‘What may I do for you?’
One late night, an old lady with advanced malignancy was admitted to the hospital. Routinely, I asked her family for their view on DNACPR (Do not attempt cardiopulmonary resuscitation). In reply, the family asked whether they should make the decision to do CPR or not.
‘No,’ I explained, ‘DNACPR is a medical decision made by the health care team and it does not require the patient’s relatives to take part in the decision-making process. As your mother has advanced cancer, if she leaves the world, she has come to the end of her natural life. We do not want to perform resuscitation or intubation on her.’
‘Do you mean that the relatives have no right to decide and you are not going to save her?’ asked the son, ‘We have the right to sue you if such a medical incident occurs.’
I sneered and said, ‘Of course, you have the right to sue but whether you will succeed is another matter. Anyway, you have to understand that resuscitating your mother is just to satisfy your wish. It will not do her any good and may cause her pain instead. It is OK to proceed with resuscitation as long as you understand this.’ As I spoke, my heartbeat raced, and I left the room immediately without saying goodbye. In fact, I was just bluffing like a paper tiger. I knew perfectly well that if the old lady had a cardiac arrest that night, I would resuscitate her unwillingly, whilst blaming the son for being inhumane.
Of course, I knew that had I had signed the DNACPR and the family subsequently made a complaint, I would have been fine in every aspect. However, I did not do so. Laziness, and a desire to avoid conflict prevailed. Instead I went for a snack with the nurses.
It was on the same day that Alfie Evan’s case sparked a huge controversy in the UK. Alfie, a one-year-old boy, suffered from neurodegenerative disease. He had been gradually losing life-sustaining function ever since he was born and was eventually put on a ventilator. The hospital in which he stayed succeeded in obtaining the court’s approval to remove his ventilator. However, his parents did not agree with this course of action and contacted an Italian hospital. Having obtained an assurance from the Italian hospital that treatment would be provided for Alfie, they applied for a hospital transfer. The request was rejected by the UK hospital stating that long-time travel would only worsen Alfie’s situation. The parents confronted the hospital in court thrice, but the ruling remained unchanged in the Supreme Court: Alife should not be transferred to Rome.
Alfie Evans.
Ultimately, Alfie died 5 days after his ventilator was removed.
Not being a paediatrician, I am not in a position to comment on how promising the treatment plan of the Italian hospital would be. The only thing I can perceive is that the UK hospital was facing a big temptation: Let go, hands-off, let the parents take the child away. It is none of our business once he leaves the hospital.
I am facing similar temptations incessantly. It is just CPR, why should I try so hard to avoid it? Pink curtains up, nurses in blue up the bed, the interns and the trainee nurses given the chance to practice CPR. One, two, three and with the fourth dose of adrenaline given, it’s time to go out and tell the family that you feel sorry for having failed to save the patient (do you really feel sorry?). After all, the patient has died. It is merely some chest compressions for a while on a dead body. How can it hurt? Why don’t we satisfy the family’s wishes? Why do I push the family to give the answer I want, i.e. “We do not want resuscitation”? Why do I keep nudging them until they give me my answer? What if there is no family to be asked?
I once took care of a curious old man who kept requesting to be discharged. Every morning when he saw me, he became agitated and started moving his upper body in rhythm. He struggled in a restraint jacket and threatened me, yelling, ‘If you do not discharge me today, I will…, I will…,’ He never completed the sentence and I always replied with a smile, ‘How can you be discharged when your kidney function is so bad?’ He gradually stopped yelling and fell into a stupor.
I fear taking responsibility as much as everyone else. When dealing with patients with no family or relatives, I try to delay signing the DNACPR. I tell myself that I will sign it, but not now. I will sign when his situation deteriorates a bit, then a little bit more. Finally, the curious old man could not wait anymore and suffered a cardiac arrest one night. Fortunately, he could not be revived after 20 minutes’ resuscitation. When I signed his death certificate, I reflected that other patients had their family members, but he only got me. If I had done a little more for him, he would probably have suffered less.
Unlike the old man, the old lady had a family; a son who loved her so much that he threatened to sue me. Actually, I would have surrendered whether or not he had threatened me. I always hope to do more for patients but there is always a gap between the ideal and reality. To the family, CPR means love, reluctance to let go or pension (see Freakonomics’ statistics on old-age pension and death rate of elderly people). To me, it is professional conduct and integrity.
When a phlebotomist asks to take blood from a patient, the latter will stretch out his forearm submissively. Taking blood is quite painful and I overcame my needle phobia only after I became a houseman. In general, sticking someone with a needle constitutes a common assault. Implied consent is given by the patient since a blood test is helpful for treatment. We give the patients pain for their own good. But is blood taking beneficial for the patients in their final stage of life? It took me some time to discover that writing ‘no blood taking/no inotropes/no positive airway pressure’ in the progress note is another way to protect end-stage patients.
On what basis can we assume that CPR and intubation for an advanced malignancy patient is a medical treatment rather than a common assault? Every time I am forced to perform CPR, I feel that my integrity is hurt. I hurt my patients by CPR, CPR hurts me in return. It is a fair world after all.
That night Alfie was still attached to his ventilator. Having finished my snack, I returned to the ward where the old lady was resting. A nurse whispered to me, ‘The daughter has just scolded her brother at the bedside saying, “You know very well that this is not doing any good for mom.”’ I made a gloating grin and was happy that I had found a secret ally. Earlier, I was so annoyed that I did not consider the feelings of other family members. Perhaps my firm attitude inadvertently provided support to the daughter.
Conflicts are unavoidable if standards are to be maintained. It may take a while for me to acquire the wisdom to better handle disagreements, but before that, at least I can be a person who is not afraid of facing conflicts; a braver person.
Dr Muk Lam graduated from HKUMed in 2016. She is currently working as a medical resident in a public hospital in Hong Kong.