter.
The British Medical Association, Age Concern and The Royal College of Nursing all advise discussion between the patient, families and health care practitioners as the disease progresses to the terminal stage.
I believe that it is important that we actually start to have a transparent dialogue about the appropriateness of resuscitation much earlier on in the disease process rather than waiting until the terminal stage before we even begin to talk about it. Or perhaps we should encourage it long before that. I have previously discussed the importance of letting your family know your wishes regarding organ donation in the event of an untimely death.
While many of us understandably shy away from discussing death and dying it is important to do so long before we reach a crisis point and only then can we hold out some hope that our final wishes regarding how and where we die may be taken into consideration.