Mr. X, a 42 year old patient admitted for several ethanol related disorders, deteriorates and develops permanent brain damage resulting from, among other things, long term ethanol abuse. Various consultants have pronounced him brain damaged and unlikely to do any other than go to a nursing home with a trach and feeding tube. I agree with those assessments and for purposes of argument, you can assume that they are true. He has mild renal failure (creatinine 2.4) which is increasing,and some mild liver failure. He also has a distended belly and it is unclear whether he has an ileus or a mechanical obstruction. He is on a ventilator and requires 50% FiO2 because of his longstanding COPD. He is effectively ventilator dependent, with no real chance of ever coming off the blower.
His clinically poor condition can reliably be predicted to progress to inevitable death eventually, but it is difficult to predict a time schedule. He will not die quickly as long as he gets continued aggressive care. But he will not remain in a self perpetuating Persistent Vegitative State indefinitely as long as he's fed and watered. His multiple organ system failure is not reversable. There is only one path, but it's length is unclear.
There is no living will and the wife freely admits that he never told her anything verbally about what his wishes might be concerning life support should he become incompetent. She, however, surmises that he would not want to be kept alive on machines. The social worker's interview states, among other things, that the wife related in a previous interview she was completely fed up with Mr X and had planned to throw him out of the house shortly before he landed in the hospital. There is no appreciable insurance money involved here.
His wife states that she wants "all the life support removed" so he can "die with dignity". It is your clinical opinion that Mr. X will die shortly after being removed from the vent, but if trached and fed, could go on for an indefinite time in a nursing home before he dies of inevitable and irreversable multiple organ system failure. He does not have a "rapidly" terminal disease.
Should you unplug the vent?
Ken Mattox:
As presented, I would NOT pull the trach, but would proceed with the following "protocol"
1. Discontinue the ventilator as a source of continuous support
2. Wean from the ventilator, but leave the trach tube, perhaps an occassional breathing treatment
3. Continue tube feedings
4. Optimize the oxygen/room air/content of the trach cuff suppliment, taking it to room air only if possible.
5. With the trach, he is in a theoritical better shape than when he arrived.
6. I would start no NEW treatments, such as antibiotics, renal dialysis, etc.
7. If he tolerates this plan for 24hours, I would send him home, not to a nursing home for terminal care of suctioning, tube feeding, and custodial care 8. The chart would reflect that he has received optimal care in the ICU and that his continuing care is custodial.
9. There is literally NOThING at this point that can be done for this patient which requires an ICU.
Stephen Streat:
David Crippen asks : Should you unplug the vent?
I say : why not ? Do your options include writing something like the following in the case notes :
Opinion : "This patient has multiple organ failure including ventilator-dependent respiratory failure and severe brain damage. He has no prospect of recovery and further intensive therapies are, in my opinion, not indicated and should be withdrawn. My colleagues .... and .... and .... and .... agree. We have also consulted a shaman/exorcist/priest/ethicist/rabbi/water diviner/lawyer/ethics committee (delete as required, no offence intended) who are in accord with this. We have discussed this matter with his wife .... who concurs. The patient is not mentally competent by virtue of severe brain damage. Plan : Withdraw IPPV, ensure that no distress ensues. Signed : FL.
I guess this is all a matter of societal constraint, not clinical medicine - what are your constraints ? Ours would be fewer I suspect.
and FL says He does not have a terminal disease and I say : other than multiple organ failure including ventilator-dependence and severe brain damage ... Question : how did he come to be on IPPV anyway ? Therein lies a tale ...
Frank Breheny:
This decision although complex is not a major problem in our community. If the Medical personnel are happy that they have done as much as they can to improve the medical condition of the patient and are of the opinion that further 'invasive ' therapy is to no avail, then I see no problem in extubating the patient providing him with supplemental oxygen, NG feeding if neccessary and nursing him on his side if neccessary. This is dependent on the patient being able to breathe, if he is apnoeic or unable to initiate ventilation it is a more difficult decision. In this case there does not appear to be external pressure (relatives wanting you to continue treatment in the face of obvious insurmountable odds) to provide anything but decisions based on the medical condition of the patient.
There is no doubt that extubation and 'letting nature take its course' would appear to be an acceptable course to take and appears medically and ethically consistent. The patient may not neccessarily die with this course of action but the problem will be resolved.
Gary Collin:
Yes, unplug. If you discount the wife's views as possibly having an interest in seeing him dead, and there are no other kin, then you can do whatever the so called "average person" would think medically appropriate. Since the man's medical condition has shown that he will not be able to achieve any situation of "meaningful" existence (whatever that really means), the appropriate method of care would be to withdraw care in this case. The "average person" concept comes into play when there are no surrogates who can give information about the patient's wishes. A hospital bioethics committee consult would be the appropriate first step, to have an uninvolved group examine all issues.
