Tuesday, August 19, 2008

a wood pigeon

This is a room of white. The early morning light is filtering in through two long drop white net curtains. A warm current of air is nudging through the opened sash. There are two beds in the room, both with white counterpanes, and the clinical curtain divider between them is white.
The bed on the left of this divider is occupied by an ancient man, a thoroughly dessicated figure propped up on a banana-shaped pillow, taking cursory tugs at a plastic beaker of tea. He drops the spout from his lips to give us a little smile as we walk in.
Our patient is in the bed by the window. He is also propped up on pillows, but his head is being supported by Ken, the ECP who was also assigned to this job and got here first.
‘Could you come and take Geoffrey’s head for me, please?’ he says. ‘He’s rather slumped over and we need to get him into a better position.’ I walk over to help. Geoffrey’s breath is coming quickly, in fluttering gasps. In the last throws of emaciation, the skin of Geoffrey’s chest pulses against the outline of his ribs.
‘Geoffrey has been refusing food for the last couple of weeks,’ says the home matron, who has come to stand at the foot of the bed, and is thumbing through his case notes.
‘Is there a DNAR for Geoffrey?’
‘Not as such. But he has said a number of times recently that he wanted to die and didn’t want any help’
I wipe away the meagre strands of hair sticking to Geoffrey’s forehead. His eyes have receded deep within his sockets. They are half opened, but red and dry and without recognition.
‘What about the relatives? What do they have to say?’
‘Oh, they’re absolutely in agreement’
‘And the GP?’
‘Hasn’t been in a day or so’
‘Well – I’ll make a call to the GP, if you wouldn’t mind getting in touch with the relatives and letting them know the situation. As you’re probably aware, Geoffrey is going to die very soon. I don’t think he would want us to resuscitate him, and I don’t think it would be appropriate. But we’d better start getting things in order. And we need the doctor here to make Geoffrey as comfortable as possible in his last moments’

Ken goes outside to call the GP whilst Ellie and I make Geoffrey comfortable.

Apart from the rise and fall of his chest, the only movement Geoffrey makes is a delicate rolling of the oxygen tubing between the shrivelled pads of his right thumb and index finger, the kind of exploratory movement you might make if you were blindfolded and asked to identify something. But the movement seems removed from him, an automatism rooted in some profound dream of absence.
I feel for his radial pulse, but his heart beat is only detectable now as a faint brachial twitch in his upper arm – the tail end of a rhythm set running when he was just a tiny embryo no bigger than his fingernail, easing away now ninety years later, here in this whitened room, in blue-striped cotton pyjammas, a clutch of photos propped up on pots of emollient creams and packets of wipes, the white net curtains ballooning inwards on the breeze, and a wood pigeon high up somewhere near, who-hoo-hooing, announcing itself to the world.


Shade said...

Beautifully written, setting a peaceful scene in sad circumstances.

Spence Kennedy said...

Thanks, ET!

I was really glad that this time we weren't drawn into a resus, even though technically speaking in absence of a formally written and witnessed DNAR we would have to go down that road. I think it was an oversight on the part of the home, and it would've been wrong to make Geoffrey pay the price (in other words, to endure a traumatic end rather than a respectful, gentle death).

I think I've said before somewhere how I wish there was an End of Life plan - an equivalent to Birth plans - to encourage the patient along with family, friends and GP to adopt early on a fitting sequence of events to deal with the moment of death. Currently it still often ends up as a rush, with death being declared either on a hospital trolley or on the floor surrounded by the mess and apparatus of CPR. (Although of course it's also true that despite the best Birth plan, events conspire to make it rather more medical than you might otherwise want!)


Anonymous said...

Absolutely the best thing for the patient.

Out of interest........ Are we (as ambulance persons) covered by permission of the family and presence of the care staff/GP when there is no signed DNAR present. Is the verbal confirmation of other people enough? Not come across this situation before.

Anonymous said...

Hey Spence,

Another wonderful post, thannks - I always look forward to the little peaks into your world you allow us.

I was just wondering what the legal situation is in a scenario like that - where there isn't a DNAR but everyone is in agreement that its not in the best interests of the patient?

Keep up the good work saving lives and writing about it!

Spence Kennedy said...

Thx for your comments.

In this case, the patient was in an advanced terminal stage, extremely emaciated. The nursing staff were quite clear that the patient had withdrawn from eating for some time, and had talked quite frankly about his desire to die and not to be resuscitated when it happened. When the ECP spoke to the GP they were also clear that this was the case, and did have a note on his records at the surgery. This should have been in writing with the nursing home, too - it would have put us in an impossible situation should we have arrived and the patient arrested. Strictly speaking under those circumstances we would've been obliged to carry out CPR - to noone's benefit. As it was, the patient was on a long, slow exit, and there was time to sort all this out.

I was glad that an ECP was on hand to co-ordinate all this. A senior paramedic, he was calm and compassionate and clear with everyone concerned.

Anonymous said...

My sister (aged 46) has a DNR on her file in the home she is in. It is one of the hardest pieces of paper I have ever had to sign.

Spence Kennedy said...

Hi Carol
I'm so sorry to hear about your sister. I can't imagine how difficult it must be for you. I hope that you're getting all the help and support that you need, and that your sister's as comfortable as possible.
Best wishes

uphilldowndale said...

And the gent in the other bed?

The movement of the the thumb and fore finger, reminded me of my son, as a baby he used to do that with the labels on his blankets and toys,I think it comforted him. :(

Anna said...

I think I will remember the last paragraph of that post for a long time. We don't think about when that heartbeat started. Ninety years...

I will think about that, now.

loveinvienna said...

I'm pleased you and the others were there to give him as dignified an end as possible :) That is how I would want to go - a light breeze, warm sunshine, photos of those I love around me and someone to hold my hand as I go.

However, working in a Care Home has shown me it can't always be that way unfortunately but I have been able to give a little bit of comfort to those who are moving on even if I wasn't there when they actually went.

Thank you for doing what I have been unable to Spence :)

Liv xxx
PS. If the Care Home cares at all about it's residents and the fact they could be sued by the family for neglect, they'll have written everything down. I know we have to.

Spence Kennedy said...

Hi Liv,
I'm sure that in this case it was just an administrative error - but an important one. The care home seemed pretty caring and well run in other respects. I think everyone (including the patient) was lucky that the missing paperwork didn't impact on the closing moments.

It is a shame that so much seems to be governed by a fear of litigation. I know a signifcant amount of the jobs we turn out to are purely the result of 'legal coverage'. At least in this case common sense prevailed.


cogidubnus said...

oh Spence that was beautifully observed, and the thought of the fluttering pulse at the end reflecting that at the beginning...so poignant...I'll remember that forever...