Grey Areas

”67 year old male, ? overdose, acting aggressively”

Despite the offer of police assistance we declined and said we'd be happy to investigate first and then request police only if necessary. I felt that with 3 of us on hand we should be able to manage by ourselves! As I've written about previously, it saddens me to attend suicidal elderly patients. They are given anti-depressants and sedatives like smarties. It almost feels like they are given them just to shut them up. Rather than address the cause, let's just make them sleep more, eh?!

We pulled up outside and were met by the patients daughter. She told us that he didn't know we were coming and that he wouldn't be remotely pleased to see us! Regardless of health problems I really wish people wouldn't do this! It makes our job infinitely harder and sets us off on an uphill battle from the get go! I understand why people do it, the emotional tug of loved ones is hard to ignore, it just makes them much harder to treat when we do arrive.

Sure enough, we were greeted with a steam of expletives. Reading between the lines, I think the essence of what he was saying was "Go Away". I am, of course, paraphrasing! He was indeed confused and overly aggressive, nothing like the way he appeared in all his photos. Apparently, he had taken an overdose of pretty much everything he had. We weren't sure exactly how much and of what, but he did need medical help, that was for sure. His family had rung the GP, but the minute they said 'overdose', the GP rightly called us.

At this juncture, where a patient is refusing treatment, but is, in our opinion, in need of help and may lack the capacity to refuse, we would assess him under the Mental Capacity Act (2005) to determine whether he has the capacity to refuse. It involves a form and some questions. The upshot is, the patient needs to be able to explain a rational and reasoned decision and withhold information given to him. If he fails, in our opinion, them we have the right to treat him against his will. It is a crude tool that is often mis-used but in a patients own home, is all we have available to us, short of the GP arranging a mental health assessment and a sectioning. That, doesn't happen quickly, by any stretch of the imagination!

Now, all I've just said, we did. We assessed his capacity, for what he had done. Every question we asked him he replied something like:

"Fuck off, get out of my house, you're not taking me to prison."

I didn't take it personally, clearly something was going on. There was a twist however. Under normal circumstances I wouldn't have thought twice about taking him to hospital for treatment. The issue was that he was a palliative care patient with weeks to live.

Is it morally right to force someone to have treatment in hospital when they want to die at home? There was a DNR in place and this mental deterioration was likely due to the cancer. Surely his previous wishes of non-treatment should be adhered to?! That said, we weren't here for his cancer or even his mental deterioration, we were here for the overdose and that was something that could be treated without conflicting with the wishes of the DNR. Yet again, we were stuck in a grey area, a mine field of mental health uncertainty! I certainly wasn't comfortable with putting him through the distress of being physically forced into going to hospital. And the likelihood was, if we had to take him, then it would be the police who would have to physically drag him out screaming. It isn't how I'd want my friends and family to remember me. 

We decided to call the GP back. Luckily, after eventually bypassing the GP reception security and interrogation I was put through to the locum doctor. She didn't know the patient and it would have been very easy for her to pass the buck and be of little help. Instead, she was excellent. She agreed hospital was not the right place and offered to come out and assess him. Due to his aggression and refusal of treatment, even at home, we requested police. This wasn't necessarily a police job, it was health related, and even though mental health is a huge part of police work, this still wasn't really their remit, but we felt their presence was necessary for the safety of us and the GP. Within half an hour, everyone was there, and with the assistance of the police, he got assessed by the GP. 

She decided that based on what he had possibly taken, he could stay at home. She offered to come back later and check on him and if further treatment was required she would call us back or arrange a home assessment. We thanked her, thanked the police, and we all left.

THIS is how healthcare in the NHS should work. THIS is how mental health should be treated and THIS is how the police should be used with regards to mental health. An outcome that is in the best interests of the patient. An outcome which is as least restrictive as possible and utilising the police when they are needed and not because the words 'mental health' appear. The NHS can work, inter-professional working can work and work very well. There is no need for us to stretch each others resources when it isn't appropriate. The patient got the best and most appropriate treatment, taking into account his physical and mental well being. Perhaps if other areas of the NHS can see things like this as a model for GP led treatment then things will start to improve. 

A Beautiful Death

"97 year old female, DIB, terminally ill"

There is always a sense of appreciation when you are sent to someone so elderly. So many years of experience and knowledge. It's hard to comprehend being alive in 1915. George V was king, Herbert Asquith was Prime Minister and the world was at war. It's an era most of us are lucky not to have been a part of but similarly it's an era and generation where respect is embedded. We arrived relatively quickly, despite the weather and the traffic and were met at the door by the patient's son-in-law. A welcoming smile greeted us and we were thanked for coming. It may sound silly but we a rarely thanked for coming, it's not that I look for thanks or notice when it's not given, but I do notice when it is given and appreciate the gesture. We followed him through the house and up to the bedroom of the annex. 

