Paramedics are trained to save lives through cardiopulmonary resuscitation (CPR). They attempted to resuscitate approximately 28 000 people experiencing out-of-hospital cardiac arrest (OHCA) in England in 2013 (British Heart Foundation, 2014). Members of the public are urged to reduce the time to first chest compression by getting involved themselves (Resuscitation Council, 2017). As a person who has received resuscitation, as a member of the public having stepped forward, and as a qualified nurse, I have experienced resuscitation from all sides. I am living proof that resuscitation works—but my current work in a care home has made me aware that while paramedic and bystander CPR saves lives, sometimes decisions are made to stand by and let go instead.
Coming back to life
When I was a toddler, I choked on a boiled sweet. I became silent and turned purple. My quick-thinking mother (a carer for children with learning disabilities) picked me up by my feet, sharply slapped my back, and the sweet came flying out. I was one of the lucky ones and didn't need CPR; 2-year-old Francis Dean choked to death on a hard-boiled lollipop (Bunyan, 2009). In fact, 5051 people died from choking in 2015 (National Safety Council, 2017). When someone is choking, the need for CPR can rapidly develop (St Johns Ambulance, 2015).
As a University student, I suffered a grand mal seizure and stopped breathing. My mother came to the rescue again, administering CPR before the ambulance arrived. It happened in Singapore, I received first-class hospital treatment but it did rather interfere with the holiday of a lifetime.
During a college firework party, the crowd rushed back to avoid a rocket headed in their direction. I was crushed under a heap of people at the bottom of a garden pond on a cold November evening. Adrenaline, not my mother, resuscitated me that time.
Bringing back to life
I have been the person to send out the emergency call in hospitals when cardiac arrest occurs. As the skilled team got to work with airways, defibrillators, cannulas, and even thoracotomy scissors (for cases requiring open-chest cardiac massage), I would wait to receive instructions. However, some patients were revived, and others were not.
Life support presents altogether different challenges on the street corner, involving paramedics and the public. A young man lost his lower leg following a motorcycle crash outside my house; my bathroom towels stemmed the blood flow and perhaps helped save his life until paramedics arrived. My great aunt collapsed with an abdominal aortic aneurysm at a family funeral. I was one of the family members to assist in CPR before paramedics arrived. She later died.
Even when attempts fail, it's essential for non-professionals to be trained in basic life support and be prepared to have a go. The British Heart Foundation (BHF) (2014) states that 80% of cardiac arrests that happen are OHCA and happen in the home. Of the 60 000 cases of suspected OHCA attended to by UK ambulances in a year, less than half will have resuscitation attempted by a paramedic—either because the person has been dead for several hours or because a resuscitation attempt is now deemed futile, since no early attempt had been made by a bystander (due to lack of confidence or training) (Perkins et al, 2016).
Through their #Don'tStopAt999 campaign, the Red Cross is keen to increase CPR participation by encouraging training in schools and for new drivers, calling for first-aid skills to become a part of the driving test. (British Red Cross, 2017).
Modern technology is lending a helping hand to those willing to become involved. A life-saving application (‘app’) designed to allow users to find the nearest defibrillator has been launched by South Central Ambulance Service NHS Foundation Trust (2017). This is proof indeed that paramedics recognise the role that the public can play in resuscitation
Standing back
Most residents in nursing homes have a Do Not Resuscitate (DNR) Order on their notes, with the decision always made between the doctor, the family and the resident wherever possible. ‘Futility’ and ‘fragility’ are the most often cited reasons for these orders.
Many of these people lie in the ‘shadowy and vague boundaries which divide life and death’ as described by Edgar Allan Poe in The Premature Burial. Speaking of these boundaries he said:
‘who shall say where the one ends, and where the other begins?’
The DNR order acknowledges this mystery, and removes human intervention or interference from it.
Early discussions surrounding DNR are essential. When the paramedics are called, their first priority is to ascertain resuscitation status. It's too late to make the DNR decision once the patient has almost died, although the British Medical Association (BMA), the Nursing and Midwifery Council (NMC) and the Royal College of Nursing (RCN) launched a joint statement earlier this year to assure doctors and nurses that when ‘irreversible death’ has occurred, they should be supported in a decision not to commence CPR (RCN, 2017). This clarification was needed after a nurse was disciplined for failing to contact paramedics or attempt CPR on a patient who was ‘waxy, yellow and almost cold’ even though no DNR order was in place (McCartney, 2017).
What else we can offer?
When the person is not for resuscitation, paramedics may still be of paramount importance. CPR may not be appropriate but individual decisions need to be made about the appropriateness of antibiotic therapy or whether fluid resuscitation is fitting on the seriously ill patient. I recently called paramedics to an urgent case of septicaemia; the patient had a DNR order but other valiant attempts were still made to save him.
If the decision is taken by the multidisciplinary team that the patient is no longer viable for CPR or for any type of active treatment, this does not mean that we abandon an elderly resident as they breathe their last breath. I make it my aim that nobody ever dies alone. Family are called and if they can't or don't want to be present, I sit with the person, talking to them, tending to them, and observing any wishes they might have expressed—such as a favourite piece of music or clothing, or a visit from a religious minister.
Even for those we do not resuscitate, I like to think that we do pull them back from the brink in a different way. Every time we mention their name or share a memory, they are brought back into our consciousness. Terry Pratchett evoked such an idea when he said:
‘No one is actually dead until the ripples they cause in the world die away’