Doctors' management should not make things worse for patients

Editor—Much has been written about the need for “do not resuscitate” orders to be explicitly determined by discussion with patients or their relatives, or both. This has mostly been driven by fear—of litigation (by hospitals), of relatives (that not enough was done), and by patient groups (that some effective treatment was denied). Consequently, trusts have declared that policies based on a controversial document by the BMA, Resuscitation Council, and Royal College of Nursing should be in place.¹ As Fallowfield says, who in their right mind would discuss a treatment that is futile with a patient with widespread metastatic malignant disease nearing the end of his or her life?² Well, sadly, increasing numbers do.

Recently we were involved in the care of a 44 year old woman with metastatic carcinoma. The disease progressed relentlessly despite radiotherapy and chemotherapy, and much support was needed for her and her family. Recognising that time was short, she decided to have a holiday with her children. Not unexpectedly, but sooner than she had hoped, her condition deteriorated and on her admission to hospital it was found that she had developed lymphangitis carcinomatosa. She was breathless and anxious to return home, so arrangements were made for her to be taken by ambulance back to her oncology centre in Scotland. Physically and emotionally she was distraught.

Just before she was taken to the ambulance, a doctor whom she had met once before came to tell her that it was policy for patients in her situation not to be resuscitated should their heart stop in the ambulance. She was asked to sign a form confirming her agreement. She knew she was dying, her mother knew she was dying, and one presumes the doctor also knew this. Nevertheless, a signature was required. She spent seven hours in the ambulance terrified that her heart was going to stop. The paramedics were sympathetic, but she could not forget this conversation and was inconsolable; it haunted her until she died one week later.

There is something deeply disturbing about our response to impending death as a result of advanced incurable illness. Death due to cancer is cruel enough; our management should not make it worse.