Our patient was laying in a cot-bed with her daughter at her side. She looked very frail, very pale and exhausted. Her respiratory rate was about 50 and you could hear the bubbling on her lungs as you entered the room. Her oxygen levels were extremely low so we started her on full flow oxygen. She was suffering an acute episode of heart failure. Basically, the heart wasn't pumping properly and fluid was backing up on her lungs. She needed hospital and she needed it quickly. I started to set up the chair in preparation for moving her while my crew mate did her blood pressure.

"We don't want her to go to hospital. She has said she doesn't want to go."

Unfortunately, she was now in such a bad way she was unable to talk, her eyes fixated on the ceiling, breathing was taking every bit of her being. There was no DNR (Do Not Resuscitate) order in place or any palliative care program despite her late stage kidney disease and heart failure. She had been seen by her GP a few weeks previous, who had stopped all of her medication and recommended palliative care but as yet nothing official was in place. This put us in a the very grey area of capacity and our duty of care to act in the patients best interest. We knew that if we left her at home she would die and if we took our oxygen away she would die, but we also knew that with no DNR in place, if she was to die in front of us now, we would have a very difficult job to justify not starting a resus. As horrible and futile that would be on a 97 year old we have to start unless a DNR is in place.

We explained all this and the family were very understanding of our predicament but also quite rightly adamant that they wanted what was best for her and her wishes.

"She wants to die at home, with us and not in a hospital, we are scared that if you take her she won't come home."

She was right, she probably wouldn't. Our thoughts were, that this episode of illness was terminal and it was going to be a matter of hours not days. We needed a plan B and we needed it pretty quickly! We called our local out of hours GP service and explained the situation. After much much debate and various phone calls later, the GP said he'd be with us within the hour and would be able to provide a DNR for us and some medication for the patient. That was a great relief to the family. It was now not about taking her to hospital but about what we could do to make her comfortable. We spent the hour monitoring her and talking to her daughter and son-in-law. Despite the obvious emotion of the situation they showed great interest in us. We talked about the job, what we did before the job, our families and health care. All the while our patient was lying in between us all, fighting hard. Nothing we had done had improved her breathing, it was as bad as it was when we arrived and that was hard to watch. 

Before long the GP arrived. His professionalism and bedside manor was excellent. He engaged with us in everything he was doing and we assisted him drawing up various drugs. He explained everything he was doing to the family and explained he was making her as comfortable as possible. The DNR was openly discussed, written and signed. Everything was in place now for her to die on her own terms. 

We had been on scene for just over two hours before her breathing started to settle down. Her blood pressure was gradually dropping, 102/68, 93/52, 77/44, 63/38. My crew mate was outside the room with the GP and the son-in-law whilst I stood with the daughter, who was holding her mums hand tightly. 

"Is she going to die tonight?"

I knew the answer but didn't know how to respond. Partly because I was choked up and holding back the tears but also because telling someone that their mum is about to die isn't something that is said easily.

"Stay holding her hand, she knows you're there."

She knew what I was saying and asked us to remove all of the monitoring equipment. I left her by the bedside. She told her mum how much she loved her, how much she has inspired her and how much her grandchildren loved her. I ushered the son-in-law back into the room and we stood in the doorway as they said their final goodbyes. The time was now. She wasn't afraid of death and neither was her daughter. Her respiration rate slowly dropped and dropped until she drew her final breath. Very slowly her eyes closed and she let go. There was a peaceful smile on her face It was in that moment her daughter turned to me with a look of fear and desperation and said:

"No, Has she gone?" with tears pouring down her face.

It was as if as much as she knew it, and had made peace with it, but in the moment of death a fear of death had gripped her. I just nodded my head. I walked over and removed the oxygen mask, unable to hold back the tears trickling down my face. We shared a look, one I'll never forget. A look full of appreciation that our inaction had been the greatest gift we could have given their family. It was one of the most heart breaking and distressing things I've ever witnessed yet beautiful at the same time. To be there with someone who isn't afraid of dying and is ready to die, and share that with the family is a humbling experience and one I will never forget. I was so thankful that we avoided a resus because it would have seemed such a tragic way to end what had been a wonderful lifetime.

We went downstairs and in a very British way made them a cup of tea. That is, after all, the done thing in such circumstances. After saying their final goodbyes they came downstairs, teary eyed yet almost relieved. Relieved that they had been able to fulfil her final wish. Death in any circumstances is difficult, but ultimately it's the sacrifice we must all pay for living.

