Posted by: medicblog999 | January 8, 2009

Do not resuscitate!

Last week I was unfortunate enough to be sent to two cardiac arrests in succession. This in itself is not that uncommon and has happened on a number of occasions, the worst one being 4 cardiac arrests in 4 hours.

What made these two different was the fact that both of the patients were classed as DNR (do not resuscitate). This had been decided and agreed a number of days before their discharge home from hospital with their known terminal illness. This should have made the job very simple. A family who calls 999 for a loved one who is effectively dying imminently, and who has a DNR form correctly filled in and signed will still get an ambulance response, but we will not carry out any advanced life saving measures, such as cardio-respiratory resuscitation or use of drugs to prolong the inevitable.

On this day I was working on the rapid response car, and I arrived on scene to find the patient in cardiac arrest, but who had been witnessed to stop breathing only 1 minute prior to our arrival. Immediately, the patients wife informed me that he had just been sent home to hospital within the last hour so that he could die at home and that he had a DNR. For me to not work on a patient, I need to physically see the DNR form and ensure everything is in order, however in this case the family did not have one with them.

This placed me in a very uncomfortable position, in so much that I could see that the patient had a terminal illness just by his appearance in the bed. I could tell that the family were very distressed and they stated that they only phoned 999 because they were caught unawares by how quickly their husband/dad had died after being sent home (they expected him to last a day) and they had panicked.

The problem is that I am now in the house and have to make a very quick medical and ethical decision. I quickly explained to the family that I would start BASIC CPR until I could ascertain the facts and how to progress. I apologised profusely for this and luckily the family understood fully the dilemma that we were all in and let me continue. At this point my backup crew arrived and they took over from me so that I could contact our control room and the GP (family doctor).

The wife approached me with a hospital discharge letter from her husbands consultant which stated that he was being discharged home for terminal care. Now, even though this was not a formal DNR, it was a letter from the patients consultant stating that he was terminally ill. I decided that I would try and get some details of the formal DNR form to backup the decision that I knew I was about to make…. to stop the resuscitation.

I contacted the patients GP who confirmed that the patient had a terminal illness and even though the GP did not have a copy of the DNR, he was happy for us to stop. I discussed this with the crew that arrived to back me up and we all agreed to stop.

Then, unbelievably, the patient regained his pulse and started breathing again, although only agonally. The family had been present and part of the discussions throughout the time we were working on the patient and with their consent we all decided that we would comply with the DNR order (which a copy had now been faxed to our control room) and let nature take its course. We moved the patient into his bed and made him comfortable, we took all of our equipment off him and moved back to let his family be next to him. 

He died 4 minutes later, comfortable, in bed, in his home. 

His wife told us that his last wish was to die at home with his family. He may have only been in his house less than an hour, but the most important things was that he made it there. It was a traumatic job for all involved, but I am eternally grateful that we didn’t have to transport him back to hospital.

Before I joined the ambulance service, I used to be a nurse. I worked in Oncology (cancer care) and hospice care, before moving into theatres and anaesthetics. From my early days looking after cancer patients, I still firmly hold the belief that it is so important to try and give patients the death that they want in the place that they want to die.

Sometimes that means standing back and letting the patient go, which is a very tough thing to do when all your training is screaming at you to start jumping up and down on chests and sticking needles and tubes into your patient to try and “get them back”


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