Funny old ward

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"There is a growing feeling among doctors that the grieving process of relatives would be helped if they witness resuscitation." So says Dr Michael Mitchell (The Independent, 5 March), a casualty consultant at Queen Mary's University Hospital, Roehampton. I have to admit I wasn't aware of this "growing feeling" and neither, it appears, were the junior doctors of Roehampton who opposed the idea of opening the doors of the emergency room to grieving relatives. The minority of senior staff, however, most of whom will not actually be present at resuscitations, decided it merited a pilot study and over-ruled their juniors. Such is the democracy of hospital medicine.

The idea of eavesdropping on doctors at work is nothing new. Many surgeons willingly put themselves under the camera for the sake of prime-time exposure, although a suggestion by one NHS chief that all operating theatres should have close-circuit cameras to allow managers to peek in was greeted much less enthusiastically. The Good Doctor Guide (Now on Video) will have to wait a while. Some doctors do make tape recordings of difficult consultations, such as breaking bad news or explaining a complicated diagnosis, and these have proved very helpful for replaying to relatives at a later date. However, these demystifications have all taken place with the patient's consent - those relatives whom the patient does not want to be so graphically informed don't get to hear the tape.

It's difficult to imagine how an unconscious patient could give informed consent for his relatives to witness the traumatic electrocution of his heart first hand. Perhaps every casualty in Roehampton will be given a consent form to sign the moment they come through the door. "In the event of my heart stopping, I am happy for my relatives - except Auntie Maud whom I detest and who would probably laugh anyway - to witness assorted health professionals trying to start it again." This may sound a trifle over the top, especially as the majority of casualty attenders have nothing more serious than a cotton bud lodged in the ear, but in these days of defensive medicine you have to cover all the angles. A patient who survived a cardiac arrest (and, yes, they do occasionally) may feel that allowing his family to see him in such a demeaning position without his consent constitutes a breech of confidentiality. Certainly, I know a few lawyers who would see it that way.

On the point of survival, those that make it through a cardiac arrest (about 10 per cent) tend to be those who have received both prompt and expert resuscitation. This is far more likely to happen if the arrest occurs somewhere where staff are geared up for it (eg casualty or the coronary care unit) than, say, the toilets in eye outpatients or the mortuary. However, time, staff and space are of the essence, and there often isn't enough of any in casualty to shepherd the relatives in and explain what's going on. No amount of sanitised medical soaps can prepare you for the sight of a loved one without a pulse, and it may be cruel to introduce such a scheme without the training and resources to do it properly. Hospital staff would need substantially more communication skills training than they get at present and there may even be a case for preparing relatives. We already have ante-natal classes. Why not ante-fatal ones?

One of the problems with grief is that it's very unpredictable. Relatives can react with shock, anger, numbness, denial and uncontrollable weeping. It's possible these emotions could impede the doctors' judgement; for example, they may obliged to carry on with treatment when it would be kinder to stop. However, the vast majority of next of kins have a strong desire to be there at the moment of death. In America, where such schemes have been tried, they have on the whole been successful and appeared to help with the grieving process. Whether the idea can cross the cultural divide to Britain remains to be seen, but it would be foolish to introduce it nationally without ensuring that the staff involved are competent. Various studies in recent years have found that a fair proportion of doctors, both junior and senior, are not terribly good at resuscitation. The fact that we've got away with it for so long is partly due to a lack of observation.

How will it affect medical culture? As a student in a casualty department not far from Roehampton, I attended a cardiac arrest and, after the death, the anaesthetist decided to teach me how to put a central line (if you've watched ER you'll know what this means) into the recently deceased. As I was practising, 20 relatives appeared unannounced and presumed the patient was still alive (why else would I be sticking needles into him?). It was a stern test of our communication skills. For some doctors, emergency situations are a rich source of black humour. When I asked a group of today's students what happened at a resuscitation, they said: "You jump up and down on the chest, crack a few ribs and nick the chocolates." This went out on Radio 4 and received the following complaint: "Dear Sir, as someone who has suffered a cardiac arrest I can assure you it is no laughing matter." Well, I suppose it depends on which side of the defibrillator you're on. Comedy and tragedy are never far apart, and in a highly charged situation it could go either way. As Henri Bergson put it: "Laughter requires a temporary anaesthesia of the heart" - and so does a cardiac arrest. You've got to laugh, even if you work in Roehampton casualty. Just don't do it in front of the relatives.

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