In the Midst of Life

by Jennifer Worth

  Eventually, in the 1950s, the medical profession got on to the idea, and the modern techniques of cardio-pulmonary resuscitation (CPR) were developed at the Johns Hopkins Medical Research Faculty in Baltimore, USA – although many other medical teams in other countries were working on the same theories. Within a decade, their findings and teaching had gained widespread acceptance throughout western medicine.

  Different techniques were developed and experimented with. The open-heart resuscitation that I witnessed being applied to Dr Hyem, was the first method adopted by the medical profession, and its popularity lasted for around ten years. It has been replaced by electrical impulses, or shocks, directly administered to the heart, which are no less violent, but more effective. The giant international drug and engineering companies started competing with each other for the huge financial gains to be accrued from producing ever more powerful cardiac stimulants, and manufacturers of surgical equipment bent all their efforts into resuscitation technology. It was big, big business.

  From the 1970s onwards in the UK (earlier in America), the intensive care unit and resuscitation became central to clinical practice, and no hospital could afford to be without the latest techniques and equipment. ‘Crash’ was all the rage. Everyone was very gung-ho about it and cheerfully tried it on almost any dying or dead patient. Young doctors, nurses, and technicians had to be taught the techniques and older ones needed to practise. Pompous old consultants and starchy old ward sisters who questioned the technique were told to get up to date and live in the real world. Those who warned about ‘playing God’ were told they were religious fanatics and everyone would be better off without them.

  Those were exciting days to be in medicine. Anything was possible. We could conquer death itself. Job vacancies appeared in the Nursing Times: ‘Be in the Front Line. Be a Life Saver. Join the Resuscitation Team. Work in the Intensive Care Unit at Hospital. Apply in writing.’ Adverts like this were quite common, and I attended a conference where this type of wording was strongly condemned by the RCN.

  Exhilaration was in the air; but then, slowly, the demoralising feeling sneaked up on us that something was not quite right. Respect for the dead had been thrown out of the window.

  *

  The speed with which resuscitation swept through the medical profession was astonishing, and it was far too quick for it to be properly thought through. Drugs were introduced with bewildering haste – too hasty for proper trials to have been conducted. I gained the impression, in those days, that new cardiopulmonary drugs were tried on patients, the attitude being, ‘He’s dead, anyway, so there’s nothing to lose.’ The equipment and the voltage of electricity was hit or miss because no one really knew how far to turn up the dial. Medical and paramedical staff had to master techniques that could only be learned on the job.

  When I was a staff nurse at the London Hospital, we had a death on the ward. I was off duty at the time, but the next day the ward sister told me that she went behind the screens about twenty minutes after the patient had died to ensure that the eyes were closed and the chin supported, and found two young doctors trying to insert a central line into the iliac vein in the groin.

  ‘What are you doing?’ she demanded – ward sisters had a presence in those days. The young men looked up at her guiltily.

  ‘Have you no respect for the dead?’ she said contemptuously, as she covered the body with a sheet. They said nothing, and went away.

  My sister Pat is a Queen’s Nurse (Queen Alexandra Royal Army Nursing Corps). She trained from 1965–69, mostly in Singapore. She returned to England in 1969, to Aldershot Military Hospital, and was put straight on to night duty. The first night, she took the report and was told that if an emergency occurred she must press the AMSET button (Army Medical Services Emergency Team), but she was not shown where the emergency button was situated.

  She did the usual drug round and noticed that a man was not in his bed. Thinking that he would return later, she finished the drug round, which took about half an hour. By then, he still had not returned, so she went to look for him. She couldn’t get into the lavatory, and so she crouched down on the floor to peer under the door, and saw two feet sticking up. Her first thought was to press the AMSET button, but she didn’t know where it was. She searched everywhere, poor girl, but still couldn’t find it. So she telephoned the night sister, who called the emergency team. They came with mobile resuscitation equipment and dragged the dead man out of the lavatory.

