Striving for the right resuscitation decision
Posted on 19 September 2012 by Melody Clarke
‘I’ve got an output,’ called my colleague, his fingers on the femoral.
My eyes turned to the monitor. The patient was back in sinus rhythm, and had started to make some respiratory effort. But the anaesthetist had left, and the rest of the crash team had disappeared. Our sense of victory was short-lived.
The patient wasn’t a candidate for intensive care, and this was probably his time to die, but we’d just bought him three more days. Although he could breathe independently, he never regained consciousness.
A few days after he died, I was summoned to speak to his daughter. Older herself, she was polite and composed.
‘Why did you try to resuscitate him?’ she asked.
It had been an elective admission for something minor. He had been fit and well. We hadn’t expected him to die.
‘But he was 98,’ she persisted.
Without a blanket hospital policy of making resuscitation decisions on admission, the honest answer was that we hadn’t thought about it. And while making the decision was usually easy, communicating it to the patient and their relatives was often much harder.
Usually our discussions were met with quiet acceptance; the relatives understood that their loved one was dying.
Occasionally, however, this provoked much stronger feelings. Regret and guilt turned to anger and frustration directed against the doctors with shouting, crying or accusatory fingers jabbing the air in front of my face.
So what if we ask the patients themselves on admission? Surely this should circumvent the need for difficult conversations with the relatives later on.
Many patients admitted with a poor or terminal prognosis don’t want to be resuscitated, yet there are some, who despite the overwhelming likelihood of failure, still want us to ‘give it a go’.
TV medical dramas don’t help. After a few minutes of jumping up and down on someone’s chest and a couple of zaps, the patient inevitably comes round and by teatime has made a full neurological recovery.
For most people, their only experience of a cardiac arrest is on the small screen, and I frequently find myself confronted with skewed perceptions and unrealistic expectations.
Communicating a DNAR decision is almost like breaking bad news before the event. Getting it right is important, allowing time for questions and being sensitive to the patient’s or relatives’ wishes.
Melody Clarke is a specialty trainee
Read the joint BMA, Royal College of Nursing and Resuscitation Council (UK) guidance Discussions Relating to Cardiopulmonary Resuscitation