Tuesday, October 06, 2009

Spare Chaynge

Our attitude to death, or Death, if you will, constantly fascinates me. I suspect it is, at least in part, related to the secularisation of society. I think people fear death considerably more now they aren't assured that it means going to paradise to meet one's maker. Coupled with the idea that we can do so much to stave off death, this seems to me to have resulted in a world where we no longer accept that death comes to us all, and devote much time and money to prolonging the inevitable.

Even when this has been accepted, people seek to transfer the responsibility to someone else, usually the medical profession, often me, because I stand by the front door.
Last week, among the throng that seems to be increasingly the norm at South Coast General, and this is only the beginning of Winter, were two elderly patients who spent their last minutes in an overcrowded, noisy ugly room surrounded by strangers.

The first, an elderly lady, from a Care home. Her quality of life sounded poor, heavily dependent, demented. This is an all too familiar story. We are not evolved to live so long. Her family had seen her deterioration, and seemed to have made the sensible choice, that if she should become ill, she should be kept comfortable at what had become her home, and allowed to die. So when she did become ill, and collapse, the Ambulance was called. Once they arrived the Staff told them of the families wish that she should not be actively resuscitated. No 'formal' documentation of this plan existed: the fabled DNR, or Do Not Resuscitate. This leaves the Ambos with little, or no, choice. If you don't want someone resuscitated, don't call an Ambulance. Why call someone, to tell them you don't need, or indeed want them?
I suspect they wanted validation of their decision. Or maybe they just panicked. I don't know, but the end result was a crumbly, frail woman intubated and ventilated in my Resus room. Yes, her heart was beating again, but she showed no sign of purposeful neurological activity.

Next door, an elderly man, not quite so dependent, but a cardiac cripple, a man so determined to be at home he had taken his own discharge from hospital that very morning. He was unwell, and had been told so; much time had been expended counselling him, warning him of the risks he was taking. He understood, he was clear about that. He didn't care, he wanted to be at home.

He lasted a few minutes.

Now, I respect people's rights to give the NHS the big "fuck you". Many members of the public avail themselves of this right in my face, on an almost daily basis. Adults have to have the right to choose; I must confess to being slightly frustrated when this happens. We spend time counselling someone of the risks, they give us the big "fuck you", we spend money (taxpayers money!) getting them home, then whist we said would happen, happens, and they call an ambulance to come back again. (MORE taxpayers money!)
He, too was dying, and I think he knew it. His resolve to do it at home had crumbled.
They died on trolleys next to one another, both with plans to do so with dignity, at home, in comfort, in tatters.
Is it possible to have a good death? I think it is, but not in an overcrowded ED. I wonder if my nerve will hold when my time comes?


Conundrum said...

I used to work on the ambulances back in 2006, eventually left to do other things. If there is no DNR when attending a call then there is no choice about leaving them at home. 'Protocol' says take him/her to hospital toot sweet. If you dont, and a family member decides to complain, then you're out of a job. Choice, or 'bad decisions' dont come into it. Cos there's no deciding to be done at grass roots level. As long as ORCAN has been served the management dont give a toss.

Alice said...

To be fair though, it's one thing to sit around intellectually contemplating the fact that we're all going to die eventually and that home is a nicer place to be than hospital.

It's another thing to suddenly know that it's happening NOW, you don't know what to do, you only get to do it once, and you're very very scared. And quite possibly don't happen to have all the friends and relations around you that you'd fondly imagined would be there to see you off.

Seems entirely sensible that when it comes to it, most people want to at least be in the company of a load of people who have done "dying" many times before, and who officially Know What To Do in some way.

Personally I don't mind my tax being spent on these last minute changes of mind at all.

Might help if people close to death could be helped to formulate more realistic plans of action though.