The Doctor Will See You Now [Non-Fiction]

Chapter 63: Geriatrics

A nurse calls me to inform me that Esther, an elderly 95-year-old woman with a host of health issues, is a new admission who was found in cardiac arrest outside the hospital. When she was in A+E, she had arrested a second time and somehow managed to get a new heart rhythm going. She is now once again deteriorating.

The registrar speaks to the family about a DNACPR. There's nothing further to do. Despite the best management, she's heading into the final stage of her life and if we try CPR again, at best we buy her another hour or two like A+E had done or at worst, she still dies but with broken ribs and a tube shoved down her throat and needles shoved in everywhere.

I took the usual blood tests for post-cardiac arrest cases that arrive on the ward. The family couldn't decide yet. During this time, Esther arrests again. A third time.

Because there isn't a DNACPR, we jump on her. Miraculously, thirty minutes later, we manage to restart her heart. Thirty minutes' more of downtime, during which her brain was deprived of oxygen. Then, after all that, the family agrees for a DNACPR. After we've broken her ribs in exchange for however long again until her next and final arrest.

Esther stabilised, I leave the ward for my other jobs. Two hours later, I get a call again. Another cardiac arrest. The same ward. I set off on a run in disbelief and skid into the cubicle.

Esther. Again.

Let me just repeat: Esther is 95 years old with dementia, heart disease, and kidney disease, who has already died twice in three hours. She will not wake up again, never mind survive CPR permanently, never mind be discharged, never mind have any potential of quality of life.

For some reason, the family then changed their mind again and rescinded the DNACPR. And now my nurses are jumping up and down on her chest again. I feel her ribs break beneath my hands as I take over chest compressions.

Forty minutes and ten shots of adrenaline later, the resident calls time of death. We stop. Esther's chest is caved in at the centre from vigorous CPR. Blood oozes out of the many puncture sites showing where we'd tried in vain to gain more access sites to give her fluids and medicine. Her eyes lay open, pupils fixed and dilated.

I shake my head and leave to attend the rest of my jobs. What an awful way to go.

For the record: DNACPR is a clinical (i.e. doctor's) decision, not the family's, nor is it the family's burden to bear when deciding whether or not their loved ones get CPR when their heart stops. We decide based on expected clinical outcome and survival rate -- and take into account the patient's prior wishes (which is the most important) and the family's wishes. Unfortunately, because the dead can't sue us for overdoing and the family can for (what they perceive as) 'doing nothing' when their loved one reaches the final stages of their life, we tend to resuscitate when the family can't decide or refuses a DNACPR, even when it's so obviously futile as in Esther's case. Yes, that can potentially mean even when the patient themselves agree for a DNACPR and is now unable to reinforce that agreement and the family wants to overturn it.