Tom Woodcock:
Personally I'd train him to get by with lower PO2; bring down the inspired fraction to about 0.3 over several days, and give him five minutes per hour t-tube breathing. Agree with family that we will keep "weaning" him, and if he succeeds, great, if he doesn't, then going back up is futile and we'll let nature take its course. Here in rural Hampshire we call it a one-way wean.
Farhad Kapadia:
If you anticipate that he could go on for a long time with a trach, will unplugging the vent actually precipitate a terminal event. Maybe, if the airway stays patent after extubation, he will continue to breathe. The problem may not go away.
What I would do in my setup, would probably be to wean & extubate him with the clear understanding from family that there would be no further intervention from the ICU team. I would then have go at the admitting consultant for sending him to the ICU in the first place. Also, before intubating the patient, I would work real hard on the admitting consultant to consent to a DNI/DNR strategy. I would try to explain to the wife, the futility of starting this treatment. Unless the intubation was a real emergency, I would have considered it a partial failure of ICU care if this patient got intubated before this was done. However, despite trying all this, we end up ventilating a lot of patients and then finally agreeing to a DNR status. Of our last 110 medical deaths, 27 got DNR orders after the initiation of mechanical ventilation. So despite working on admitting consultants an family we are not doing a great job on preventing futile intubation & ventilation.
Considering your (D Crippen) usually aggressive approach to avoiding futile ventilation, how come this patient got intubated in the first place. I remember a post of yours regarding a terminal cancer patient whom the admitting physician wanted ventilated. After you spoke to the family, terminal care was offered outside the ICU. At that point we had three futile onco ventilations an I was fed up with the whole onco team. I printed that post of yours rubbed their collective noses in it. Haven't had a single futile transfer in since then. If they remotely feel that ICU is required, they first call one of us for a consult to their wing, and only demand a transfer if they can make a convincing case of meaningful reversibility and quality of life.
Errington Thompson:
This scenario is unfortunately very common in the trauma population. Families can be very dysfunctional. The family member that is trying to make "family" decisions hasn't seen or associated with the patient for months to years. In situations like these I believe that the clinician has to use his/her best judgment. Is the family member acting in his/her best interest or in the interest of the patient? I believe in a given situation it is completely appropriate and ethical for the clinician to ignore the family's wishes if the clinician believes that the family is NOT acting in the best interest of the patient.
Situations like these can come up with less life and death decisions. A family member could ask for a simple letter stating that the patient is unable to make decisions (critical ill on vent). This letter would then give the family member power of attorney. The family member can then take care of the patient's bills, etc. I had a family member "steal" the patient's clothes, house and car. The patient recovered and had to take legal action to get his things back, the car was wrecked.
Tim Buchman
While this may seem a radical position, I think the safest course is the common sense course. Patients with multi-system organ dysfunction and clear evidence of a brain injury do not make a functional recovery. While it is certainly possible to keep such individuals' hearts, kidneys and lungs supported for an indefinite period of time, the common sense question is "to what end?" I suppose some zealous individual could accuse any of us of withdrawing support at a point where such supoort could prolong the process of dying. But we are in the business of helping people live, not prolonging their death.
Put differently, I imagine that if you choose to withdraw care, and if someone were to accuse you of violating the law, many of your colleagues --myself included--would speak on your behalf.
David Crippen:
This is an issue of what constitutes "terminally Ill". The "Living Will" law in Pennsylvania is written to protect physicians who allow "terminally Ill" patients to die of an untreatable disease process IF they have written evidence that they would not want to be sustained with life supporting technology. There are two potential loopholes in the law that could conceivably put physicians at risk for prosecution if someone, somewhere desires to make an issue of it.
As it pertains to the withdrawal of life sustaining technology:
1) The law specifically says that the patient must be "terminally Ill". That means there is nothing that can be done to reverse organ system failure and the patient will inevitably die. Unlike California (must die within six months), Pennsylvania does not put a time limit on expected death.
2) There must be written evidence before he became incompetent that the patient's wishes specifically proscribes life supporting modes in the event of persistent organ system failure.
At the current time, this patient is NOT "Terminally Ill" in the rapid sense of the word. His organ system failure is "treatable" in that it can be prolonged for a variable period of time. He could get a tracheostomy, feeding tube and be moved to a nursing home where he would vegetate on life support systems and dialysis until he inevitably died of his irreversible disease process.
He does NOT have written evidence of how he would have his physicians proceed in the even he is unable to speak for himself. His spouse has a documented history of marital strife and she has made the statement that she had plans to "throw the bum out", before he became ill. She has also made the statement (documented): "I think he would be better off dead".
