It’s hard to miss this topic which has exploded in the media again this week. The lady in front of me on the bus home on Wednesday was reading the Daily Mail. The headline “Do you want us to let you die?” was brandished across it above a large photo of Cliff Richard. Luckily I’d learned about the story the previous evening from Twitter. It pertains to the experience of Mrs Lilley, Roy Lilley, the health policy analyst’s mother, who had had a recent negative experience when a district nurse visited to discuss Advance Care Planning, including the ever emotive topic of resuscitation.
I made my own decision not to be for cardiopulmonary resuscitation the day after I discovered my cancer had spread to my liver and bones. I wanted it to be clearly documented at a time when I had full mental capacity that I did not want to go through a futile, brutal treatment that was never going to somehow magically take my cancer away. I have a pelvic malignancy so the chances of me dropping dead from a pulmonary embolism are fairly high. I have also in my time been very ill following chemotherapy with serious infections, again another risky time.
There is no way I would like to have my chest exposed while somebody attaches large electrodes and does chest compressions. Another member of the team would most likely put a tube down my throat or use a tight fitting face mask to ventilate my lungs. Somebody else would no doubt be digging around in my arms with needles looking for a vein to insert a cannula, which because of the situation and my past history would be very difficult. I would also probably suffer the indignity of someone exposing my groins while they tried to take blood from the large artery there to assess my oxygen levels. There would be lots bleeping and raised voices. Depending on my heart rhythm I may need electric shocks in an attempt to restart a normal rhythm. The voltage used is so high that patients physically jerk as the shock is delivered. Drugs such as adrenaline may be administered. There would be empty packets from the equipment discarded on the floor around my bed. The picture I am painting is, even in the most well run cardiac arrest call, of a chaotic scenario and cannot be aligned in any way to my vision of a peaceful death. Because when resuscitation is used the patient has died. Their heart and lungs have stopped working. In the majority of cases we are not successful. If we do manage to re-establish a heart rhythm then the risks of the patient having suffered a hypoxic brain injury are high.
I talk to patients and their families about resuscitation every day I work. I look after frail, older adults and it is a question we need to consider very frequently. Some people would argue a question we should consider for everybody. In our population success rates are even lower with chances of surviving to discharge from hospital in the pre-morbid state even lower again. The risks are higher too. Anyone who has done chest compressions on a frail patient has probably felt that terrible crunch as you break ribs. Cerebral hypoxia is more common too as the blood supply to the brain is less good. This may manifest as agitation or coma.
Of course how these conversations are handled takes time and requires sensitivity. It should be a conversation, not just a tick box. Previous knowledge and opinions should be sought, information should be given, thoughts and ideas elicited and ideally both parties will agree. It is important to emphasise that a DNACPR decision does not mean we are going to stop actively treating the presenting health problems. It is also important to agree when a decision should be reviewed as with most things in Medicine it does not have to be set in stone forever more.
But we do as a society have to accept that some health conditions are incurable. That as we age our bodies do eventually wear out. We are all going to die, nothing in life in more certain. Whether the media want to make us all more frightened of this fact is their business, what I want to focus on as a clinician is achieving comfortable, dignified deaths for my patients when that time has come and hope that somebody will do the same for me when it’s time for me to meet my maker too.