“Good morning, it’s Gregory the surgical SHO. You bleeped – how can I help?”
To contact a doctor overnight, you generally paged them, and I had a well-rehearsed patter when replying. The delivery was slightly too jaunty for 2AM on a Saturday morning, but there were worse images to project than eccentric enthusiasm.
“Hello, it’s Sabine the sister on ward eight. Can you review Mr. Amir? I think his breathing has gotten worse.”
My heart sank. I was on call, and although Mr. Amir wasn’t under my team when I was working normal shifts, I knew him by reputation. Metastatic colorectal carcinoma, resection was unsuccessful, leaving him with both a poor prognosis and a major operation to try and recover from. I had heard his team talking about him with little hope – the best case scenario would be he would recover from our forlorn attempts to help him and could go home with palliative treatment. The worst case would be that he would die in hospital. I knew he wasn’t doing well: recurrent chest infections, multiple courses of antibiotics – ineffective, poor wound healing, bedbound.
“Of course. Is there a purple form?”
“Yes, there is.”
Purple form – a euphemism for ‘Do Not Attempt Resuscitation’ form. Unlike the movies (or the medical dramas) chest compressions and electric shocks seldom revive someone, and still more seldom lets them leave hospital with acceptable quality of life. Better than nothing, but not always: for a frail terminal cancer patient the chances are so remote it might be better to let them die without battering their body one last time.
Yet many have inappropriate attempts at resuscitation. Partly this is unjustified optimism – doctors tend to overrate their patients chances, and so fail to prepare for a terminal decline. Another part might be cowardice: best practice (if not legal requirement) is to discuss resuscitation decisions with the patient and their family, and few doctors relish telling their patients bad news or be confronted with the fact they did not make them better.
There are helpful rituals you are taught about ‘how to respond to a bleep’: confirm patients details, ask for observations, read-back, etc. Asking for DNAR status might give the wrong impression – that if they are not for resus, you would care less if they deteriorate. Yet I knew I did not want to resuscitate him if he was dying, and if there wasn’t a ‘purple form’, I’d have to get my boss urgently to complete one. I figured I could address other issues when I was there.
“I’m on my way.”
I marched sleepily along the white linoleum to the ward. Dark, with the exception of a low sallow glow around the nurses station. One of the women noticed me and prodded her colleague, who noticed me in turn.
“Hello doctor, thank you for coming.”
“My pleasure,” I said, moving around to get Mr. Amir’s notes. “What’s up?”
She stood and followed me. “It’s Mr. Amir. His breathing is really laboured, and he isn’t responding to anyone. The family’s there, they’re really worried. I am too, to be honest. I think he might die.”
I nodded, flicking through to the last couple of days of his medical records. No clinical improvement, microbiology recommended another course of antibiotics, poor wound healing from tissue viability, unable to engage with physiotherapy. Plan: Continue. I flicked back for a plan of escalation, scanning for the phrases “ceiling of treatment”, and “ward based care”. Nothing. Irritation flared – why hadn’t the day team made a plan for this eventuality?
“Dare I ask the observations?”
“Blood pressure one-hundred ten over eighty, pulse one hundred and twenty, saturations ninety one air – they’ve gone up a bit on nasal specs. Afebrile.”
Not awful. “Thank you.” I scanned the board to check where he was – still side room two. “I’ll see what I can do.”
“Thank you, doctor.”
The light from side room two cut across the corridor. It’s texture shifted, hinting at people moving in the room beyond. There were ‘bedside notes’ on a table nearby, I leafed through them, more out of distraction than anything else – my mind rehearsed the various possibilities. I put the notes down and rounded the corner.
Mr. Amir stared at me through the open door, eyes uncomprehending and mouth agape, breathing a rapid, irregular, wet rasp. His family huddled around him. Despite the scientific and technical advance of modern medicine, much still relies on gestalt impressions and gut instinct: “what does the patient look like from the end of the bed?” My adrenaline surged; He was dying.
“Hello,” I said.
The family turned to me as I stepped inside. “He’s sick,” one of the men said.
“Yes, he’s very sick,” I said. I was trying to lay the groundwork for a conversation I was going to have to have in two minutes time. Doctrine is that when breaking bad news, it is better to give some impression – ‘a warning shot’ – that the news is going to be bad before coming straight out with it.
“Mr. Amir, can you hear me?” I said. Nothing. I shock him gently, then more vigorously, repeating myself. The third time his eyes met mine, but he said nothing. Very bad signs.
“Alright, I’m just going to listen to your chest.” I said.
I assessed him, mostly to buy myself time – I knew what I was going to find. Airway clear. Probably sepsis, is it reversible? No. Has had antibiotics for weeks. Next step would be intensive care, they wouldn’t take him, no prospect of good recovery. Would be wrong of us to even ask. Respiratory rate 30, saturations 92%/Nasal specs, bilateral crepitations across both lung fields, mild bilateral wheeze, air entry reduced both bases. God, his chest sounds awful. Chest sepsis? Not that it really matters. Sepsis Six? Seems futile, inhumane. Could push in more oxygen – treating numbers, not the patient. At least not Cheyne-Stokes. Yet. Heart rate 135, irregularly irregular, blood pressure 85/60. Haemodynamically unstable. Septic shock by definition. His family keep looking at me. How much do they know? They must suspect – I really hope they do. Not orientated in time, place or person, responsive to pain, GCS ~ 4+2+5. Temperature 38.0. I could bounce this to my senior. What if he’s in theatre? Abdomen soft, no tenderness demonstrated. Central laparotomy scar with dressing.
