Inappropriate medical intervention at end of life in particular Cardiopulmonary Resuscitation or CPR

I guess most of us have seen ‘resuscitation’ with actors on TV or film in a hospital setting; obviously, it isn’t for real.

Real life CPR is brutal and sadly, even with fit young people more die than will survive. Out of hospital it is a very different story. If CPR is not started or a defibrillator used the casualty’s brain will die within THREE minutes, that is why hospital resus teams run!

I am of an age where one’s mortality needs to be considered and dealt with so as to get on with the business of living. There are things I would wish for at the end of my life and some definitely not. If for any reason I am not able to say what these are then the burden would fall on someone else to decide. From a socio-medical point of view technology and skills have changed greatly. Intervention can be traumatic and not always appropriate

So. if your heart stopped would you wish to have rib crushing CPR performed on you?

A tough question deserving some thought because your answer will depend on the circumstances.

If you’re fit, otherwise healthy, suffer a cardiac arrest and CPR can be started immediately, then obviously, yes and if you survive, fantastic.

With a cardiac arrest it is the heart that stops first with the other organs failing afterwards.

With an ‘ordinary death’ the other organs fail and the heart is last to go. CPR is no use with an ‘ordinary death’, but CPR is being done in these situations.

There are people, nurses, carers, families, in some instances members of the public and even doctors who have been and are still being placed in the untenable position of suffering the consequences from performing inappropriate CPR. Conversely medical staff have been sacked and disciplined for not performing CPR even though there was no medical reason to so do. These are specific concerns over CPR, but other interventions, though not so obviously  traumatic, are still potentially inappropriate.

Currently I believe the rules are inadequate and have been made such that clinical judgement is not given due consideration. As a consequence there is a trend towards inappropriate intervention becoming the norm. Partly this is due to digital technology directing the requirement for CPR and partly risk averse institutions fearing negative actions which might cost reputations and money. It requires sorting out for all concerned.

What is true is that anyone who is concerned about their own end of life should start the conversation about their wishes whilst they are able. You can require that CPR is not attempted inappropriately whilst other procedures are given to benefit your comfort.

For families and carers etc. it is difficult to initiate these discussions. If possible talk to the person concerned, it may well be welcomed and do speak to the doctors and nurses.

Now I’m not a medic so this is from one who is. Warning it is a tough read!

Break his sternum. Break some ribs; crack beneath your hands. Push, push, push; one hundred times a minute please. ‘Good compressions’ calls the computerized voice from the defibrillator. Don’t stop, now feel for a pulse; you’ve got it? OK, now leave him to die again. Pillow? There are no pillows in A&E, we will find a blanket and roll it up under his head. He isn’t for intensive care. What’s his name? 

I don’t know it.

You could tell that story many ways and it is the story of many. I could paint it rosier, add more details, but when I relive these cases I often don’t. I recall it just like that.

‘Cardiac arrest call ED resus, five minutes; ITU to attend’ the voice crackled over my bleep. I arrived in to resus to receive a woman in her eighties who had choked on her dinner, stopped breathing and then had a cardiac arrest. CPR was started at her care home and an ambulance was called. They arrived, cleared her airway as best they could, continued CPR and brought her in. She had what we call ‘return of spontaneous circulation’.

The patient arrived unconscious with a pulse. We transferred her on to our trolley. She had fluffy white set hair like my grandmother, I used to like to pat my hand gently on top of it and watch her laugh when I told her it felt like a cloud. I looked at the patient’s soft wrinkly skin and her tongue, that lolloped out of the side of her mouth next to the laryngeal mask airway that had been pushed inside.    

We knew very little about her, but we set about the basics as a start.

‘This airway isn’t working properly’, I said as I pulled it out of her mouth and discovered a match box sized lump of meat partially clogging the end. Moving on inside, I continued to clear the remainder of her stomach contents that had exploded into her mouth with CPR.   

Airway: check

Breathing: check

Circulation: check 

What happened next? The A&E consultant logged onto the computer and gathered what information we could about this patient who arrived without anybody who had ever known her before.

Dementia, diabetes, hypertension, full-time care and previous admissions to hospitals for falls. 

I phoned my consultant and we discussed the situation. She would not be escalated to intensive care. Death was inevitable; of course it was, that was true from the first time her heart stopped. 

I put down the phone and looked at the monitor. Her circulation was already failing again, so we rolled a blanket under her head and a nurse found a clean gown to place over her broken chest. She was given all the dignity A&E resus could afford her. 

Her family came later and the A&E consultant told them about the series of decisions we had made. They understood and recounted many years of their loved one living with dementia and co-morbidities. They agreed they wouldn’t have wanted her to have CPR and they wouldn’t have wanted escalation to intensive care anyway.

They wouldn’t have wanted her to have CPR.

There’s a form for that, I thought, as I remembered standing in a busy resus department looking at her broken, see-saw chest heaving irregularly on front of me.

There is a form for that. 

By the Secret Doctor

Read the blog and follow @TheSecretDr on Twitter and check out #CalmEndOfLife

Some advice on what to do when a death occurs

http://announce.jpress.co.uk/help?page=lasting_post%2Fwhen_death_occurs;s_source=jpno_dfpc_gco

Many thanks to Dr Gordon Crawford for allowing me to give these links — Imagine you are coming towards the end of your life, can you paint me the picture that you see in your mind’s eye of your dying bed? 

https://www.dropbox.com/s/sxs9kiva9soh2ex/NEJM%20Paint.pdf?dl=0

Giving the medical background for my layman’s blog.

Time to Change from Do Not Attempt Cardiopulmonary Resuscitation

https://www.dropbox.com/s/8gmbn8z3cbbf41n/V2%20Time%20to%20Change%20from%20Do%20Not%20Attempt%20Cardiopulmonary%20Resuscitation.pdf?dl=0

Some potentially useful Links:

Advanced Decision http://www.nhs.uk/Planners/end-of-life-care/Pages/advance-decision-to-refuse-treatment.aspx

A report: Discussing death

Most people express a considerable degree of confidence around discussing death and planning for the end of life. Planning for end of life Yet this expressed comfort and confidence is not always translated into actual discussions and practical planning, largely because death is seen as far off – even among many older people. Recent policy, legislation and campaigns advocate greater openness and discussion around dying and planning for end of life care. What are the public’s attitudes on this issue and how far do these vary for different sections of the population? How far have individuals put plans in place for the end of life and what factors are inhibiting planning in this area?

http://www.dyingmatters.org/sites/default/files/BSA30_Full_Report.pdf

Worth a visit

http://blog.finalfling.com/welcome/

Advance care planning resources

 https://www.dorsetforyou.gov.uk/407390

Dorset – Planning for your future care (pdf, 101kb) (opens in a new window)

Thinking ahead (pdf, 35kb) (opens in a new window)

Advance decision to refuse treatment, a guide for professionals (pdf, 2Mb) (opens in a new window)

Capacity, care planning & advance care planning (pdf, 1Mb) (opens in a new window)

Concise Guidelines to Good Practice: Advance Care Planning (pdf, 256kb) (opens in a new window)

Differences between general care planning and decisions made in advance (pdf, 44kb) (opens in a new window)

Mental Capacity Act 2005 Code of practice (pdf, 1Mb) (opens in a new window)

Best interests at End of Life (pdf, 939kb) (opens in a new window)

Enabling Care Priorities – Gold Standards Framework (pdf, 223kb) (opens in a new window)

Lasting power of attorney (opens in a new window)

Planning for Your Future Care (the National Council for Palliative Care) (opens in a new window)

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