In the Midst of Life

CARDIO-PULMONARY RESUSCITATION (CPR) IN HOSPITAL

In 2008 I was visiting a friend who was in an acute medical ward of a large county hospital. I walked directly into the single room where I expected to find her, but she was not there; she had been moved to the main ward. In the bed was an old, old lady who looked as near to death as anyone I have seen. Her skin was as white as the sheets, her eyes sunken and rolled up towards her forehead; her cheeks were hollow, her mouth hung open, and her breathing came in ragged gasps. In my nursing days, we would have assessed that she had only a few hours to live and the ward sister would have instructed a nurse to sit beside her, just to hold her hand or to stroke her hair, or to whisper a few words now and then.

There was not a nurse in sight. Two gently humming machines were her only companions. Monitor pads were stuck to her arms with wires leading to one machine where lights flickered and a graph line was being traced. The other machine had wires attached that disappeared under the bedclothes. An oxygen cylinder hissed continuously, and a transparent catheter was attached to her nose with sticking plaster. A saline drip running into her arm and a urine drainage bag hanging from the bedside completed the picture.

I stood gazing at her for a couple of minutes thinking, Poor old lady. What have you done to deserve this? She was a total stranger to me, and I knew nothing of her medical history, but as the bed was in acute medicine, the likelihood is that she had collapsed from acute coronary failure caused by a heart attack. Someone had found her and called an ambulance, and this was the result. Nearly dead, surrounded by advanced medical technology, and not a soul around, except a stranger who had walked in by mistake.

This is what most of us can expect, unless we are very lucky. If anyone collapses, from whatever cause, at home or in a public place, the chances are that they will be taken to hospital. Only the medical team involved knows what goes on in the resuscitation room of a hospital, because lay people are excluded. When my mother died, I was pushed out and the doors were locked on the inside. There may be good reason for this, such as the risk of introducing infection into the room, but I suspect it is more because a relative may try to stop what is going on.

Sherwin B Nuland was a consultant surgeon at Yale University Hospital and teaches surgery and the history of medicine at Yale. In his remarkable book, How We Die, published in 1995, he has described the process of hospital resuscitation as accurately and objectively as any medical man can for the lay readership:

Having countless times watched those teams fighting their furious skirmishes, and having often been a participant or their leader in years past, I can testify to the paradoxical partnering of human grief and grim clinical determination to win that actuates the urgencies swarming through the mind of every impassioned combatant. The tumultuous commotion of the whole reflects more than the sum of its parts, and yet the frenzied work gets done and sometimes even succeeds.

As chaotic as they may appear, all resuscitations follow the same basic pattern. The patient, almost invariably unconscious because of inadequate blood flow to the brain, is quickly surrounded by a team whose mission is to pull him back from the edge by stopping his fibrillation or reversing his pulmonary oedema, or both. A breathing tube is rapidly thrust through his mouth and down into his windpipe so that oxygen under pressure can be forced in to expand his rapidly flooding lungs. If he is in fibrillation, large metal paddles are placed on his chest and a blast of 200 joules[4] is fired through his heart in an attempt to stop the impotent squirming, with the expectation that a regular beat will return, as it frequently does.

If no effective beat appears, a member of the team begins a rhythmic compression of the heart by forcing the heel of his hand down into the lowest part of the breastbone at a rate of about one stroke per second. By squeezing the ventricles between the flatness of the yielding breastbone in front and the spinal column in the back, blood is forced out into the circulatory system to keep the brain and other vital organs alive. When this form of external cardiac massage is effective, a pulse can be felt as far away as the neck and groin. Although one might think otherwise, massage through an intact chest results in far better outcomes than does direct manual compression.

By this point, IVs [intra-venous drips] will have been inserted for the infusion of cardiac drugs, and wider plastic tubes called central lines are being expeditiously inserted into major veins. The various drugs inserted into the IV tubing have assorted purposes: They help to control rhythm, decrease the irritability of the myocardium, strengthen the force of its contraction, and drive excess fluid out of the lungs, to be excreted by the kidney. Every resuscitation is different. Though the general pattern is similar, every sequence, every response to massage and drugs, every heart’s willingness to come back – all are different. The only certainty, whether spoken or not, is that the doctors, nurses and technicians are fighting not only death but their own uncertainties as well. In most resuscitations, those uncertainties can be narrowed down to two main questions: Are we doing the right things? And should we be doing anything at all?

Far too often, nothing helps. Even when the correct answer to both questions is an emphatic ‘yes’, the fibrillation may be beyond correction, the myocardium unresponsive to the drugs, the increasingly flabby heart resistant to massage, and then the bottom falls out of the rescue attempt. When the brain has been starved of oxygen for longer than the critical two to four minutes, its injury becomes irreversible.

Actually, few people survive cardiac arrest, and even fewer among those seriously ill people who experience it in the hospital itself. Only about 15 per cent of hospitalised patients below the age of seventy and almost none of those who are older can be expected to be discharged alive, even if the CPR team somehow manages to succeed in its furious efforts.

It has probably been known for centuries, even millennia, that the heart can stop, and be restarted, although nothing was written about it for posterity. Nearly two hundred years ago, a Dr Silvester described how it could be done, by laying the patient on his back and raising the arms, to aid inhalation, then lowering the arms and pressing them against the ribs, to aid exhalation. It is not recorded whether anyone believed him in the early 1800s.

A century later, the idea was taken up by several doctors, and a similar technique described, combined with mouth-to-mouth resuscitation. This technique was included in Scouting for Boys by Baden-Powell, published in 1908. Few other people took it seriously, and certainly not the conservative medical profession, who always take decades to accept a new hypothesis. But, for the whole of the first fifty years of the last century, it was vaguely known that if you fished someone out of the canal, or something like that, mouth-to-mouth puffing and rubbing the chest could sometimes be effective in restoring life.

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.[5]

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

— Dame Cicely Saunders