Surrogates do NOT have the authority to withdraw life supports from patients who are NOT "terminally Ill", and any physician who facilitates such wishes is at great legal risk. Therefore, the letter of the law concerning how much indemnification I have from prosecution should I discontinue his life support systems is VERY shaky. He is NOT terminally Ill, he has no evidence of a living will and it could be construed that his wife might be taking the path of least resistance to get him out of her life.
On morning rounds, the Critical Care Fellow states that we must do one thing or the other. If we are going to withdraw, we must do so. If we are NOT going to withdraw, then the standard of care dictates that we much then pursue an aggressive course, including placement of a Pulmonary Artery Catheter to ascertain baseline hemodynamics, optimize those hemodynamics and then place a dialysis catheter.
His family is furious and vow never to sign consent for such things. The hospital attorney is talking about going to court to get a legal guardian.
Would you perform these procedures?
Tim Buchman:
While this may seem a radical position, I think the safest course is the common sense course. Patients with multi-system organ dysfunction and clear evidence of a brain injury do not make a functional recovery. While it is certainly possible to keep such individuals' hearts, kidneys and lungs supported for an indefinite period of time, the common sense question is "to what end?" I suppose some zealous individual could accuse any of us of withdrawing support at a point where such supoort could prolong the process of dying. But we are in the business of helping people live, not prolonging their death.
Put differently, I imagine that if you choose to withdraw care, and if someone were to accuse you of violating the law, many of your colleagues --myself included--would speak on your behalf.
Noel Gibney:
I sympathize with your dilemma but I find it hard to believe that a patient who has:
Severe ventilator dependent COPD,
Profound cerebral injury from chronic ethanol abuse
Hepatic impairment
Worsening renal failure since you mention inserting a dialysis catheter
- Has any chance of longtime survival (not to mention meaningful survival). Even without being ventilator dependent this patient has a combination of conditions that are likely to prove lethal within a few months. Even with warehousing on a ventilator does anyone really believe he will live 3 months? 6 months??
Just because he can be supported for a few months with technology doesn't mean that he should be. This may one of those few cases where you wish to spread the blame with a consult to the ethics committee.
Errington C. Thompson:
I don't think I understood your question. Your original question seemed to be what to do when a family member who wants to turn off live support is unreliable. What you have now presented is a different ball of wax. You have a patient who is sick but not terminal. The patient doesn't have irreversible disease. The patient doesn't meet futile criteria. You have no living will. You have a family member who is unreliable. I don't think that you have any other choice but to treat the patient. Get a court order if you have to but I would treat the patient until the court makes a decision.
Daniel McNally:
Physicians withdraw support from patients, not surrogates. When the patient does not create a document expressing his wishes, the surrogate may be the source of information about the patients wishes, founded on explicit discussions or their best guess. The physician has the responsibility to evaluate this information as part of determining the patient's wishes.
The various statutes our states have about withdrawal of support differ widely, but in Connecticut (and it sounds like in Pennsylvania) they provide a level of added protection against legal action if one follows a precise format in the decision process and the patient meets certain requirements. In Connecticut, for example, it requires executing a document with specific content, that the patient be "permanently unconscious or terminal, and that an appropriate physician make the neurological assessment if one is needed. If all that is done, the physician withdrawing support enjoys an added "layer" of protection for his actions.
However, there are other occasions when, with appropriate information from families or directly from patient, without a document driven by a particular statue, that we take action including withdrawing support in accord with the patients wishes. We don't have that added layer of protection, but we are certainly are acting appropriately medically and legally.
David Crippen:
Extraordinary life support was withdrawn and the patient expired with the family at the bedside.
If one were a purist, it could be argued that in the "snapshot" sense, this patient is NOT terminally ill, because he has the potential for life supporting hardware to sustain his multiple organ system. Therefore, if one were to take a snapshot of him, he would be salvageable for the time it took for the photo to develop. Using that criteria, I would be obligated to continue life support until some change occurred that made him liable for certain death within the time it took the snapshot to develop.
However, if one chooses to look at a trend rather than a snapshot, it could be argued that he was, indeed, terminally ill because his multiple organ system failure is irresolvable. therefore, he WILL die in time regardless of what support systems are applied to him. So if one looks at the concept of inevitability, he is clearly terminally ill, but the "terminal" portion of the equation is more or less open ended. The ethics committee felt comfortable with this interpretation as did the family.
Should I have supported him until he got to a nursing home on mechanical ventilaton, feeding tube and dialysis to consider withdrawal after some "more" terminal event occurred? It isn't an easy question to answer. None of this is easy. This has been my rationale and it is up for dissection.
Stephen Streat:
David seems concerned about the "terminal" nature of the patients illness and its time course - indeed we all have terminal multiple organ failure in one sense - we are slowly deteriorating with time in terms of our physiological reserve ...
