Wednesday, 10 April 2013

Liverpool Care Pathway - More Care, Not Less.

Death – Let’s talk about it; there’s more to it than you might think...

Doctors, sworn to defend and protect life and to do no harm, should be a source of strength and support...

In 1996, Daphne Banks, a farmer's wife from Huntingdon, attempted suicide by drug overdose on New Year's Eve. She was declared dead by doctors at Hinchingbrooke Hospital in the early hours of New Year's Day, only for an undertaker to rescue her from the mortuary slab 34 hours later after hearing her snoring.

Her husband pronounced his wife's salvation 'a miracle'.

Equally miraculous was the case of the Egyptian chauffeur who rose from the dead. In July 1997, Abdel-Sattar Badawi was laid in a coffin and taken to the mortuary of a hospital in Menoufia.

Doctors had declared him dead, but he was in a deep coma, and after 12 hours he woke up. Mr Badawi, then in his 60s, said: 'I shouted for someone to come and rescue me. When no one heard me I started to chant verses from the Koran to seek God's pardon.'

Unable to see anything, he pushed open the lid of the coffin (luckily it had not been screwed down) and found himself surrounded by corpses.

Confused and anxious, he climbed out and continued to shout for help.

Three hospital staff came into the morgue and were confronted by Mr Badawi waving and chanting.

A male nurse collapsed with a heart attack and died from shock. As Mr Badawi left the hospital, he vowed never to return. Who can blame him?

Earlier this year another Egyptian, Hamdi Hafez al-Nubi, a 28-year-old waiter, was declared dead after suffering a heart attack at work.

His relatives took his body home and prepared it for burial in his village of Naga al-Simman in Luxor. However, a doctor sent to sign the death certificate was surprised to find the body was warm. Closer checks revealed Mr al-Nubi had a pulse. He was revived, and the funeral turned into a celebration.

Egypt seems to have suffered its unfair share of animated corpses, but such cases occur the world over.

In April, a Chinese woman aged 95 climbed out of her coffin six days after she 'died'. Li Xiufeng was thought to be dead when a neighbour found her motionless in bed. a time when controversy is raging around the Liverpool Care pathway - which allows NHS doctors to stop medication for patients they believe are close to death - such cases should give us pause for thought about the powers of the human body to cling to life.

She was placed in a coffin at her home so friends and relatives could pay their last respects.

The day before the burial, the neighbour called round to discover the coffin was empty. He was even more stunned to discover the sprightly corpse sitting in the kitchen, cooking a restorative meal.

Steve Moore has compiled some of the more bizarre incidents of resurrection for his book Back From The Dead And 350 Other Stories Of Amazing Luck.

He tells the story of Gerry Allison, whose body was making its way through Los Angeles in a hearse in 1977 when a tyre burst. The hearse careered into the window of a rival funeral parlour.

The doors flew open and the coffin toppled out. Passers-by saw Mr Allison, in a shroud, walk out of the wreckage. Doctors believe the crash brought him out of a deep coma.

Then there was Fagili Mukhametzyanov, who woke up at her funeral last year, and promptly died of shock.

Mrs Mukhametzyanov, 49, had been pronounced dead by doctors in Kazan, Russia, after a heart attack at home.

As relatives filed past her open coffin, she started to scream. She lived for only another 12 minutes before dying — this time permanently. Her case is not untypical. Often patients who come back to life are left with severe brain and organ damage and never recover their health.

Michael Wilkinson, a roofer from Preston, Lancashire, 'died' in hospital in 2009 aged 23 from a previously undiagnosed heart condition. But after he was given the last rites, doctors found a pulse. Mr Wilkinson was transferred to intensive care at Royal Preston Hospital, where he survived for two more days.

Lazarus Syndrome is rare. In 2010, a paper in Critical Care Medicine by researchers from McGill University, Montreal, identified 32 reported cases.

All involved the spontaneous revival of apparently dead heart attack patients after attempts to resuscitate them.

The evidence was limited, but enough to convince the authors that more study into the phenomenon was needed.

Some believe it may be caused by the delayed delivery of adrenaline injected to revive a patient after a heart attack.

Another theory is that attempts at resuscitation create a build-up of pressure in the chest. After 'death', the released pressure allows the heart to expand, which somehow kick-starts it.

Other doctors are wary about labelling an unlikely series of events a 'syndrome'. Harley Street consultant cardiologist Duncan Dymond says: 'I have never seen anything like that, and I have been qualified for 40 years.'

Though these events occur only on rare occasions, they raise questions about how long doctors should wait before declaring a patient dead.

Indeed, at a time when controversy is raging around the Liverpool Care Pathway — which allows NHS doctors to stop medication for patients they believe are close to death — such cases should give us pause for thought about the powers of the human body to cling to life.

Until Lazarus Syndrome has been fully explained — or discounted — it may make sense to follow the example of George Washington.

The American president was so concerned about misdiagnosis that he ordered his doctors not to bury him for at least two days after he was declared dead, giving him ample time to effect a dramatic resurrection. Unfortunately for him, we are still waiting.

