Beatrice’s words to me, when she told me what had happened, stick in my mind. She’d said, ‘The trouble was, we’d never discussed it. We didn’t ask her what we should do if she had another attack.
We should have done, because we knew she had a weak heart, and it could happen any time. But we didn’t. I think everyone should talk about these things.’
Beatrice is right – everyone should discuss these matters, and make their wishes known. But accurate knowledge of the reality of events is in short supply. Most people get their information from the media, especially television hospital dramas, which portray a fantasy world in which resuscitation is usually successful and has no side-effects. There is a lot of debate amongst medical ethics committees, which is valuable, but their efforts are hampered unless the general public knows what the real issues are. Everyone should have proper information about what resuscitation involves; what the initial success rate, the long-term success rate, and the possible side effects are.
Cardio-Pulmonary Resuscitation may be more carefully monitored and restrained in hospitals today, but the incidents in the community are increasing. For example, in 2010 St John’s Ambulance started a national fund-raising campaign to raise money to purchase thousands of Automatic External Defibrillation (AED) machines. This is just one of the many initiatives in the community.
Anyone involved in healthcare, however loosely – police, ambulance crews, clinicians, social workers, Red Cross volunteers, care assistants, first aid workers – all are shown how to use the AED machine, and the rule is that an attempt to resuscitate must be made unless there is a clear and unequivocal order not to do so. This is the DNAR order (Do Not Attempt Resuscitation) commonly used in hospitals. However, in the wider community such an order is not generally available, even if it has at some time been made. A person may have a living will, but if they collapse at the shops, who is going to know?
In country areas, where a hospital may be some distance away, lay people are trained and given the equipment to resuscitate, so that they can be immediately available. These people are volunteers, called Community First Responders, and they are linked to the ambulance service. I think Kelly and Beatrice’s mother must have been treated by such people at first, because two men arrived within a few minutes of Kelly’s phone call, whereas it took about thirty minutes for an ambulance to get to the house, which is in the countryside.
Since the turn of the millennium, portable defibrillators have been developed and are being used in the community. They are monitored electronically, and require no training. You simply open the lid and all the instructions are clearly printed: lay the collapsed person flat on their back, expose the chest, attach the pads to the points indicated, and switch on. The machine will pick up the extent to which the heart is fibrillating. At a signal from the machine, everyone around must stand back, and a shot of electricity is directed into the heart, which will stop the heartbeat altogether, thus stopping the fibrillations. This can be repeated several times, and will usually allow the heart to restart a rhythmic beat, at least temporarily, until an ambulance arrives with trained paramedics who can administer more aggressive treatment.
These defibrillators are now available on the open market, and there is a great deal of interest and excitement about them. Supermarkets, shopping centres, sports arenas all have them. Before many years have passed, health and safety regulators will no doubt require every public place to have one. Our love affair with machinery ensures that, once it is available, it will be used – regardless of whether it is appropriate or not.
Old age is no protection, because this would be described as age discrimination, which is, of course, illegal. I can envisage an old lady, of eighty-five or more, collapsing in a church service. The churchwarden rushes to get the defibrillator. Should the vicar be the one to say, ‘Wait a minute. We all know this lady. Isn’t this what she has said she wants? She is old and ill and lonely. She has told many of us she wants to join her husband, who died ten years ago. She should be left to die in peace. Put away your machine, and in the presence of Death, let us pray.’
Pity the vicar who has the guts to say such a thing. It would split the parish down the middle. Half the old ladies would say he is a hero; the other half would call for a public unfrocking. Special meetings of the PCC would be needed; the police, magistrates, the local paper, the bishop – it might even reach the ears of Canterbury or Rome!
The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) issues guidelines to their members on when not to start resuscitation. They are in cases of:
Decapitation
Massive head destruction
Massive injuries incompatible with life
Decomposition or putrefaction
Incineration – full thickness burns greater than 95% of body surface
Drowning – known submersion for longer than an hour
Rigor mortis
Livor mortis (post-mortem lividity)
The known existence of a DNAR order.
I suppose it is some small consolation to be told that if I have been decapitated, no one will try to resurrect me!
The ambulance team has an unenviable job. They do their best, but they get a lot of blame from the general public, which is demoralising. In a situation such as the one just described, with Kelly and Beatrice so clearly upset, it must have been profoundly distressing for them. But, legally, no relative can say what medical treatment should or should not be given to another person.
Success for the ambulance team is defined as ‘admission to hospital alive’, and they are duty bound to strive for as long as necessary – up to one hour – to achieve this objective. They are empowered to declare ‘life extinct’, but as long as there is the smallest electrical response it can be argued that life is not extinct, and they must continue. Even if the ambulance crew get the patient to hospital alive, the side-effects can be severe, especially if the brain has been starved of oxygen. Some people in long-stay geriatric wards and care homes are there because of brain damage following a successful resuscitation (see also Appendix I).
Louise Massen is Clinical Team Leader for the South East Coast Ambulance Service, working in Gravesend, Kent. She was invited to speak at the National Council for Palliative Care annual conference in March 2009. She called her lecture ‘Dying Differently’. The following is taken from her lecture notes, with her permission:
Ambulance clinicians from all services work within the Ambulance Service JRCALC Guidelines 2006 (Joint Royal Colleges Ambulance Liaison Committee).
Ambulance clinicians’ role traditionally has been to:
Preserve life
Prevent deterioration
Promote recovery.
The role of the modern ambulance service is far more than this. Ambulance clinicians have specialist skills in primary and critical care, and, increasingly, take healthcare to the patient – especially out of hours.
The only way that very ill patients are able to get to hospital will be when someone asks for an ambulance to attend.
The Ambulance Service offers a 24-hour service, seven days a week, following the JRCALC Guidelines 2006.
– the guidelines are specific that in the event of being called to a cardiac arrest or near-life-threatening event the ambulance crew is obliged to initiate resuscitation – unless
A formal Do Not Attempt Resuscitation (DNAR) order is in place, in writing, and given to the crew.
The DNAR order must be seen and corroborated by the crew on arrival. If the ambulance crew is not satisfied that the patient has made a prior and specific request to refuse treatment, they must continue all critical care in the usual way.