However, I think that it is sematically clearer (and perhaps comforting) to think that this patient was not so much "terminal" as "irreversibly damaged" to the point that it was not going to be possible to return him to a level of independence and interaction that seemed worthwhile and reasonable and worth the time, effort and money - to his physicians and family, the ethics committee and the ever watchful nurses .. I bet that there were a few "SODs" involved too - pulmonologists ? nephrologists ? neurologists ?
This is what I refer to as the evidence of "reasonableness" in any society - (that quintisentially British concept of the "reasonable man" again) - Does it seem reasonable when viewed from many orthogonal points of view ? If so, it is probably reasonable.
I take heart from our bereavement followup data and the quote that Malcolm often refers to - something along the lines of - "it is perhaps less the number of patients that survive that should be seen as the absolute measure of the quality of an ICU - more the experience of those who die and their families and what we add to that".
Errington Thompson:
As we have no objective measure of the patient's neurologic dysfunction and we know that patients have lived for years with hepatic dysfunction (Child's class A or B). Renal dysfunction with a creatinine of 2.4 is worrisome but not a cause for alarm. I'm not sure that I could have come to your conclusion. Based on the information presented I would not have withdrawn therapy.
David Crippen:
I find it very interesting that we have lost the concept of what rational humans would do if faced with unimaginable horrors. Has anyone in this group EVER observed a sane person writing out a "living will" stating that they desired to be placed in a nursing home on a ventilator with a feeding to be and thrice weekly dialysis so that they could suffer cerebral horrors the nature of which we can only speculate in our worst trembling nightmares. Then maintain that with frequent trips to emergency departments for lots of needle sticking, and trips to ICUs for a change in scenery where people who obviously have no sense of mercy make them as uncomfortable as possible to maintain their vital signs and lab values, only to repeat the cycle over and over and over.....until you finally and mercifully die, no help or pity from your caretakers.
Yet, with great piety, Errington Thompson tells me that that is the right path because, in the absence of written requests to the contrary, I MUST assume that any rational person would desire the horrors of life-in-death. If Errington's wife , God forbid, suddenly were placed in the same position, and they had never actually DISCUSSED, what her wishes might be, would he assume she would desire a fate like the patient in question. What would he say to a physician that told him it was mandatory that she be put in that position because Errington's advice and consent couldn't be trusted.
Mike Darwin:
My unequivocal answer to this question is YES! And I have watched them follow through on all the horror you can imagine including being rendered aphasic (spoke 5 languages fluently) from CNS toxoplasmosis, having huge necrotic neoplastic areas from loss of local control with accompanying pain beyond words continuing through to one value destroying disability after another. In HIV I've seen patients with constant diarrhea, no p.o. intake, massive IV fluids and TPN (a perianal area that looked like a blowtorch had been taken to it) and acute pancreatitis from ddc just keep at it till they died from sepsis or PCP or just "died." I have seen this _at least_ 20 times in my life, up-close and personal.
Further, I have seen individuals who chose this course actively and went to great lengths (15 pages of detailed text in one case) to delineate the treatments they WANTED, including heroics till the last breath.
And then I've watched them follow through on it. I must say, to my considerable chagrin, and even horror, that in several cases I've been the proximate cause of the paper documentation of these wishes because my objective was to talk them out of just such a course of horrors. Part of this was a detailed explanation from me of futility and how family and physicians "interpret" living wills or durable powers of attorney for health care.
Yet more, as this nightmare unfolded I would repeatedly try to talk the person out of pursuing this course action. I have NEVER succeeded in such a case. They either die with intact mentation (rare) or slip into the twilight zone of vent supported PVS or massive neuroinjury or inability to communicate (liver failure, MSOF, etc.).
Even more amazing still to me is that a few of these people were into post-arrest cryopreservation (cryonics) which, if it has ANY chance of working, depends upon a reasonably structurally intact CNS. Thus, if you have any choice about choosing how you're ging to die, waiting until HV dementia has destroyed your entire cortex (after it has already destroyed your immune system, gut, turned you into a bed-bound skeleton, left you on supplemental O2 from multiple bouts of PCP, and put you on TPN) makes NO sense at all. But I've seen it happen: twice!
In my dialysis days I saw patients with so many nightmarish pathologies demand to continue treatment in the face of unbearable pain and compromise to quality of life I've lost track. One woman used to scream in agony every time I unwrapped her Scribner shunt (the wing tips of the arterial cannula were poking up through eroded holes in the skin). Her time on dialysis was a non-stop run of vomiting, cramps, hypotension, nausea, and frequent incontinence x 2. When not vomiting or sceaming, she constantly said "Oh Lord, Oh Lord..." for 4 solid hours. Some of the more cynnical nurses called her dialysis time in the in-patient unit (too unstable to do outpatient) "The Gospel Hour."
