COMMENTARY

A&E Perspective: We Need to Talk About Dying

Dr Dan O'Carroll

Disclosures

April 10, 2019

In 1993's Jurassic Park, Jeff Goldblum's character, Dr Ian Malcolm, argues against the idea of defying nature and going against ethics to genetically clone dinosaurs.

"Your scientists were so preoccupied with whether or not they could, they didn't stop to think if they should..."

Modern medicine often puts us in a position of being able to seemingly defy nature. I'm not convinced that we are always asking ourselves if that's right and if we should?

   

Dr Dan O'Carroll

As the emergency departments (ED) across the country continue to creak at the strain of a seemingly endless winter period of unrelenting pressure and overcrowding, ED consultants are increasingly finding ourselves trying not to decide what is the best and most appropriate treatment for a specific patient, but asking ourselves whether any treatment should be administered at all. This dilemma is facing us all on an almost daily basis.

One of the proposed new standards for EDs is thought to involve sepsis. Matt Hancock, Secretary of State for Health announced on his twitter account: ‘Sepsis kills over 52,000 every year - each death a preventable tragedy. So we're introducing new guidance to use #data to identify & treat sepsis faster - and save more lives.'

There are suggestions that trusts could face financial penalties if they fail to meet the new guidelines.

Frequently, clinical acumen and expert opinion are being pressured and over-ridden to meet sometimes arbitrary targets.

Make no mistake, I fully support efforts to try to ensure that those patients with sepsis receive the administration of antibiotics as soon as possible as well as the other supportive measures usually given in the sepsis bundles. There is no doubt that many lives have been saved by this campaign.

Problems can arise when just the blunt parameters are looked at and sepsis can be difficult to diagnose or differentiate from other conditions. For example, the COPD patient who has low oxygen saturations (normal for them) and a tachycardia due to the nebulised beta-agonists. These patients will be hitting the red-flags for sepsis. There may well be an infective process exacerbating their COPD but in many of these patients blood tests fail to show any signs of infection.

Clinical discretion can be challenged as we're penalised or criticised for not administering antibiotics within the first hour and frequently our strongest broad-spectrum antibiotics are being used as we're not able to work out the most likely appropriate antibiotic. Concerns regarding antibiotic resistance and the developing 'superbugs' are put to one side.

Red Flags

Probably the most common alert call received by ED now is for 'Red Flag sepsis'. An alert call is made by the ambulance crew, who are pre-warning the ED that they are conveying patients who are very sick or those that may require time critical interventions.

These patients are often very frail with (subjectively) poor quality of life, often with dementia, and PEG fed. Many are bed bound and doubly incontinent. Ambulance personnel are called and find these patients extremely poorly, often from urinary tract or chest infections, and they convey them to the hospital. They pre-alert the department so that space can be made and so that they can be assessed immediately. They are then transferred onto uncomfortable trolleys, where we have the opportunity to stick many needles into them to take blood tests, and administer fluid and antibiotics. All of which needs to be done against the ticking clock.

Frightened and scared these vulnerable patients are in unfamiliar, noisy and unwelcoming environments. Frantic relatives are summoned to the departments and are warned that this might be the terminal event for their loved one's life. ED doctors, who have, likely, never met the patient or the relatives need to discuss DNACPR (Do Not Attempt Cardiopulmonary Resuscitation). Relatives already upset are then made to feel they are 'giving up' on their loved one, and as a result of their decision, their relative will pass away.

Death Discussions

EDs are not the right places to be making these decisions. These decisions should be made in a calm environment, under no time pressure so that the best interests and likely wishes of the patient can be fully considered. We can give guidance, and often, bluntly, will say that attempts at resuscitation would be futile, and if need be, we can make these decisions on purely clinical grounds and against the relatives' wishes. This is not something that any of us would like to do, and it is best avoided.

It's not just patients with infections or sepsis this applies to. Too often ED clinicians are having to have discussions with patients that are plainly in the last stages of illness, whether that be extreme frailty/old age, or even advance stages of cancer, where the patients are aware that they are for 'no further treatment' or palliation. Too frequently there have been multiple medical contacts in the days and weeks before the current crisis where opportunities to discuss and make advanced care plans or DNACPR are not taken.

Why aren't these opportunities taken? Why are we afraid to admit that there is nothing more to be done, from a medical perspective other than keep the patient comfortable?

Dying at home, not suffering, not in pain, whilst with loved ones is surely what most of us would prefer rather than being surrounded by strangers having unnecessary invasive investigations or treatments which are going to be futile. Only 3% of respondents in a survey answered that a patient had 'wanted' to die in hospital.

We've become much better at anticipating the need for DNACPR forms, but we need to be better at the advanced care-planning and recognise that as we get older these discussions should be had in advance of the need for them. Average life expectancy once admitted to a care home is around 26 months. Doctors have a responsibility to have these difficult discussions with the patients themselves, and where possible, with the patient’s relatives. To make plans and establish what is in the patient's best wishes, whilst giving realistic expectations of recovery from illness or disease progression.

I know which of the above scenarios that I would prefer.

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