e 3 a s h i g R E F L E C T I O N S

Do Not Resuscitate

Some of the most difficult decisions we have to make in hospital are the “Do Not Resuscitate” orders. When some body’s heart stops, we should have an advanced plan whether we want to jump on their chest and shock them back into life, breaking few ribs in the process and burning them with electricity, or just let them go.

The decision not to resuscitate is made on one of two grounds:
1. Futility of treatment: No matter what we do, the heart will not start again. This usually (but not always) happens when the primary problem is not with the heart but the heart is one of many failing body systems. A relatively easier decision to make with the might of medical statistics and evidence to back you up.

2. Quality of life: we know that the patient quality of life is so poor that it becomes pointless to resuscitate them back into their misery. The immediate flows here is that as a doctor, you can not decide on the quality of life of the patient alone. You have to discus it at length with them and/or their family.

I looked after a woman once who had Multiple Sclerosis (MS) which is a horrible monster. Its a condition that affects your nerves and gradually erodes them bit by bit. It creeps on you very slowly taking few muscles and senses away every time it strikes. At some stage, it takes out your breathing muscles and that is when you know the end is very near. It will suffocate you to a painful and slow death and it is not reversible. My patient was bed bound, was able to turn her head, talk, swallow and move her left thumb. Her MS was so bad that she was drowning in her own mucus because she couldn’t cough it up. Her chest xray shows that the left lung was completely collapsed and the right one starting to fill up with mucus. We made a decision to stick a bronchoscopy tube into her and try to suction these secretions out. Unfortunately during the procedure, she deteriorated and it was then necessary to ventilate her with breathing machines in the Intensive Care Unit. Miraculously, she picked up and was transferred down to HDU where I saw her with my SpR and had to make a decision about resuscitation.

The decision was made easier by the large red note on the last page of her file left by the ICU consultant. “Not a candidate for further ventilation”. If this woman’s heart stops, it will be because her lungs gave up. And if a decision not to breath for her was made already, then it will be pointless to restart her heart only for it to stop again 5 minutes later without ventilation. They will not ventilate her in ICU because if she goes on the machine, she will never come off it. As as I was working through the logic of it in my head, I was interrupted by my SpR telling the HDU nurse “Yes, she is for resus!” before leaving the room.

I couldn’t get why he made that decision and on the way back to the ward, I asked him:

“Boss, what are we achieving by resuscitating this woman? I don’t think we should.”

“What do you mean?”

“It will be unfair to resuscitate her then not ventilate her. She has respiratory failure due to MS and they will not ventilate her in ICU”

“You know you are right, it will be FUTILE. why don’t you go ahead and change it.”

I got back to HDU and as I was scribbling in the note:

“SHO: d/w SpR. resus status r/v. Not for resus”

a nurse behind me goes:

“Oh No. I just told her and her family that you reversed her initial status and she is now for resus and they are all happy. You have to talk to them!”

Try telling someone (who just pulled out of ICU with a miracle) together with their family (who are so glad it she is getting better) that you are putting a ceiling on her treatment and you immediately sound you are an insensitive brick. Try doing it when your boss has just told them he will resuscitate her and you are a complete a**hole! It doesn’t matter how well you explain it: IT WILL NOT WORK. IT WILL BE FUTILE. People still hate you for it even though they know you are right and agree with you. You are the one who deprived their loved one from their last chance. You then go home and think you are the worse human being ever and consume a packet of valium.

She recovered from that episode and was seen by the consultant afterwards who fully agreed with our decision. I talked to her later to see how she feels (and to relieve my own feelings of guilt and self-loathing) and she was OK with it. She understood that we are not depriving her from a chance to live and that we are treating her fully but if she dies, it will be despite our best effort and not because we are holding something back.

I could not forget the hate looks in her family’s eyes for many weeks afterwards.

PS: This post is dedicated to Manchester Network on Facebook.