Mail Online

Erasing Death

The Science That Is Rewriting the Boundaries Between Life and Death
by Sam Parnia, M.D. and Josh Young

What happens when we die? Wouldn't we all like to know. We can't bring people back from the dead to tell us — but in some cases, we almost can. Resuscitation medicine is now sometimes capable of reviving people after their heart has stopped beating and their brain has flat-lined; Dr. Sam Parnia, a critical care doctor and director of resuscitation research at the Stony Brook University School of Medicine, studies what these people experience in that period after their heart stops and before they're resuscitated. This includes visions such as bright lights and out-of-body experiences.

Often described as near-death experiences, Parnia prefers the term "after death."

"What we study is not people who are near death," Parnia tells Fresh Air's Terry Gross. "We study people who have objectively died. ... And therefore what we've understood is that the experience that these people have of going beyond the threshold of death, entering the period after death for the first few tens of minutes or hours of time, provides us with an indication of what we're all likely to experience when we go through death." [NPR]

A study published in the Lancet showed, the better the care, the better the outcome. 

The study says -
Doctors concede that there is simply not the money to provide such a level of care for all patients.
But they say hospitals need to improve care for “high risk” patients, such as the very old
What is needed is more care, not less.

His process is rooted in his belief that most hospitals give up on patients too easily and use techniques that date to the 1960s. By using all the methods available, doctors can sustain the existence of a person whose heart has stopped beating, he says, and he believes his process could save 40,000 U.S. lives a year.

The Advance Directive - What is needed is more care, not less.
Indeed, those who undergo cardiac arrest and are resuscitated at Parnia's hospital have a 33% chance of surviving, compared to about 16% at the average U.S. hospital. Doctors, he argues, should use machines to conduct CPR (they're better at it than humans, he says) and cool the body down drastically as the patient's blood is oxygenated using a process called ECMO -- it's standard in Japan, and involves drawing the blood from the body and running it through a device that siphons out CO2 and adds oxygen.   [KSDK]

In June 2011, a 30-year-old female was found in a forest at 8:32 a.m. following an overdose of medications. She was dead. Her body temperature had dropped from 37˚C (98.5˚F) to 20˚C (68˚F), meaning that she had been there for several hours. The ambulance team arrived at 8:49 a.m., administered CPR and shocked her heart using an automated external defibrillator, but she remained dead.

When the woman arrived at the hospital at 9:22 a.m., her body temperature was still 20˚C (68˚F), and her pupils were fixed and dilated and not reactive to light, signifying that she remained dead. The emergency doctors performed CPR and inserted a breathing tube and ventilated her lungs with an automatic ventilator, all while continuing chest compressions. The drugs adrenaline, amiodarone, and lidocaine were injected to restart the heart. Despite efforts to begin warming her up, the woman's temperature remained unchanged. The doctors then hooked her up to the ECMO machine to ensure optimal oxygen supply.

After six hours of treatment, her temperature returned to 32˚C (89.5˚F), and her heart restarted. Although she had remained physically dead for at least five to 10 hours overnight without any treatment, and then for a further six hours while undergoing lifesaving treatment in the hospital, the woman was able to recover and eventually walk out of the hospital without organ and brain damage three weeks later. Because she had been naturally cooled down during the time that her heart was stopped, her cells did not sustain permanent damage and were able to return to functionality once oxygen delivery was restored. This is what is commonly known as a Near Death Experience, though I now propose that such experiences be termed After Death Experiences because the woman had, in fact, died. [Huffington Post]

The kind of CPR (cardiopulmonary resuscitation) that we are familiar with from medical dramas – the frenzied pumping of the chest – remains rooted, Parnia claims, in its serendipitous discovery in 1960. It remains a haphazard kind of procedure, often performed more in hope than anticipation. Partly, this is a question of personnel. Parnia is quietly maddened by the worldwide hospital habit, in the event of death, to send the most junior of doctors along "to have a go at CPR". It is as if hospital staff have given up before they have started.
"Most doctors will do CPR for 20 minutes and then stop," he says. "The decision to stop is completely arbitrary but it is based on an instinct that after that time brain damage is very likely and you don't want to bring people back into a persistent vegetative state. But if you understand all the things that are going on in the brain in those minutes – as we now can – then you can minimise that possibility. There are numerous studies that show that if you implement all the various resuscitation steps together you not only get a doubling of your survival rates but the people who come back are not brain damaged."

Parnia wants to ensure that more and more people are successfully returned from death to tell whatever tales they can. "I still have colleagues in ICU who say, 'I don't know why we are doing all this stuff'," he says. "Not long ago, I went for a job interview in New York at a teaching hospital and I was told if a patient comes in and has a cardiac arrest and they end up in the cardiac care unit they will be cooled, but if they end up in the intensive care unit the doctor in charge doesn't believe in it. He thinks it blocks his beds so he won't do it. I don't see this as negligence exactly because there is, as yet, no authority telling us this is the standard we should use. But surely there should be." All of this, I say, must have had a powerful bearing on Parnia's own sense of mortality. Is he comforted or made paranoid by his work?
He suggests that the experience of talking to people who have returned from dying serves only to enhance his curiosity about the process they have undergone, and which he has sometimes helped to reverse. Other than that, he says: "In ICU, I see people dying every day and each time it happens a part of you thinks, one day this will be me. There will be people huddling round my bed deciding whether or not to resuscitate and I know one thing for sure: I don't want it just down to pot luck whether I end up brain damaged or even alive."   [Guardian]

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