BTW, she was a hemiplegic diabetic with an amputation of one leg at the knee. She adamently refused any HINT that she terminate dialysis which, not including labs, acute exacerbations (hospitilizations) cost two $135.00 ambulance trips on gurney (one to and one back) to the nursing home a few blocks away 3x a week plus the $350.00 per treament charge for in-patient dialysis. She was still there when I left after 5 years on hemo 3x per week. I understand she died about 6 months after I left, from a massive stroke while on dialysis.
Between HIV and dialysis I've learned something very important: there is huge difference between not wanting to die and wanting to live. Or, put another way, between fear of death and joy in life.
Next time you are out here Dave, I'll show you, if you like, some of my videos of cryopatients who chose this (to me) insane course of action and you can actually see them DEMAND continued high level care until they become aphasic or demented. These tapes were made to document the patient's wishes so that I and others would not be accused of Nuremberg-level torture post hoc by outsiders or distant family or friends.
The take home message here is that you just never can tell what the other guy wants. Which is FINE with me, if s/he would PAY FOR it with THEIR money instead of mine, and everybody else's.
Jim Cowan:
Yes, but often the decision maker has no clue, no idea what level of discomfort they are requesting Granny be put through. I believe the concept of informed consent is more of a distant ethereal wish than an actual achieved objective.
No one wants to die, but often the choice is between immediate death and two months of suffering followed by death.
Anthony DeWitt:
That is indeed a good point. People often confuse the problem by what they HEAR. They hear "do you want your loved one to live or die?" What the doctor is usually saying, however, is "do you want them to live a few more weeks in incredible pain, and then die, to a 90% probability, or do you want to let them die peacefully now."
Of course, the contra is true too. I visited with a physician, who for client confidence reasons must remain nameless (not a member of this list), who told me several real horror stories about a hospital where DRGs were the sole determinant of life-sustaining therapy. And while a part of that story has to be taken with a grain of salt, I recognize this cash crunch is a real problem for caregivers and administrators.
As to informed consent, like all models of behavior, it has various components viewed from various angles. The patient wants every piece of information possible to either reinforce the idea that he will be okay, or give him a legitimate excuse to say no [spoken from recent personal experience]. The physician wants to give the relevant information, but rarely includes the fact that a falling meteorite might accidently hit the cath lab. Then there are lawyers who would invalidate the consent because the doctor didn't mention that once back in 1711 someone died from one of the drugs used during the procedure. The problem with informed consent is what level of "inform" is necessary to get proper consent. And that is where the battle is always fought.
David Crippen:
DISCLAIMER: Harry is (was) a real person and some of this scenario is factual, some embellished by me. It happened long ago and far away. Ask me no further questions and I'll tell you no further lies.
Harry the Hopeless: Abandon all hope ye who enter here.
Ne'er-do-well Harry never got much of a break in life. Just never seemed to get his act together and put it on the road properly. Failed marriages, failed jobs, multiple psychiatrists...inadequate personality....multiple gulps of pills followed by calls to the paramedics and pumped entrails in the emergency department. Frustrated emergency physicians.."Harry...can't you at least get a suicide right?" Finally Harry decided to take professional advice and do the job correctly. 10 gauge...double barrel...both barrels...under the chin. Harry couldn't quite get the hand-eye coordination down despite best intentions. Tried to look around the barrel to insure his toe was correctly placed. Big boom and Harry flubbed again, blowing off his face but leaving his head and brain more or less intact.
Paramedics arrived as per usual, doing as paramedics do, endotracheal tube placed down the closest facsimile to a trachea. Good vital signs...off to the ED. Surgical evaluation: everything from the chin to the eyebrows cleanly removed. Endotracheal tube in good position and ventilation proceeding normally. Vitals normal. Not knowing much else to, a trip to the OR for debridement and evaluation under the hot lights. Numerous cranial nerves waving in the wind. Debridement, permanent trach, remaining skin folded over packing.
Following the procedure and in the recovery room, anesthesia wears off and the recovery room staff are horrified to see Harry slowly raise his left hand to his face and examine the packing. An immediate neurologic exam on poor Harry shows that he uses his left arm in a semi purposeful manner and is otherwise unresponsive. He has deep tendon reflexes all around but does not withdraw to painful stimuli. As it should be only too obvious, there is no way to test any of Harry's former cranial nerves other than observing them wave in the wind. An EEG tech is summoned and the product of his labor is duly sent to the neurologist who strokes his chin wisely while pondering millions of little squiggles. The final pronouncement: "diffuse slowing, please correlate clinically." Auditory evoked stimulus shows that Harry has no hearing function. Coded commands on Harry's palms and chest to respond with the good arm are in vain. Occasionally Harry will raise his left arm into the void, then lower it slowly. Otherwise he is unresponsive.
