March's free article
Mum’s chances
Jean* stared past us into the hereafter, barely moving except to
gasp. Pale and emaciated, her breathing noisy, shallow, and fast,
she clung to life by a thinning thread. The receiving casualty
officer in A&E had given the 90 year old an intravenous line,
started antibiotics, and referred to the on-call medics. The chest
X-ray confirmed pneumonia and he had sent appropriate initial blood
tests. He had also taken the step of filling out a ‘Do not attempt
resuscitation form’, on the basis of ‘unlikely to succeed’, and
moved her from the resuscitation room to an emergency department
cubicle.
Her son and daughter-in-law arrived as I attended. She lived in
a nursing home, was normally bed-bound and completely dependent as
well as ‘severely’ demented — no longer able to communicate beyond
‘Yes’, ‘No’, and ‘Dada’. Two weeks ago she had become agitated and
was treated with oral antibiotics for pneumonia. She had rallied
such that her son had felt able to go on holiday, but over the
preceding 48 hours she deteriorated. ‘We came back to an
answer-phone message telling us that mum was in hospital.’
Jean’s son tearfully agreed that to put her through the rigors
of cardiopulmonary resuscitation would be cruel: her grandson had
lingered in intensive care following a road accident before
succumbing to his injuries. ‘Don’t let me go like that’, she had
told her son. We agreed that ‘what would work’ (the advice of the
doctors) and what ‘Jean would want’ (the advice of Jean’s family)
allowed a trial of antibiotics until the drip failed. She had been
a struggle to cannulate, and we agreed to hold off any further
invasion of her body, besides subcutaneous fluids and medication
for respiratory distress or pain. ‘She’s more peaceful than she has
been in weeks,’ confessed her son, but agreed that oxygen and
fluids would ‘make her more comfortable’. Son and daughter-in-law
did not have any further questions, but wanted to be called if Jean
worsened overnight. The son hesitated, but the daughter-in-law was
in no doubt.
‘What are Mum’s chances?’ asked the son.
‘Your mother is very poorly, and she may not respond to the
antibiotics …’
He blinked tears and held her un-cannulated hand in both his
hands, ‘Does she have any chance?’.
‘She may yet rally … like she did before.’
The encounter was documented, and Jean was ‘handed over’ to the
night medical team. My seniors on call were of the opinion that if
she went home, she should not be readmitted to A&E.
The next day as I attended one of my patients on the acute
admissions ward, I heard singing. No words, just, ‘Dadada …
DAAAHHDadada …’ tunefully shouted. In a corner of one of the bays,
Jean sat up in bed. She looked happy, though the other two patients
in the bay did not. She clutched both bed rails and sang at
anything that moved. Agitation did not seem an appropriate word.
She had rallied. She was far from peaceful, but she was eating and
drinking, and she looked happy.
Had we given up on her too soon, and would she have rallied
without 4.5 grams of tazocin dripped into her veins every few
hours? Our decisions had not been difficult. We had gone with the
flow of events and agreed to do no more than had been done. We made
it easy for her relatives to tell us what she might want without
giving them the decision as to whether she lived or died. There was
a satisfaction that her life had been preserved. She seemed to have
some degree of happiness, and she and her family were not ready to
be parted.
I came across Jean a fortnight later. On one of the acute wards
on a Friday afternoon, I heard a familiar voice shouting. The
tunefulness had gone. The shouting sounded anxious and desperate.
Without going into the bay, I asked a nurse:
‘Is that …’
‘Mrs Smith yes.’
‘Didn’t she go to her nursing home?’
‘Yes. But she was back within 48 hours, and the medical team had
said that she was for TLC and that it wouldn’t be appropriate to
send her back. She’s not having any antibiotics this time. She’s
just sitting here waiting to die, bless her.’
Andrew Papanikitas
*Jean Smith is a fictional name based on many people’s
mothers.
DOI: 10.3399/bjgp09X420130
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