  Pat told me that he was quite cold and stiff, and must have been dead for some while, because she had done a complete drug round and then spent time searching for him, then more time searching for the AMSET button, before the team arrived. Nonetheless, with all the drugs and equipment at their disposal the team attempted to resuscitate.

  Pat said, ‘He was an old man, bless him, over seventy, and he was sick. I watched it all with horror, all that violence. There was no way they could get him back to life; he was quite dead, stiff and cold. But they carried on. Eventually, they gave up, of course. He had had a ruptured aortic aneurysm.’ A ruptured aneurysm is not cardiac arrest, so resuscitation attempts in this situation were futile and inappropriate.

  When I trained at the Royal Berkshire Hospital in the 1950s, there was no resuscitation. My niece, Joanna, trained at the same hospital twenty-five years later, and I asked her how much of it went on. She said,

  ‘It was relentless, every day on every ward throughout the hospital. Every bed had a crash button beside it. There were half a dozen crash boxes around the ward, and the crash trolley placed centrally. If anyone died the nurses had to rush to the bed, press the crash button, detach the top and bottom of the bed, lie the patient flat with no pillows and start banging hard on the chest, pumping the sternum up and down to force a heartbeat, whilst a second nurse had to do mouth to mouth resuscitation until the crash team arrived. Then they started intensive resuscitation with drugs and electrical equipment. All nurses had to do this; it was a rule and was absolutely enforced. There was nothing we could do about it. We young nurses would ask the sisters, “Why? Why old Mrs C or why Mr S? Why is he not No Crash? He’s terminally ill. He’ll never get better.” The sister would say, “I don’t know, but we’ve got to do it. All I can say is don’t rush, don’t be in too much of a hurry to press the crash button, don’t bang too hard on the sternum – if you can delay things for a few minutes, he might be able to die before the crash team can get at him.”’

  I told Joanna about the solemnity in a ward that had accompanied a person to their death when I was a young nurse. She said, ‘Well that’s all gone. When I trained it was rush, noise, panic, even shouting sometimes.’

  I asked Jo what the success rate was. She thought a bit, then said, ‘Very low. I can’t really put a percentage on it, but very low. The trouble was that very often the body would twitch, and they thought this was a sign of life, and when the electric current hit the heart the body would really jerk – again, taken as a sign of life. But it’s not, at least not necessarily. There can be a twitch, more than one, after death, which I think is part of the nervous system shutting down.’ I agreed with her, and said that quite often I had seen someone die, and then, a minute or even two minutes later, suck in a great noisy gulp of air, which is called an ‘agonal gasp’.

  She laughed and said, ‘I’ve seen that too; and heard it. It can be really scary, especially if you are a young nurse in the middle of the night, and you are not expecting it … spooky!’

  I joined her laughter and commented that medical people are known to have a black sense of humour.

  ‘Too true. We need it,’ she said.

  These are just a few examples from a family of nurses to illustrate the frenzy that overtook medicine during that period of medical history. It also illustrates that medicine, like any other profession, is prone to fashions. Today, in the twenty-first century, there is more discrimination in undertaking resuscitation, but even so, the prognosis is poor. Nuland stated that only fifteen
per cent of hospitalised patients below the age of seventy would survive cardiac arrest and resuscitation, and almost none over that age. That proportion has remained unchanged.

  Yet, even with more selection, a lot of resuscitation goes on in hospitals. Doctors know that in most cases it will be futile, so why do they carry on doing it? The answer is two-fold. Firstly, and most importantly, for the sake of the fifteen per cent who do survive. The second reason is more complex. The burdens placed upon doctors and nurses by public expectations are crushing. Doctors feel blamed for every death and, driven by a combination of guilt and doubt and fear, they strive all the time to save a life. They know that if they don’t make the maximum effort, and someone dies, they could be in serious trouble, which could destroy a career. The fear of litigation is ever-present.

  Yet the public, and particularly the media, are so fickle that, having saved a life, doctors are then often accused of needlessly prolonging life and causing suffering. Whatever they do they will be in the wrong. Sometimes I wonder why anyone ever becomes a doctor or a nurse at all!

