As nurses, we are all aware that when delivering information, it is often not what we say but the way we say it that matters. It is an adage applicable to nearly every aspect of our work. When I trained as a nurse, it was fairly common, with very ill patients, to see not for resuscitation written in red on their notes. This was a decision reached by the medical staff, not always in consultation with the patient or relative. The decision was deemed to be made with clinical expertise and, most importantly, common sense. It was a time when there was great trust in doctors 'knowing best.' Later in my nursing career, it became a requirement to resuscitate all patients admitted within twenty four hours. This led to distressingly futile resuscitation attempts. Patients were denied a dignified death, relatives were left traumatised, and clinical staff demoralised.
Now, we are supposedly wiser. We know there is a right time to die, and patient involvement is important.
An elderly relative was recently admitted to hospital as an emergency. He was in pain and very ill. This was distressing for the family to witness. Amidst the crisis, the doctor asked relatives: 'Do you want him resuscitated?' With that one question their faith in the medical staff was eroded. They believed if they said NFR, he would he be left to unceremoniously die with no effort made towards his recovery or comfort. It was difficult for them to understand that the doctor wasn't being callous – he was simply carrying out an edict from above. That one question created a huge barrier.
The question may seem to be politically correct, and yet in an emergency situation, with high tension and speed, while clinical decisions are being made, how can the question be asked with dignity and respect? In those crisis moments, it easily comes across as a throwaway: 'While I'm here, do you want us to try hard?' Relatives are unnecessarily made to feel angry and fearful. It seems little consideration has been given to the complex emotions at the time of an emergency admission, which can confuse any rational decision.
Discussing resuscitation at an emergency admission is not the right time for everyone. While we are quicker nowadays to acknowledge shortcomings in care, our problem solving tactics often fall short. Tick boxes do not appreciate the subtle nuances of being human. The realities of improving end-of-life care still have far to go.
Bernadette Higgins is a practice nurse in Newcastle