What does resuscitation mean to you? If you presented that question to the world of social media you would be given a variety of answers. Out of those it’s likely that most could agree out of hospital cardiac arrest (OHCA) is the most common form of resuscitation pre-hospital care provider’s encounter. We spend countless hours preparing and honing our skills, keeping up on the latest evidence all for that chance in a single call to save a life. Bringing someone back from the clutches of death is an honour and I have been lucky enough to meet some survivors of which I have played a part in their resuscitation. The feeling is incredible. These moments are rare and we should cherish them because we know the odds with OHCA. Many patients are pronounced in the field, some in hospital and the few we get back do not have favorable neurological outcomes. As any resuscitationist should, I often reflect on past arrests, the ones I have been a part of and think about how they have played out. It provides an opportunity for reflection, improvement and better management of a critically ill patient.
Recently as I was scrolling twitter I came across a tweet posing a foundation shaking question: have you ever felt dirty after running a code? And no, not dirty in the sense that you need a kit change but rather during that moment of self reflection when you think, “Wow, I don’t feel good after that arrest.”
I paused for a moment, reflecting: I’ve found myself feeling this way on numerous occasions. Was I burned out questioning my career as a paramedic? No, that wasn’t it. I was reflecting on patients that I have come across at the end of their lives, in which we were obliged to resuscitate yet death had clearly come knocking. Had I put more emphasis on going through the motions? Instead of asking, “Can I?”, could have I been asking “Should I?”. Resuscitation is invasive, violent and often difficult to watch. It’s the farthest thing from dying with dignity and the last think I want to do to someone who did not wish it so.
As I mentioned before I have come across this on a few occasions. I work in a large urban center and typically see around 20-30 cardiac arrest per year. The scenarios can play out in different ways but I have a few that come to mind. The first one a middle aged male with terminal cancer. He was dying, but nobody expected so soon. His wife found him in bed in unresponsive and called 911. We arrived to find family members confused and scared… “He wasn’t supposed to die so soon”. The family was stunned and so was I: no advanced directive to not resuscitate; it’s not something that had been discussed yet with his physicians. I was a fairly new advanced care paramedic (ACP) at the time, helping to mentor a friend and colleague who was consolidating their training with me to earn his second stripe. He had not had much arrest exposure, so I was happy to let him take the reins to gain experience. After all, with no DNR order we were required to resuscitate this patient. The lines, drugs and tubes went in, but we suspected the outcome already. The resuscitation was terminated in the field and his family was informed of his death, they took it as well as anyone could. Over the next few days I couldn’t help but think why we put this man with terminal cancer through the trauma of a full resuscitation. Was this a system failure, a failure on the part of his healthcare team or a failure on my part as another human being striving to endorse compassion and empathy in all that I do for my patients? I felt ashamed, I asked myself if there another way? What could I do differently if I could do it all over again?
Fast forward in time and I found myself once again presented with another patient in cardiac arrest. An elderly female patient with stage 4 cancer, no DNR at home in a hospital bed. Upon arriving scene I go through the motions, I walk in to witness an ongoing resuscitation. I take in my scenery and began to think about situations I have been in before; this looked so familiar. I made quick contact with family and attempted to ascertain information on the patient – most importantly their final wishes. I was informed that the patient had a DNR but the family had revoked it when they noticed an improvement in her health over the last few days. Armed with this information I took pause – I asked the patients family if this is what the patient would have wanted, if they would want the efforts of full resuscitation? I explained the procedures that we would be doing and the steps we would take during resuscitation, also the steps we would take if they wished to have resuscitation stopped. It’s not easy to make these types of decisions when you are presented with the death of a family member. I gave them a few moments as I set up my equipment. They decided that their mom, their wife, their loved one was to be spared the trauma of an attempted resus. I made contact with a base hospital physician and explained the situation – they agreed with my thought process and I received a field termination of resuscitation.
I walked away from this code feeling a sense of pride and accomplishment, a stark contrast from the one I previously discussed. I had completed my job to the standard of duty but also given this patient an opportunity to pass in the peace of her home by her family with no tubes or IVs or defibrillators. She still had to endure the physical trauma of effective CPR but that’s the system – its not perfect. Death and dying is hard to see and talk about and family members are often in denial or scared to let go a loved one. We have a real need as health care providers to discuss advanced directives with our patients even if we think it’s up to their primary care provider. Paramedics often come in contact with patients during their multiple trips to the hospital, this is especially true for terminally ill patients. This might be the right time to bring up the topic and ask if they have discussed end of life wishes – to plant the seed.
I’ve learned from my experiences and have altered my practice. Putting human dignity over an opportunity to practice skills is the right thing to do. Ask a patient and their family about their wishes and do your best to honour them. And to quote a legend, “Are your intentions honourable?”. We are all humans and one day we might just be in their shoes. Let’s do our best to let dying people die with dignity.
– Drew and Ivan.