  The heyday of resuscitation in hospitals was around 1970-95. Since then, much more restraint and discrimination has been observed. Doctors are now more ready to write a Do Not Attempt Resuscitation (DNAR) order if it is foreseen that a patient has a diagnosed condition with progressive advanced illness from which they will not recover, and for which resuscitation would be futile. Details of the General Medical Council (GMC) directive to doctors issued May 2010 can be found in Appendix I.

  To discuss the prognosis with the patient is ideal, but it is often difficult, or plain impossible. Some patients are not approachable on the subject of their own death; some doctors cannot bring themselves to mention the dreaded word, and, in that case, an experienced nurse may be better. Some patients, surprisingly, have never even thought about it and say, ‘I don’t know - I leave it to you, Doctor.’ Others say, ‘I want to go when my time comes.’ Everyone is different, every doctor and nurse is different, and every clinical situation is different. What is necessary, in all ‘Would you want to be resuscitated?’ situations, is time. Such a discussion, if handled sensitively, could take all afternoon - and who, in the busy setting of a modern hospital, has that amount of time at their disposal? Probably no one. So an informed discussion is often hurried, even rushed, or pushed aside for a day that never comes.

  Everybody must think about these things and discuss them with family, friends or carers long before a nervous young doctor tentatively raises the issue, or a lady with a clipboard comes round and says, ‘I’m filling in a patient’s questionnaire – do you want to be resuscitated? Shall I put a tick in the box, or not?’

  At this point, it must be emphasised that resuscitation is the only medical procedure for which you have to say, quite specifically, that you do not want it. In the absence of such a refusal, resuscitation will be attempted.

  What happens if the patient cannot make this decision? It used to be the law that no one could make such a decision for another person. But the Mental Capacity Act, 2009, alters that. An assessment must be made thus:

  1. Can the patient understand and retain the information?

  2. Can he/she weigh the risks versus benefits?

  3. Can he/she rationally come to a decision?

  If the answers are negative, relatives, close friends, and long-term carers can assist, or even make a decision, providing he or she does not stand to gain financially from the death of the person involved, and providing he or she is rational and reasonable.

  The Reverend Mother of a convent I know well, told me that Sister K had suffered a severe cerebral haemorrhage and was taken to the local hospital where the bleeding continued. When the Reverend Mother arrived at the hospital, the staff had Sister K on a trolley, and were on the point of transferring her to the neurological surgery unit of the City Hospital several miles away. Reverend Mother, who was an experienced nurse and midwife, said, ‘I could see at once she was dying, so I said to the staff nurse, “Look, she is not going to recover. Is this necessary? Can you not put her back in bed and leave her to die in peace and with dignity? I will stay with her.” And they did. Sister K died peacefully and prayerfully a few hours later.’

  In preparation for this book, I visited the archives of the Royal College of Nursing in Edinburgh. The archivist told me that her sister had trained in Dublin at a time when nuns ran many of the hospitals. She said that the nuns always seemed to know when someone was going to die, and they weren’t afraid of death, they knew how to handle it. On the same visit, I also spoke to several nurses and care assistants. In the course of conversation, a senior cardiac nurse said, ‘Death in hospital is a violent event,’ and the others agreed with her.

  Most emphatically, we don’t know how to handle it. It’s no good blaming the medical profession. There is a collective responsibility here. We have lost the ideal of reverence at the hour of death, and put our faith in science and technology instead. That is what has transformed the natural and peaceful ending of life into a violent event.*

  ‘How people die remains in the memory of those who live on’

  — Dame Cicely Saunders

  999

  Beatrice is a friend of mine. She and her husband are farmers, and I rang her to order some meat for the weekend. She told me that the family had had a very stressful time.

  ‘My mother died nine days ago. She was seventy and had suffered a heart attack. She’d had one twelve years ago when she was only fifty-seven, but had recovered, though she had to take it easy. She knew the heart wall was thin, but she was OK.