A uniformed police officer greets you in the ED and hands you Harry's suicide note, found later at the scene.
"Goodbye cruel world, I'm taking a chance on reincarnation."
A relative (only son) is found in California who is contacted and states that he is sorry to hear about Harry. When asked if he would be interested in making medical decision for poor Harry, he states he will be happy to talk to the physicians about Harry's care unless it involves him making any decisions which might incur any form of liability on his part, and all such requests for action on his part should be sent to his attorney for consideration. He also wants it understood from the out set that he will have no liability for any of Harry's medical expenses. You guessed it; Harry's son is a California trial attorney.
Aside from the fact that Harry cannot hear, talk, smell, see or move any other than his left arm, he is in pretty good shape.
What are your options at this point?
David Crippen:
No takers, eh? Lets sweeten the pot a bit.
Harry cannot hear, talk, smell, see or move any other than his left arm. He has so sensory apparatus to feel or experience any form of pleasure or satisfaction, or even quietude. The only available sensations to him are pain and discomfort. What would YOU think if you thought you were effectively ending your life and you "woke up" with no sensory ability at all except searing, diffuse pain in the quiet darkness.
Of course, you would know you were in Hell.
AND.....let's remember that Harry left a VERY convincing "living Will". His states wishes were that he desired to live no more, and the only reason he's more or less around for us to worry about is simply that he bungled the attempt. Therefore, Harry has an eventually terminal illness, he's in constant pain and he has a living will (sort of) that clearly states his wishes should he become incapacitated and incommunicado.
He meets all the criteria any ethics committee would agree to. Unless I hear any convincing objections, I am pulling the plug on Harry without any further ado and moving on to a Billy Joel Concert review.
Ted Rogovein:
How Un-American not keep this body alive forever...you have the technology. Where do you get off playing God here? What "terminal illness" is Harry suffering from...life? This poor soul was crying out for help....that was what his note was... not a "living will". As for your comments about the ethics committee accepting this...I don't think so. Harry was not competent to make any type of decision since he was obviously depressed. No David, you have the moral duty to keep Harry alive forever. Start a narcotic drip to keep him pain free and start a slow, successful (not one-way) wean from the ventilator. Feed and water him daily and give a daily (collect) call to Harry's son to update him on his dad's progress.
Joyce Evans:
My comment: people fear death so much...I just don't really think about it. Some people who are suicidal are:
1. not really suicidal but attention-seeking (as you see so often in ER)....don't quote me but I've heard the +teddy bear sign as the description
2. clinically depressed...no organic cause, temporarily suicidal and will improve with medication
3. mood disordered due to organic causes......alcohol created depression, post cocaine anhedonia....if you can get them away from the substance long enough maybe there's a chance
4. comorbid depressions.....MS, pain disorders...treat the pain and they regain the will to live
5. cognitively intact. Do no want to live. Have made a decision. Have decided not to ask for help and quietly just do it. Want others to respect their decision. e.g AIDS
You know all this.....you've seen it a million times. Why can't people accept things at face value? The guy wanted to kill himself for probably numerous reason. His feet had been nailed to the perch for quite some time. And there are probably numerous reasons (genetic, up-bringing, life, failed rehab attempts, etc.) which were all factors in his decision. Why do people think we can rescue everyone? The guy left a note....I want to die.....he puts a gun to his head and pulls the trigger...sounds straightforward to me.
Playing God is keeping a dead person alive. Let nature takes its course. Maybe the writer wants the US to become the Land of the Undead...or the Land of the Living Dead (due to fear of litigation or unresolved death issues). This sounds more like projected fear of death onto the patient. Healer heal thyself. I would agree with the writer that Harry was probably depressed.
I find this discussion so weird..especially considering all the experiences I've had with family and friends regarding these issues. Here, I'll give an example: close friend has a brain aneurysm, kept alive with vent til family arrives from California and says good-bye. We're there when taken off vent....dead. Mom has massive stroke....limbic system....nothing medical done (no IV), nothing...see what course nature takes .The writer is asking you to play God or to be God...then blaming you for thinking that you are God....
When you deal with issues of mental health, you have to be so objective, totally aware of your own biases and really watch not to project your own issues. I find this whole topic fascinating. Anyway, this time I'll sign my email with my "letters" although usually don't unless at work.
Peggy Bear:
Just a thought in regards to the "playing God" argument. Why are we "playing God" when we allow people to die, but we are not "playing God" when we don't? I have had people tell me that "God could take them if he really wanted to (regardless of the drips, vents, dialysis etc.)." If God is that powerful, why can't He keep someone alive without all of that? I have never understood this argument.
