The Bell Tolls

Her bones are clearly visible through her yellow tinted skin. She has a cannula in each arm both have tissued, her veins having shut down hours before. Her last set of observations tell me her systolic blood pressure was sixty-seven, barely compatible with life. She has been on the liverpool care pathway for two days. She is Dying.

Despite all this my patient was incredibly lucid. She was aware of what was going on around her and could answer all of our questions appropriately. This is why, when I was asked to take a set of observations on her I refused. She is on the pathway for the dying with twenty-four hours left on it all of her previous vital observations and physical observations suggest it will be much sooner than that. I refuse to tug a blood pressure cuff onto her arm, inflate it to a painful level and drag it off again when the results will be of no use to anyone. I still cant believe the nurse asked me to do that to my patient.

Failure

In this profession you standardise you're level of success or failure based on how many patients are alive when you leave the ward. If you have worked a shift and none(or in critical care very few) of your patients have died then you mentally tick that off as a successful shift.

Many wards at any one time have patients who are palliative, they are dying and there is nothing that can be done medically to prevent this. Fortunately there are care pathways(protocols) in place for any patients who meet very specific criteria. This takes a lot of the difficult decisions out of the hands of doctors, nurses and the patients family. The standard care pathway in my trust is the Liverpool Care Pathway. Once a patient has started on this care pathway their treatment is purely for comfort. Analgesics, Anti-emetics, etc are administered
more or less constantly via a syringe driver. A device that slowly injects medications over a given period so rather than a patient getting a dose of morphine for their pain at 1300 and needing another dose at 1500, the driver releases the same dose into the body constantly over x amount of hours. This not only means the patient is constantly receiving pain and sickness relief but the nurse doesnt have to wake the patient up every three hours to administer the drug.

Once a patient is on the LCP and non-essential medications are discontinued(pretty much anything they wont die immediately if you take them off) and their observations are either ceased or taken only once a day as it is an uncomfortable thing to do to a patient but absolutely necessary for a patient who has a chance of recovery. In patients with no chance of recovery whats the point of waking them up at 0500 every morning to take their blood pressure, pulse, oxygen levels, etc. On a regular basis the patient is assessed for pain, agitation, nausea,
breathlessness, etc and if there is any variance on these then the medication the patient is on is adjusted so that they are as comfortable as possible.

This phrase always made me laugh "as comfortable as possible". The patient is dying, they are scared, exhausted, probably in pain. What we make the patient isnt anywhere near comfortable. And to add to the discomfort we take them off fluids and food and of course they are bed bound so they will be cathatarised. Ethically is this the right thing to do? they are dying and food, fluids, etc will prolong this however do we want their last hours to be spent, thirsty and hungry?

And back to my original point when you leave the ward and one of these patients has died how do decide if it was a success or a failure on your part?