  ‘My sister Kelly went to her house to take her shopping, and found her dead in her chair. Kelly dialled 999. The voice that answered ordered her to lift our mother on to the floor and start resuscitation by compressing the sternum to restart her heart. Kelly obeyed. While she was carrying out the instruction she heard a crack from the ribcage. She says she will never forget that crack. Two men arrived very quickly and cut off Mum’s nightdress and started work. Kelly telephoned me, and I came. It took me about twenty minutes to get there. As soon as I walked in, I could see Mum was dead – I’m a farmer, I see death all the time, and there’s no mistaking it. The men were working away with their equipment. I pleaded with them, “Stop it. Can’t you see she’s dead?’ They just replied, “We’ve got to. We can’t stop yet.” I shouted back, “Well, you won’t be doing her any favours even if you do bring her back to life. Her brain will be dead by now.” But they wouldn’t stop. Eventually, the ambulance arrived, and then the paramedics took over.

  ‘It was a dreadful time. My poor sister – she’s in such a state of shock. She says she can’t get the sound of that crack out of her head. I don’t know when she will get over it.’

  Beatrice was talking fast, the words tumbling out. Then she paused and spoke more slowly and thoughtfully. ‘The trouble is, we’d never discussed it, never asked Mum what we should do if she had another heart attack. We all knew it was possible – in fact, if I’m honest, we knew it was quite likely after the last one. But that was twelve years ago, and I suppose we had put it out of our minds. We should have discussed it. I think everyone should. It would have saved her, and us, from all that dreadful business. I don’t like to think what my poor sister is going through. She blames herself, of course, but it wasn’t her fault. I think everyone should discuss these things.’

  It was a couple of months before I managed to speak to Kelly. I had asked, but perhaps she did not want to talk to me or anyone else so soon. But a couple of months later, after she had been on holiday, she felt ready to re-live that fateful morning.

  Kelly told me, as Beatrice had, that she had driven to the house to take her mother shopping, and found her dead in her chair.

  ‘She was sitting quite still and peaceful, but absolutely dead – there was no mistaking that. I reckon she had been dead for quite a long time, because she was in her nightie. When she was expecting me for our weekly shop, she would always be up an
d dressed by about 9 o’clock. But it was 10.30 and she was still in her nightie … so I reckon she died before 9 o’clock.’

  Her voice was very quiet, and it faltered several times as she spoke. She continued:

  ‘I didn’t know what to do … I suppose the shock made me panic. My first thought was, I must get help, so I rang 999. I spoke to a man, who said, “I have ordered the ambulance crew, and until they get there you must start resuscitation.” I said, “It’s too late, she is blue.” He said, “No, you must.” I repeated, “It’s much too late. She’s quite dead.” He ordered, “You have got to. Get your mother on to the floor, and do as I say. I’ll talk you through it, until they arrive.” I struggled to lift my mother, and told him, so he said, “You must get her off the chair and on to the floor.” I ended up pulling her. It was an awful thing to have to do.’

  I gently asked, ‘Why did you do it? You don’t have to do what a voice on the telephone tells you to do.’

  ‘No, I know. But I suppose I was numb with shock … I don’t know …’ Her voice trailed away. ‘Then he said, “Start firm, hard pressure on her breast-bone, rhythmically, about two beats per second. I will count you through, start now – one, two, one two.” I did … and then … I heard that crack, from her ribcage.’

  She couldn’t speak after that for a long time. I didn’t know what to say. I think I murmured, ‘You poor soul,’ or something like that. Eventually she was able to carry on.

  ‘Two men came and took over. They pushed a tube down into her windpipe and pumped in air, or perhaps it was oxygen. They cut open her nightie and wired her up to a machine, which they switched on. I couldn’t bear to see her like that, on the floor, she was so modest, her nightie pulled away, and two men over her. I tried to cover up her lower parts, so she wasn’t too exposed – it was silly, really – but I kept thinking how mortified she would have been.