Roy Richardson:
I've never understood the reasoning that so many people seem to use that pulling the plug is playing God, but keeping people alive by artificial means is NOT? It seems that God's plan is & has always been that earthly physical existence is temporary. It makes no sense that if a person would die within minutes or days of removing some type of support, would obviously never survive etc, that pulling the plug is 'Playing God'. I've had conversations with priests about this subject & the consensus has been that people with this view are being hypocritical. On one hand the want the patient to die 'naturally 'not 'artificially' by pulling the plug. To quote Dr. Crippen - poop! There's nothing natural about anything we do in critical care except pass excrement. The majority of all else is as artifical - created by man - as anything may be.
I believe that if a person drops to the ground with a probable terminal injury and we then 'save' him/her for a life of questionable quality, we have perhaps thwarted God's 'plan' for that person & a case could be made that doing such things is also 'Playin God'.
Real life example here: Anacephalic baby born - the family insists that 'everything' be done for it, so the hospital weenies fearing a lawsuit agree to it. The baby 'lives' for about 3 years, the parents have it home, take it on trips to Disney World etc and in the process require frequent ER trips because the thing stops breathing on a regular basis So, who played God? We know that God (whatever your concept of that may be) created this baby without a brain and one could surmise from this that the baby wasn't meant to live. You could believe the parents have some history of terrible sins and this was their punishment (just a theory - my actual belief is a few cells went astray during embyonic development).
I know this is subject makes many uneasy but with the ever forward advance of technology, this gets addressed with increasing frequency.
Dick Burrows:
"Playing God" is one of those trump card arguments which have been used since Adam "played God" and ate the forbidden fruit!
Voltaire said the if God didn't exist it would be necessary to invent him! Thus it is an invented argument with no substance and no design other than to impress those who have an unreasonable fear of devine retribution - from their fellow man!
You don't need priests and popes to understand the failure of the argument. You just need to ask yourself what is different between us and those benighted fools of the Dark Ages who literally whipped pigs for breaking God's Law by being unclean - not a lot.
The argument is used in the face of our uncertainties and unwillingness to take reasonable decisions and thus the invocation from each side that you are playing God if you stop treatment and the burgeoning argument that you are also playing God if you do not stop treatment and allow the patient to die a natural death.
Ask yourselves the following question What is a natural death any more than a natural birth? Take this to its illogical extreme and caesarean section would be an unnatural birth preventing a natural death!
In your rigid pursuit of principles at all costs you have all forgotten that principles are just that - principles - they are not whips to flagellate one with when one steps slightly out of line. They are ideals which should be tempered by tolerance, forebearance, trust and reason.
When principles are questioned thus the argument shifts and we will then all flagellate each other with definitions of what is reasonable? And we will still accuse each other of being unreasonable in the face of our uncertainties.
The real nub of the argument however is that except in some rare circumstances (decapitation) we are never certain about outcome, therefore any decision (defined as a choice between probabilities) to stop treatment must necessarily mean somebody will enter an early grave. We are unable to accept that to the point that we prefer "God," the patients and their relatives make medical decisions because if they make the decision the physician is no longer culpable either legally or ethically. A sad reflection on the practice of medicine. And an erroneous one too.
The only thing that you should ask yourself when you are accused of "playing God" is whether or not you are acting unreasonably and forcing your idea of quality of life onto the patient. If not acting unreasonably then your action should carry and furthermore and I would go so far as to say that your reasonable action (in general terms) should have legal backing.
So reasonably "playing God" is an argument which can never be thrown out - only defeated in the individual case. Isn't that what the practice of intensive care is all about?
David Crippen
The End is Near
I've called in the nurses who have cared for Harry for the last few weeks to explain what we're going to do here. They have dealt with Harry for some time now and I know they all have some feelings about Harry and an interest in this case. It is more than fair to let them in on what's going on.
OK Ladies and Gents, here's the take:
You all know Harry here. Harry decided that he did not want to participate in life anymore. He wrote these wishes in a note that I believe is authentic and authoritative. Harry then tried to end his life in a very effective manner. No pills followed by a call to paramedics, no cry for help. Harry meant it. Unfortunately Harry also botched it and now his situation is infinitely worse than when he started on this course. Harry wanted to die, but unfortunately, through no fault of his own, didn't finish the job. Instead of being dead, Harry is now in the realm of Life-in-death, just like the Ancient Mariner only adrift in a sea of pain, not water. Harry has recurrent bouts of sepsis, pressure sores, muscle spasm and requires constant sedation to keep him from thrashing about in an agitated fashion. Harry's options do not include the quietude of Persistent Vegetative State.