'To die proudly when it is no longer possible to live proudly. Death of ones own free choice, death at the proper time, with a clear head and with joyfulness, consummated in the midst of children and witnesses: so that an actual leave-taking is possible while he who is leaving is still there.'

                Friedrich Nietzsche

Peace..........

"41 year old female. DIB. Lung cancer patient"

In health care, no one really wants responsibility. We are bottom of the food chain and from us, upwards, there is a long line of people to pass the buck onto. We pass the buck to a nurse, who passes it to an HCA, who passes it back to a nurse. The nurse in turn passes it to a House officer (junior doctor) who passes it onto a Senior House officer who passes it to a Registrar. If the Registrar doesn't know what to do he passes the buck onto a Consultant; top of the food chain. If they don't know what to do, you'll probably die. Sometimes however, this marvellous system of avoiding blame is scuppered by someone not going to hospital. The problem here is that if the GP has been to see them and wants them to go to hospital he or she will phone an ambulance. If the patient refuses you end up with the buck stopping with the lowest level of the NHS. The only place we can turn is our illustrious Clinical Support Desk. However, those who have had contact with our CSD will know they have a phrasebook consisting of only three phrases:

1. That's a decision you'll have to make.
2. I'm afraid that's a grey area
3. Please hold the line..................That's a decision you'll have to make.

Needless to say, when the buck stops with us there is nowhere to turn making these jobs some of the most difficult to deal with.

This particular job was a case in point. We were sent to a private residential address where the GP had already visited. He had assessed our patient and been told by the family that our patient did not wish to go to hospital and would not go to hospital. Needing to pass said buck, we were called. Whether he thought we could convince her to go or just didn't want the responsibility of leaving someone struggling to breathe I don't know but the end result was the two of us entering Amy's bedroom armed with our bags and a smile. Amy had lung cancer. The very late stages of the disease. The disease that had manifested itself throughout her body. A disease that can attack anyone without cause. She'd never smoked, lived a healthy life and worked hard. Where is the justice? She was in palliative care, at home, with her family at her side. When we walked in we were introduced to her two daughters and her husband. Her mother and father were also present. It was a very sombre affair.

"Please don't take her to hospital, she wants to die at home, please" 

"We won't take her anywhere she doesn't want to go"

As I said that, Amy took hold of my hand and gently squeezed it. She didn't have the strength to speak but mouthed 'thank you' to me. She was struggling to breath, her resp rate was high and her SpO2 was very low so with her permission we gave her some oxygen. We spent a while talking to her family while checking her over and it was a very humbling experience. They were such a lovely family, at peace with the inevitable but had called the GP because their mother / wife / daughter was suffering. She was on a syringe driver for pain and everyone was just waiting for her last moments to come. I felt like an impostor that didn't belong there. This family needed to say their goodbyes in private but we couldn't leave our oxygen with them. Obviously when Amy was comfortable we could leave but in taking the oxygen away I didn't want to be the cause of her passing. I phoned clinical support and got a combination of answer 2 & 3 from their book of knowledge. We agreed that we'd go and do our paperwork then come and get our oxygen before we needed to leave. I told Amy what we were going to do and in a moment that I'll never forget she closed her eyes with a smile. As she opened them a tear trickled down her cheek. Being left at home with her family was her only wish and we were able to give that to her. In all honesty we should never have been there but that's the system. 

We sat in the ambulance for a little while doing our paperwork, it was a very sad job and one that frustrated us. It wasn't the fact we were called knowing there was nothing we could do, it wasn't that the buck was past. It was the fact that we'd intruded on a families precious last hours and had to stick around so we could tick all of our boxes and cover our asses. For every job there is a paper trail. One that is scrutinised by our service and what our performance is judged on. That was frustrating. We went back in to get our O2 and leave a copy of our paperwork. I was halfway up the stairs when an unmistakable sound engulfed the landing. It was the sound of sobbing, the sound of pain, the sound of grief. In the fifteen minutes that we had been gone Amy had passed away. Passed away with everyone she loved, and who loved her, at her bedside. Her suffering was over. We sat on the stairs for twenty minutes feeling rather numb. Her husband came back out of the room, tears pouring from his face, yet he was smiling. He was happy his childhood sweetheart could hurt no more. I entered the room to confirm death so I could fill out our Recognition Of Life Extinct form. She looked asleep still with the half smile on her face. She was at peace. I felt the lump in my throat so decided just to grab by bits and make my excuses. I'm sure there is some procedure I didn't follow to the letter and a box I didn't tick but I don't care. There was nothing for us to do and we had no place being there now. I left the paperwork on the dining table so the family could make the arrangements they needed to. Us? We went to go and do another job.