In the Midst of Life

there is the smallest electrical response it can be argued that life is
not
extinct, and they must continue. Even if the ambulance crew get the patient to hospital alive, the side-effects can be severe, especially if thebrain has been starved of oxygen. Some people in long-stay geriatric wards and care homes are there because of brain damage following a successful resuscitation (see also Appendix I).
    Louise Massen is Clinical Team Leader for the South East Coast Ambulance Service, working in Gravesend, Kent. She was invited to speak at the National Council for Palliative Care annual conference in March 2009. She called her lecture ‘Dying Differently’. The following is taken from her lecture notes, with her permission:
     
Ambulance clinicians from all services work within the Ambulance Service JRCALC Guidelines 2006 (Joint Royal Colleges Ambulance Liaison Committee).
Ambulance clinicians’ role traditionally has been to:
Preserve life
Prevent deterioration
Promote recovery.
The role of the modern ambulance service is far more than this. Ambulance clinicians have specialist skills in primary and critical care, and, increasingly, take healthcare to the patient – especially out of hours.
The only way that very ill patients are able to get to hospital will be when someone asks for an ambulance to attend.
The Ambulance Service offers a 24-hour service, seven days a week, following the JRCALC Guidelines 2006.
     
    – the guidelines are specific that in the event of being called to a cardiac arrest or near-life-threatening event the ambulance crew is obliged to initiate resuscitation – unless
A formal Do Not Attempt Resuscitation (DNAR) order is in place, in writing, and given to the crew.
The DNAR order must be seen and corroborated by the crew on arrival. If the ambulance crew is
not
satisfied that the patient has made a prior and specific request to refuse treatment, they
must
continue all critical care in the usual way.
Thecondition of the patient must relate to the condition for which the DNAR order is written. Resuscitation should not be withheld for coincidental reasons.
Resuscitation may be withheld if a known terminally ill patient is being transferred to a palliative care facility. This can only be valid if Ambulance Control has been given prior and specific information, which has been recorded against the patient’s name and address, and the ambulance crew has been informed.
     
    Louise called the second part of her lecture ‘The Moral Dilemma’. What happens when an ambulance crew arrives at the house of a patient who has suddenly ‘collapsed’ and Ambulance Control has received no other information? What will the crew do? Imagine the scene:
     
The ambulance crew will come running into the house laden with response bag, AED (automatic external defibrillator), an airway bag and drug kit.
The crew will take the stairs two at a time and rush over to the patient who has collapsed in bed.
They will perform a quick primary survey to establish vital signs. If there is no Airway obstruction, Breathing, or Cardiac output (known as ABC), the crew will commence resuscitation.
The crew will grab the patient by the arms and legs and lift them on to the floor, and using medical shears slice the nightclothes up the middle to expose the patient’s chest and throat.
Next, they will place defibrillator pads on the patient’s exposed chest and commence cardio-pulmonary resuscitation using JRCALC guidelines.
The crew will intubate the patient with an endotracheal tube, or in some circumstances, a laryngeal mask airway.
They will gain intravenous access, either using a jugular or peripheral vein; then administer intravenous drugs.
Thecrew will use the AED to deliver defibrillator shocks if necessary.
If resuscitation is successful, the crew will lift the patient on to a carry chair, downstairs and out to the ambulance, and race off to the A&E department of the nearest hospital.
When resuscitation is not successful, the crew will perform a Recognition of Life Extinct (ROLE), and contact the police, who must inform the coroner’s office.
The crew will fill out the Patient Clinical Records.
     
    Louise continued her lecture by asking these questions:
    Is this right or is it wrong?
    Why does it happen?
    What can we do to make sure it does not happen?
    How can we help?
    To which she gave some answers:
     
The Ambulance Service needs to be incorporated into the Integrated Care Approach for all end of life care