A couple of weeks ago I gave a talk to a group of sixth form students (17 years old) at @mcamossbourne. I get nervous about these talks, maybe more nervous than talking to a group of doctors at a conference. Maybe it’s the fear of being judged by teenagers, deemed boring, or maybe it’s the responsibility of being able to influence their thinking one way or another, and much more so than an older audience. I wanted to be a little challenging and thought provoking so I wanted to cover a taboo subject, and as it wasn’t going to be sex, I made the choice to talk about death.
I told them about two patients, one of whom I think I failed and the other I think I and my ED consultant colleague looked after really well in difficult circumstances. (I’ve changed some of the details to improve anonymity, but the story is still the same).
The first man, where I think we failed him, was transferred to us from another hospital with a ruptured aortic aneurysm. This is a serious condition which will result in death, quickly, if not treated. The operation to fix it is a huge one, with a high risk of dying on the operating table or on the intensive care unit afterwards. He was in his eighties, still smoking, didn’t leave his house much, and had a lot of other medical diagnoses which increased the risk of doing an already high risk operation. In fact the likelihood of him returning home with the same quality of life he had beforehand is pretty much zero, and if he survives the operation he is likely to be in a nursing home for the rest of his life.
This man had already had a discussion with one of my surgical colleagues who also painted a bleak picture, but the man had heard the chances of death were not completely zero. His desire not to die was strong and he was adamant he wanted to go ahead with the operation. Despite me being very honest about the likelihood of death or complete dependence nothing would sway him. His family was also very optimistic, saying he was a fighter and would pull through against the odds.
We went ahead with the operation and he did survive initially. Unfortunately he eventually died on the intensive care unit about two weeks later, still unconscious and ventilated. He was swollen and bruised from all the drips inserted and the family were in and out visiting him, visibly exhausted and distressed seeing him die slowly without ever regaining consciousness.
I truly feel we failed this man. We allowed him to go ahead with a futile operation, removing from him the chance of a dignified rapid death. We gave his family lasting memories of a slow decline with the enduring images of their father/grandfather as a swollen bruised body attached to a ventilator, completely dependent on others for life.
My other story is of an eighty-two year old woman who was making her husband a cup of tea and fell down the stairs in their home. Her husband found her at the bottom of the stairs unable to move her arms and legs, straightened her out and called an ambulance. When she came in to us the first thing she said to us was “I don’t want this”. It was clear she knew exactly what had happened: her cervical spine had broken in the fall and transected the spinal cord. She would never regain movement, and she would be fully dependent on others for all her personal care.
Her blood pressure at this point was unstable due to the injury and we had to give her drugs to support it. Her breathing was laboured but she still held her own. We got her down to the MRI scanner to rule out anything reversible, and it turned out as we feared. The spine was transected. Her son and daughter were with her by this point and it was clear they had previously had conversations about death and about this kind of scenario. We explained the findings to her, with her husband and children present, and made a decision together to withdraw treatment and allow her to die.
This all took place in the resuscitation area. At this time it was very small and not fit for purpose (after the Care Quality Commission visited us we finally got a refurbished area which is much better). It was a very busy trauma day, but despite this we managed to create an atmosphere of intimacy. When we withdrew the drugs keeping the blood pressure up she became more drowsy, and over the next half an hour she became progressively more unconscious and died peacefully surrounded by her family.
It would have been very easy for us to intubate and ventilate her, fix her neck, and she would have survived on the intensive care unit for days, weeks or even months before dying. She would not have been able to do anything for herself and her death could have been long and protracted. She had previously discussed death with her family, and this made all the difference when deciding on the right course of treatment for her. Her children had already thought through the scenarios and maybe visualised them before that day. There was no doubt what the right course of action was for her and I truly feel we provided excellent care for her in her last few hours.
When I went to speak to the young men and women of Mossbourne I wanted to give them something to think about, and something to challenge their outlook on life. I wonder if the first patient would have had a different experience if his seventeen year old granddaughter had heard a doctor talk about a good death at school and decided to have a conversation with him about it?