Yet, even with more selection, a lot of resuscitation goes on in hospitals. Doctors know that in most cases it will be futile, so why do they carry on doing it? The answer is two-fold. Firstly, and most importantly, for the sake of the fifteen per cent who do survive. The second reason is more complex. The burdens placed upon doctors and nurses by public expectations are crushing. Doctors feel blamed for every death and, driven by a combination of guilt and doubt and fear, they strive all the time to save a life. They know that if they don’t make the maximum effort, and someone dies, they could be in serious trouble, which could destroy a career. The fear of litigation is ever-present.
Yet the public, and particularly the media, are so fickle that, having saved a life, doctors are then often accused of needlessly prolonging life and causing suffering. Whatever they do they will be in the wrong. Sometimes I wonder why anyone ever becomes a doctor or a nurse at all!
The heyday of resuscitation in hospitals was around 1970-95. Since then, much more restraint and discrimination has been observed. Doctors are now more ready to write a Do Not Attempt Resuscitation (DNAR) order if it is foreseen that a patient has a diagnosed condition with progressive advanced illness from which they will not recover, and for which resuscitation would be futile. Details of the General Medical Council (GMC) directive to doctors issued May 2010 can be found in Appendix I.
To discuss the prognosis with the patient is ideal, but it is often difficult, or plain impossible. Some patients are not approachable on the subject of their own death; some doctors cannot bring themselves to mention the dreaded word, and, in that case, an experienced nurse may be better. Some patients, surprisingly, have never even thought about it and say, ‘I don’t know - I leave it to you, Doctor.’ Others say, ‘I want to go when my time comes.’ Everyone is different, every doctor and nurse is different, and every clinical situation is different. What is necessary, in all ‘Would you want to be resuscitated?’ situations, is time. Such a discussion, if handled sensitively, could take all afternoon - and who, in the busy setting of a modern hospital, has that amount of time at their disposal? Probably no one. So an informed discussion is often hurried, even rushed, or pushed aside for a day that never comes.
Everybody must think about these things and discuss them with family, friends or carers long before a nervous young doctor tentatively raises the issue, or a lady with a clipboard comes round and says, ‘I’m filling in a patient’s questionnaire – do you want to be resuscitated? Shall I put a tick in the box, or not?’
At this point, it must be emphasised that resuscitation is the only medical procedure for which you have to say, quite specifically, that you do not want it. In the absence of such a refusal, resuscitation will be attempted.
What happens if the patient cannot make this decision? It used to be the law that no one could make such a decision for another person. But the Mental Capacity Act, 2009, alters that. An assessment must be made thus:
1. Can the patient understand and retain the information?
2. Can he/she weigh the risks versus benefits?
3. Can he/she rationally come to a decision?
If the answers are negative, relatives, close friends, and long-term carers can assist, or even make a decision, providing he or she does not stand to gain financially from the death of the person involved, and providing he or she is rational and reasonable.
The Reverend Mother of a convent I know well, told me that Sister K had suffered a severe cerebral haemorrhage and was taken to the local hospital where the bleeding continued. When the Reverend Mother arrived at the hospital, the staff had Sister K on a trolley, and were on the point of transferring her to the neurological surgery unit of the City Hospital several miles away. Reverend Mother, who was an experienced nurse and midwife, said, ‘I could see at once she was dying, so I said to the staff nurse, “Look, she is not going to recover. Is this necessary? Can you not put her back in bed and leave her to die in peace and with dignity? I will stay with her.” And they did. Sister K died peacefully and prayerfully a few hours later.’
In preparation for this book, I visited the archives of the Royal College of Nursing in Edinburgh. The archivist told me that her sister had trained in Dublin at a time when nuns ran many of the hospitals. She said that the nuns always seemed to know when someone was going to die, and they weren’t afraid of death, they knew how to handle it. On the same visit, I also spoke to several nurses and care assistants. In the course of conversation, a senior cardiac nurse said, ‘Death in hospital is a violent event,’ and the others agreed with her.
Most emphatically, we don’t know how to handle it. It’s no good blaming the medical profession. There is a collective responsibility here. We have lost the ideal of reverence at the hour of death, and put our faith in science and technology instead. That is what has transformed the natural and peaceful ending of life into a violent event.[5]
‘How people die remains in the memory of those who live on’
— Dame Cicely Saunders
999
Beatrice is a friend of mine. She and her husband are farmers, and I rang her to order some meat for the weekend. She told me that the family had had a very stressful time.
‘My mother died nine days ago. She was seventy and had suffered a heart attack. She’d had one twelve years ago when she was only fifty-seven, but had recovered, though she had to take it easy. She knew the heart wall was thin, but she was OK.
‘My sister Kelly went to her house to take her shopping, and found her dead in her chair. Kelly dialled 999. The voice that answered ordered her to lift our mother on to the floor and start resuscitation by compressing the sternum to restart her heart. Kelly obeyed. While she was carrying out the instruction she heard a crack from the ribcage. She says she will never forget that crack. Two men arrived very quickly and cut off Mum’s nightdress and started work. Kelly telephoned me, and I came. It took me about twenty minutes to get there. As soon as I walked in, I could see Mum was dead – I’m a farmer, I see death all the time, and there’s no mistaking it. The men were working away with their equipment. I pleaded with them, “Stop it. Can’t you see she’s dead?’ They just replied, “We’ve got to. We can’t stop yet.” I shouted back, “Well, you won’t be doing her any favours even if you do bring her back to life. Her brain will be dead by now.” But they wouldn’t stop. Eventually, the ambulance arrived, and then the paramedics took over.
‘It was a dreadful time. My poor sister – she’s in such a state of shock. She says she can’t get the sound of that crack out of her head. I don’t know when she will get over it.’
Beatrice was talking fast, the words tumbling out. Then she paused and spoke more slowly and thoughtfully. ‘The trouble is, we’d never discussed it, never asked Mum what we should do if she had another heart attack. We all knew it was possible – in fact, if I’m honest, we knew it was quite likely after the last one. But that was twelve years ago, and I suppose we had put it out of our minds. We should have discussed it. I think everyone should. It would have saved her, and us, from all that dreadful business. I don’t like to think what my poor sister is going through. She blames herself, of course, but it wasn’t her fault. I think everyone should discuss these things.’
5
For an update, see Appendix I, Medical Aspects of Cardio-Pulmonary Resuscitation, by David Hackett, MD, FRCP, FESC.