Harry has no sensory apparatus to ameliorate constant pain and discomfort. His only sensation is misery and woe and he thinks it will be for eternity, which relatively speaking might be the case since we have the capability to keep his vital signs stable and his corpus warm indefinitely with machines. It has been suggested by consultants that we are obligated to artificially prolong Harry's suffering because Harry cannot tell us his current wishes, and his only relative has no interest. It has been suggested that Harry might change his mind and desire us to continue his suffering and cannot tell us so. As a practical matter, I do not believe that this is the case. If Harry's psychic pain made him miserable in life, his current sensory depravation and REAL pain/discomfort is infinitely more noxious and continuous. It is inconceivable to me that Harry would want to live in this terrible world we have created for him. Therefore, as Harry's physician, I have decided to give Harry the benefit of the doubt and let nature take it's course unfettered by technological life support.
What we're going to do here is apply the Darwinian Tolerance Test to Harry. We're going to take his "extraordinary" artificial life support away and compress five million years of natural selection into the next thirty minutes. If Harry survives off the vent and all other modalities except "ordinary "care: nutrition, hydration, a clear airway and comfort measures, we will get Harry a G-tube, and transfer him to a nursing home. However, if Harry cannot survive with "ordinary" care that everyone deserves, Harry will die and there is a team of surgical-types waiting in OR two to quickly relieve Harry of several unneeded organs that someone else can use.
And by the way, while the Darwinian Tolerance Test is progressing, I will be standing here with a syringe of fentanyl to offset any suffering I think Harry might be having during the (possible) dying process. If Harry looks uncomfortable, I will try and ameliorate that discomfort with some fentanyl. At no time will I give Harry a big enough blast of fentanyl to cause a pure narcotic respiratory failure. If Harry dies, it will be because his organs cannot function adequately on their own, not because I gave him some drug that killed him. I realize that this is a fine line to tread, and I'll try my best to tread it accurately.
That's the way it is. Are you all OK with this? Any questions?
Requiem by D. Crippen:
Harry is history.
His son told me on the phone he couldn't possibly make any decisions about Harry without consulting his attorney. His son the attorney was so unsettled about making any decisions he hired his own attorney for advice. The bottom line was that none of them wanted to decide anything and they would "take it under advisement". The various consultants I asked seemed to think that Harry's suicide note had no validity. We couldn't possibly know what Harry's "real" wishes were about wanting to continue to "live" even though he left a note regarding his wishes and tried to blow his head off. Some would say that there is a chance he might have had a change of mind and now desires to exist in a life-in-death real of perpetual sensory deprivation superimposed on pain and discomfort. Yeah....there's also a chance that Godzilla will poke his head out of the Fort Pitt Tunnel and start devouring cars.
Harry existed in a cruel, unrelenting world of sensory depravation that unrelentingly magnifies his previous psychic pain. As his physician, my mission was clear, to identify the best course for Harry using the available evidence and then do the right thing. I gave Harry a slug of fentanyl and pulled the plug myself....with a sure hand.
Harry had also taken the time to create a legally binding document (drivers license check off) willing his organs to others in the event of his demise. Harry's heart, liver and kidneys were transplanted. His lungs were not usable. There were also some long bones taken and some skin for graft.
I went to the funeral. There were only a few acquaintances there. The son did not show. They reverend asked me if I wanted to say a few words. I did.
"I didn't know Harry before I met him under the most difficult of circumstances. I was placed in a position of having to deal with a lot of things about Harry I don't understand, like depression and suicide. I was placed in a position of having to make decisions no one else wanted to make. I asked a number of my colleagues to help me best deal with Harry's dilemma and received a multiplicity of thoughtful answers. These well meaning consultants almost uniformly followed society's hard lines in dealing with society's anomalies. If a person assumes a philosophically uncomfortable attitude, we must always err on the side of assuming that they would snap back into political correctness if given another chance. Therefore, most of those who would give advice simply told me to assume that Harry "really" wanted to continue living even though every available bit of evidence pointed to the contrary.
Clearly, Harry had a long history of incompatibility with fruitful life. By his actions, Harry inadvertently put himself in an even worse position than that from which he began. Instead of perpetual psychic pain, Harry unexpectedly entered a realm of Hell-on-Earth. Harry clearly didn't want this, there was real doubt that Harry could ever depart it, no one wanted to make any other than politically correct decisions.....decisions that left Harry in perpetual Hell because of the inconceivability that Harry would "really" want to die, and the inadvisability of forcing our own paternal ideas of what should be on Harry's current, unstated expectations.
I was Harry's doctor. I felt Harry's pain and I ended it because in the end the preponderance of evidence as to Harry's wishes pointed in direction that seemed authoritative and reasonable. It also seemed reasonable for any "reasonable man". I had two choices; to maintain Harry in his Hell on Earth w with very little chance of getting back to the square one that Harry had previously rejected because it was politically correct. Or to allow Harry to escape from his Hell because I felt it was the right thing to do under the circumstances. The decision ultimately came down to me and I made it. In my heart of hearts think it was the right thing to do. If it wasn't....God help me".