I put my stethoscope and looked at the family, all staring at me. I could run and hide behind being a junior: “He’s very sick, and I need to get a more senior doctor to help me” – leave the difficult conversation to him. Yet he might be with another patient, or in another operation. More importantly, I should be braver: I was here, I knew what was going to happen, and I should tell them, even though it would be unpleasant to. Worse for them – even more so the longer they are kept in limbo. One of my seniors sent me to see an end of life patient on the ward round because he found it ‘too depressing’. I resolved I wouldn’t do the same. It was time to practice what I had inwardly preached.
I looked down at the linoleum, then up again. “We need to talk.”
One of the men stepped forward – oldest son? “What do you think, doctor?”
I gestured outside and followed him out, stopping just beyond the open door. I’m not sure why – I would still be audible to everyone in the quiet, and my brain clicked through the medical ethics: fine to disclose to family in best interests, patient had a right to know he was going to die, so why take steps to conceal this, even if he could not comprehend anyway?
Here goes. “I’m very sorry, but Mr. Amir is extremely sick. I know he has remained unwell before despite our treatment, and has now gotten a lot worse. I do not think there is anything more we can do.” I paused for a moment, mind compiling the next sentence whilst the ones before sank in. “I do not think he will survive this illness, and I fear he may die tonight.”
I tried to gauge the man’s face in the poor light. No immediate reaction – maybe he already knew, or at least thought. He past me to his father, then back at me. The muscles in his face gathered themselves.
“His daughter will be back any moment now. I want you to tell her exactly what you’ve told me.”
I nodded. She arrived a moment later, eyes darting between the three of us. I almost smiled, but stopped myself half way.
“Hello,” I said. I recognized her now: I had spoken to her a week or so ago, again when I was on call. We discussed Mr. Amir’s condition, and I dared to be hopeful: the surgery hadn’t worked, I told her clearly, but he had made a good initial recovery, and we were hoping to get him home – maybe with some extra treatment. I wished I could have gone back and erased my words.
“What’s wrong?” She asked.
“I’m sorry. Your father is very unwell.” I said. I stepped back inside and they followed. The rest of the family had heard me the first time. I turned to her. “I remember, we met a little while ago, it was nice-” – idiot! Nerves. I tried again. “Last time we spoke about the operation, and how it has not worked. Mr. Amir has had many very bad chest infections since then, and none of the drugs we have been giving have worked. The infection has gotten a lot worse, which is why his breathing is bad and he doesn’t respond to any of us.”
Her eyes glistened. I pressed on. “The fact that does not respond and his observations are poor – and his chest sounds so bad when I listen – are all very bad signs. I do not think there is anything more we can do. I’m sorry. I think he is going to die.”
“How long?” The son said. I took the chance to look away from her.
“I don’t know, it is hard to say. But not long – he is very unwell. He may die tonight.”
“What happens now?” she said. Crying now.
“At the moment, although Mr. Amir is very sick, I don’t think he is in any pain or distress,” I waited for a second for them to nod in agreement. “I will change the drugs we are giving him so we can make sure he doesn’t suffer. I will also discuss what has happened with my senior to see if there is anything I have missed. I appreciate I have told you a lot you didn’t want to hear. Do you want to ask me anything?”
Silence. “No, thank you,” the son said finally.
I stopped my verbal reflex to say ‘any time’. “Good bye. If you need anything or want to ask anything, I am here all night.”
I pulled the drug card off the door and walked back to the nurses station, and grabbed the phone, dialling in the number for the night surgical registrar. He rang back a moment later.
“Hi, it’s Dan the surgical reg.”
“Hello, it’s Gregory the F1. May I discuss a patient with you?”
“Do you know Mr. Amir?”
“Yes. Has he died?”
“Not yet, but I think he will: desaturating, tachypnoeic, chest awful, tachycardic, hypotensive. It looks like chest sepsis, and it has happened whilst being on Mero and Gent. It’s not entirely clear what the day time thought the escalation plan would be, but I can’t see him being a candidate for ITU. I told the family I thought he would die. I was going to start end of life care meds.”
“Yeah, that’s fine. I have a case in theatre now, but after that I’ll come to talk to them. Happy for now?”
“Bleep if you need me. Night for now.” He hung up.
I put the drug chart down on the desk and crossed out most of it. Antibiotics, anti-hypertensives, iv fluids, nutritional supplements, all now futile. I kept the paracetamol but changed it to iv – he couldn’t take tablets. There are a set of medications one prescribes ‘just in case’, for pain, agitation, nausea, secretions. Previously it lay under the Liverpool care pathway. The name has gone, but the principle remains.
“What’s the verdict?” Sabine said, emerging from one of the bays.
I shook my head, taking the medical notes I left on the desk. “End of life.”
I started writing, stress transfiguring into irritation at what the day team missed. It emerged in a marginalia of passive-aggressive verbiage: I note that despite protracted deterioration, there has been no clear plan regarding ceiling of care; regretfully, family’s knowledge of course and prognosis unclear; Impression: inadequa– I stopped myself. Hindsight is always perfect, and a precipitous decline perhaps was not so easy to anticipate ex ante. Besides, too unprofessional and catty. Better to talk face to face.
The son walked past me, speaking Arabic into his mobile phone. He nodded at me – I did the same awkwardly.
“LCP?” Sabine asked.
“Effectively,” I said. I waited until I was sure the son was out of earshot. “He’s dying. Further treatment is futile. I have stopped all the irrelevant medications. I have talked to the family and warned them he may die soon. My reg will come to see when he can.”
“Stop them. I expect they will get even worse, but we will not act on them regardless.” I got up and started to leave.
“Sure. Thanks a lot Greg.”
“Any time,” I muttered.