http://bmj.com/cgi/content/full/324/7330/172/a
Doctors' management should not make things worse for patients
Much
has been written about the need for "do not resuscitate" orders to be
explicitly determined by discussion with patients or their
relatives, or both. This has mostly been driven by fearof
litigation (by hospitals), of relatives (that not enough was done), and
by patient groups (that some effective treatment was denied).
Consequently, trusts have declared that policies based on a
controversial document by the BMA, Resuscitation Council, and Royal
College of Nursing should be in place.1 As
Fallowfield says, who in their right mind would discuss a treatment
that is futile with a patient with widespread metastatic malignant
disease nearing the end of his or her life?2 Well,
sadly, increasing numbers do.
Recently we were involved in the care of a 44 year old woman with
metastatic carcinoma. The disease progressed relentlessly despite
radiotherapy and chemotherapy, and much support was needed for her
and her family. Recognising that time was short, she decided to have
a holiday with her children. Not unexpectedly, but sooner than she
had hoped, her condition deteriorated and on her admission to
hospital it was found that she had developed lymphangitis carcinomatosa. She
was breathless and anxious to return home, so arrangements were made
for her to be taken by ambulance back to her oncology centre in
Scotland. Physically and emotionally she was distraught.
Just before she was taken to the ambulance, a doctor whom she had met once
before came to tell her that it was policy for patients in her
situation not to be resuscitated should their heart stop in the
ambulance. She was asked to sign a form confirming her agreement.
She knew she was dying, her mother knew she was dying, and one
presumes the doctor also knew this. Nevertheless, a signature was
required. She spent seven hours in the ambulance terrified that her
heart was going to stop. The paramedics were sympathetic, but she
could not forget this conversation and was inconsolable; it haunted
her until she died one week later.
There is something deeply disturbing about our response to impending death
as a result of advanced incurable illness. Death due to cancer is cruel
enough; our management should not make it worse.
Pam Levack
PALevack@aol.com
Ian Cairns
Phyllis Guild
Helen Dryden
Ninewells Hospital Palliative Care Team, Ninewells Hospital, Dundee DD1 9SY
|
1. |
BMA, Resuscitation Council (UK), Royal College of Nursing.
Decisions relating to cardiopulmonary resuscitation: a joint statement
from the BMA, Resuscitation Council (UK), and the Royal College of Nursing.
London: BMA, RC, RCN, 2001. |
|
2. |
Fallowfield L. An unmerciful end: decisions not to
resuscitate must not be left to junior doctors. BMJ 2001; 323: 1131 |
|
Related letters in BMJ:
An unmerciful end
Lesley Fallowfield and Neville W
Goodman
BMJ 2001 323: 1131. [Letter]
ALL INFORMATION, DATA,
AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR
OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING
MEDICAL OR LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN
IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN
CONSULTATION WITH YOUR HEALTH CARE PROVIDER.