Working in A&E, I see the best of care but also the worst – and that’s not necessarily the NHS’s fault.
A few weeks ago I was looking after an 89-year-old gentleman who received care that utterly failed him – devastating for him and his loved ones, and for us as clinicians. Yet it was entirely preventable. It’s a lesson for all of us.
There is only one thing 100 per cent guaranteed in life – and that’s death. But when it came to his death, we got it so wrong. He was a proud family man who’d given a life of service to the country, in the Army then as a policeman.
A keen sportsman, he was fit and well and, until a stroke hit him six months before I saw him, he’d had a brilliant quality of life looking after his beloved grandchildren.
But he’d rapidly deteriorated after his stroke, so moved in with his son and needed carers three times a day. He was incontinent, and had to be hoisted from his bed to his chair; he also developed dementia.
His last months of life were not what he would ever have wanted.
A few hours before he came to A&E he was becoming increasingly short of breath – his son called 111, hoping they’d send a district nurse to make him comfortable. But it was Friday night, and instead a blue-light ambulance was dispatched.
Without any pre-planning for what should happen if he became unwell, there was no clear guidance for the paramedics to follow or access to a GP, so the only choice was to take him to hospital.
Rob Galloway’s 89-year-old patient was left languishing in the hospital corridor. An A&E doctor, who recognised he had sepsis caused by a chest infection, gave him intravenous fluids, antibiotics and oxygen – but what he needed was palliative care (file image)
There he was seen by a relatively junior A&E doctor, who recognised he had sepsis caused by a chest infection, and gave him intravenous fluids, antibiotics and oxygen.
He was then left languishing in the corridor – there were no spare cubicle spaces in A&E or beds on a ward.
His son arrived and came to ask our nurse in charge what was happening. Overhearing the conversation, I intervened – his son told me his dad would not have wanted any of this.
He just wanted a comfortable death at home, not a prolongation of his agony.
By then he’d deteriorated and was now semi-conscious but in obvious discomfort.
I stopped the antibiotics and cancelled his blood tests and chest X-ray. None of this was necessary or appropriate – what he needed was palliative care. So I removed the fluids and the oxygen and prescribed morphine to make him comfortable.
Most importantly we organised a cubicle behind curtains to give him some dignity. He was too unwell to transport home. A few hours later he passed away surrounded by the sounds of drunken and drug-fuelled patients, his son’s tears heard by the other patients. An awful, expensive and undignified death. It didn’t need to be like this.
Recently, my friend’s dad passed away. He was frail with heart and kidney failure. But he had a plan for when his condition deteriorated.
Six months before he died he’d sat down with his GP and family and talked through what he wanted if things got worse: no hospital, no CPR. Just to be at home with the dog on his lap, his family by his side, with jazz music in the background and morphine if needed for pain relief. And that’s exactly what happened.
Because they’d planned ahead, the GP prescribed morphine and other key medications in advance, so they were already in the house – ready if needed, even in the middle of the night. The district nurses knew the plan and were on standby to help.
So when the time came, there was no panic, no rush to A&E. Just peace and love. That is the power of planning.
Not every GP practice will be quite so proactive – but this kind of planning is possible. Without it, you risk being at the mercy of overstretched services that don’t know your wishes – and might do the very things you and your loved ones never wanted.
We don’t talk about dying enough, let alone how we want to die. But as medicine advances and people live longer with dementia, cancer and heart disease, for instance, it’s just not enough to simply focus on how to keep people alive. We need to think about how to let people go well, too.
Too often in the NHS, when a patient suddenly deteriorates, we’re left scrambling to make high-stakes decisions without knowing what that person would have wanted.
Professor Rob Galloway is an A&E consultant
In 2016, the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form was brought in to avoid exactly this kind of crisis decision-making.
It’s designed for people who are elderly, or have long-term conditions, and it sets out, in advance, what treatments they would – or wouldn’t – want if things take a turn for the worse.
Ideally, it’s done with the GP, during a calm, planned conversation with the patient and, if appropriate, their family.
The form isn’t just about ticking boxes. It prompts real, practical decisions – such as whether the person would want CPR if their heart stopped, or to be admitted to intensive care, with the implications of each explained properly.
There’s also space to record whether they’d want antibiotics if they developed sepsis; artificial feeding if they could no longer eat; or fluids through a drip if they were in their final days.
The kind of questions a GP might ask to help complete the form can include: ‘If you became very unwell with an infection, would you want us to treat it with strong intravenous antibiotics – or focus just on keeping you comfortable?’ The CPR question is a key one, as CPR is widely misunderstood.
People think it’s like on TV, with someone clutching their chest, collapsing, followed by being heroically thumped then shocked back to life. Although effective for sudden heart issues, success rates in the elderly or chronically ill are very low. Most people who receive CPR in these circumstances don’t survive. If they do, it’s often to a life of significant disability.
Douglas Chamberlain, the cardiologist who introduced defibrillators to the UK, passed away last month aged 94. He used to say that many patients and relatives falsely believe that a DNR (do not resuscitate) order – don’t use CPR – means no treatment and being left to die. It doesn’t mean that at all.
You can still have full active care, such as oxygen and intravenous infusions and antibiotics. But if the treatments fail to save your life and your heart stops, then a DNR order means we won’t jump on your chest.
Importantly, ReSPECT is a plan agreed between the clinical team and the patient, based on what is medically appropriate and what matters most to the individual. It balances clinical judgment with personal priorities, and ensures that when decisions are needed quickly, they’ve already been carefully thought through.
Crucially, the patient’s ReSPECT removes the agonising guilt that families often feel when they agree with the doctor to not pursue intensive care or aggressive treatment – because that decision would already have been made, together, in calmer times.
Yet the form isn’t used nearly as often as it should be. Some GPs don’t get round to it. Some families don’t know it exists. So when a crisis hits, we fall back on ambulance calls, rushed decisions and hospital admissions that nobody wanted.
And that’s exactly what went wrong for the 89-year-old man I saw that Friday night.
One conversation could have changed everything. If the patient is unable to make decisions due to advanced dementia, unconsciousness, or confusion as a result of illness, relatives are consulted.
But doctors may, understandably, be more inclined to treat the patient than offer palliative care. That’s where a lasting power of attorney for health can help. This is a different legal document used if you lose your mental capacity – handing over decision-making to someone you trust.
These two written documents are kept by the patient, with copies lodged with the GP, hospital, care home and ambulance service. The bottom line is this: if you don’t make a plan, the system will make one for you. So, if you have a chronic illness, or worry you may develop dementia, the most important thing you can do is talk. Sit down with your GP. Fill out a ReSPECT form – and remember, you can change it. And if they’re well, talk to your parents, and grandparents, about all this.
We spend so much time planning for our weddings, our careers, our retirements. Yet we rarely plan for the one thing guaranteed to happen.
Completing a ReSPECT form won’t stop death. But it might help you die the way you lived –with dignity, with control, and with the people you love around you.
I’ve had countless consultations where someone says: ‘I don’t want to talk about that yet’. But when is the right time? When you’re already unconscious or unwell? The best time is now.
A good death isn’t luck. It’s about preparation, understanding the limits of modern medicine and the power of good conversations.
@drrobgalloway
