Life and death

Been back from the country for a while now. The first thing I had to do on my first day of my medical rotation was to certify someone dead.

This was followed by three more deaths that day. This is the standard welcome of this hospital, I've been told.

I feel uncomfortable - this push to declare someone not for resuscitation and MET calls. But this seems to be the first thing that registrars address the moment someone is admitted.

Should this person stop breathing or the heart stop beating - do we jump on his/her chest and commence CPR?

Should this person's vital observations go beyond normal limits - should the medical emergency team be called (MET call) with the view that if the patient is unstable, that they be moved to ICU?

In the previous two weeks my experience have been that if the patient is older than 80, frail, from a nursing home, demented - in other words not with it - they usually get stamped the NFR (not for resuscitation) order.

Often the reasons underlying this important decisions are that the patients will not have a better outcome i.e. a better quality of life if they are wheeled into ICU, intubated and have inotropes and a ventilator help them breathe and live. In other words, we would be wasting medical resources and funding supporting a futile cause.

In a medical system that is under-resourced where it is not uncommon to not have an ICU bed available across the state when there are very sick patients needing this high care - the older, more frail and demented are often pushed aside especially when no medical benefit can be forseen.

Also as cold as it sounds, the push to address the resuscitation status of a patient as soon as they come in is to make the night registrar's job easier to make clinical decisions when these patients go down during the night. Sorting out whether a patient will have a better outcome if they are resuscitated or intubated while the patient is literally pre-arresting next to you - is not a decision the night medical registrar should have to make. The decision should be clear cut. Or is it?

He had very severe aortic stenosis and had come in with severe heart failure and a NSTEMI. Throughout the night he fluctuated between asymptomatic atrial flutter and sinus tachycardia. Otherwise he was generally well-looking, with it and frankly none of us thought to address his resuscitation status. He was 87. Later that day he went on to have a metcall. He was in 2:1 atrial flutter and his systolic blood pressure was 90 but otherwise he was still alert, though starting to look a little grey. He was digoxin loaded and transferred to CCU. The ICU registrar, CCU registrar and medical registrar were optimistic at this stage and had not thought to address his resuscitation status.

All was well until a Code Blue was called half hour later and we knew instantly who it would be. We ran to CCU to the usual chaotic crowd of a code blue. He had a run of non-sustained VT and seemed to be pre-arresting. This time the anaesthetic registrar was here too. As the cardiology registrar ran the met call, the patient was loaded with intravenous amiodarone. His heart rate slowed down to 60 but his systolic blood pressure was 70. More fluid boluses and still no improvement in blood pressure.

The anaesthetist had his intubation bag next to him and the ICU nurse was drawing up propafol, midazolam and adrenaline. This is of course the expected next step of action. At this time, the question was then asked by the other registrars.

Is this patient for resuscitation/intubation?

There was a mad scramble for the notes to check for any documentation. Frantic flipping. But we (being the interns) knew the answer. We never addressed this patient's resuscitation status because it never occurred to us. We did not think the patient was that unwell this morning and this was the general impression our consultant had too. Basically we didn't think he was going to die any time soon.

In one corner - a work experience student was pressing her back against the wall - her wide eyes and terrified expression said it all.

You can't be serious.

After a quick discussion with the treating consultant and ICU consultant - it was decided that the patient was not for intubation or resuscitation.

An hour later he passed away. As I walked into the roomful of tear-eyed relatives to certify the patient dead, I could not help but feel a sense of discomfort. Was there anything more that we could have done? Should I have raised my hand to the roomful of senior doctors and nurses and shout - maybe we should try and intubate this patient?

So many maybes that underlie this black and white medical orders that we make. Later the work-experience student was seen crying outside CCU with some of the older nurses comforting her. Why do we not shed tears - us interns, registrars and nursing staff? Are we better at letting go? There's no time to reflect. Our pagers' are beeping away and our other alive patients need us. Time to go and run the ward.

NSTEMI: non-ST elevation myocardial infarction (small heart attack)

CCU - coronary care unit

VT - ventricular tachycardia

*Details of this case have been changed to protect confidentiality.