The Doctor Will See You Now [Non-Fiction]

Chapter 124: Acute Medicine

The worst CPR in my years so far.

A 90-year-old woman, weighing 25kg, is admitted to medicine for chest pain. She has multiple cardiovascular past history including a previous stroke, two heart attacks, and also has poor function, having moderate dementia and not left her bed for many years. After her heart attacks, she was offered the option of coronary angiography with stenting, which the family refused, as they didn't want any invasive procedures in her old age.

We ruled out a heart attack on admission, but on day two she developed cardiac arrest, likely due to her heart failure from damage sustained from previous heart attacks.

Her daughter insists on active resuscitation. Why? Because she felt her mother "ought to be given every chance at life and [the daughter] couldn't deprive her of that". I can't help but note they refused coronary angiography a few years back as they didn't want invasive procedures despite the chance it would actually give her longevity; and yet when it comes to the result of that decision, as usual, the family refuses to let her go when it's her time.

People die of heart attacks. People die of heart failures. It's the natural progression of disease. Her daughter's denial doesn't change that.

I explain CPR isn't giving her life, but trying to restore heartbeat in a heart that has given out, in an elderly patient who will not survive CPR due to poor pre-existing organ functions. I also advise against CPR from a medical perspective as it would only be traumatic on such a frail body and would not work, but she insists to overrule my decision (which legally she can't do, but the culture here means we cave to unrealistic families despite our own judgement).

After ten rounds of CPR, we get a heartbeat. Her ribs are broken. She has a tube shoved down her throat (intubation) to maintain breathing; she can't breathe on her own any more. Her pupils are fixed and dilated; she is braindead. She is on maximum inotropes, medication that forces her already beaten up heart to pump faster, harder, to maintain a still-suboptimal blood pressure.

Her daughter still insists on CPR. She has family abroad who would want to see the patient.

I ask when those family members would be arriving. She isn't sure. She says maybe not any time soon.

I say it is unethical and impossible to continue CPR for however long (days? Weeks? months?) until the family arrives. She agrees but also feels she feels she cannot not make the decision on stopping CPR. It isn't her decision; it is mine, as the clinician, but I just can't steamroller her. But my words land on deaf ears. I ask her to consider DNACPR; she says she will discuss with her children (the patient's [adult] grandchild) and call me back ASAP.

She did not call me back ASAP. 2 hours of no news later, the patient arrests again, and we start CPR again. I call the daughter. She wishes to see the patient first. Meanwhile, the patient's heartbeat is restored after five rounds of CPR.

She and her own adult children arrive just after the heartbeat is restored for a second time. She sees the patient and I let her spend some time coming to terms with the condition.

But after thirty minutes, the patient's heart rate and blood pressure drops again. Her heart is giving out again -- as to be expected.

I ask the daughter again. Does she still insist on CPR? Because this is endless torture on an elderly woman whose time has come. She says yes, she cannot refuse her mother's "right to life". At this point, I'm only treating the daughter's conscience at the cost of her mother having a prolonged and painful death.

"As you're so keen for us to CPR on your mother, then I suggest you stay to watch," I say.

"What?"

"You should watch. You need to know what you're insisting on doing to your mother. You need to see what you're overriding my medical decision for."

"Oh, no, I can't watch something like that!" she says, and she leaves the ward. Meanwhile, the nurses start the third round of CPR.

She can't bear to watch us crush her mother's ribs but she can bear to order us to do this time and time and time again? This is a dutiful daughter?

The patient fails to restore a heartbeat after the third round of CPR. Twenty-five injections of adrenaline, maximum inotropes, and a ventilator. There is some faint electrical activity on the cardiac monitor due to the sheer amount of medications we'd used, but there is no pulse, no blood pressure, and her pupils are still dilated.