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.’

• © British Journal of General Practice, 2009.