Thursday, July 13, 2006

A moral dilemma

Dr SM is working in Intensive Care at the moment. This is where the sickest hospital patients are looked after, using a variety of machines and powerful drugs to support patients’ organ systems whilst we try to fix the underlying problems.

Intensive Care is expensive, around £1000 pounds per patient per day. Each patient is looked after by a single nurse and is reviewed several times a day by senior doctors, whilst a junior doctor is present 24 hours a day. The machines are not cheap, with ventilators, kidney dialysis machines and even the monitors costing thousands.

Intensive care is also expensive for the patient. Being critically unwell is an unpleasant experience; patients often suffer hallucinations and persecutory delusions. Sadly these will often persist after discharge, with between 10 and 20% of patients developing post-traumatic stress disorder. Critical illness leads to severe muscle wasting, pain and joint discomfort, loss of fitness and appetite. Quality of life after intensive care is a major issue. Nearly half of those patients who survive to discharge from intensive care die in the year following it, many of them in hospital.

For these reasons we often have to think carefully before taking a patient to intensive care. It is important that we judge it appropriate to subject a patient to this, that it is done with a realistic hope of survival with a reasonable quality of life. What is a reasonable quality of life? What is ‘realistic’ when talking about chances of survival? These decisions are part of the day-to-day business of working in intensive care.

A recent example. Last week we discharged a young man from our unit to allow him to die at home with his family. James was 23; he had a congenital condition that had left him with significant learning disabilities, epilepsy and physical impairments. He lived at home with his parents who cared for him more or less full time and had done so for the last 23 years. He was admitted with a ruptured bowel and required emergency surgery to fix this. Following this he had difficulties breathing and came to intensive care for ventilatory support. Over the past four or five months James’s physical condition had deteriorated, he was not as strong and active as before, he had to be fed with a tube into his stomach and required help with washing, dressing and toileting.

We had several long discussions with the family, asking for their assessment of James’s quality of life, did they think he experienced pleasure, could he recognise them and his siblings, how did he express himself? We had daily debates amongst the medical and nursing staff about what we were hoping to achieve and whether there was any chance of surviving intensive care.

Over the first few days of admission he made steady improvement and we were able to get him off the ventilator. However he was still very weak and was unable to cough up the secretions from his chest. He developed a pneumonia and his physical condition deteriorated again. We had to make a decision as to whether to put him back on the ventilator and restart aggressive therapy. Further discussions were held with his parents, and we explained that without this aggressive therapy James would die but that even if we restarted he was still at high risk of death and would more disabled than before if he survived to discharge.

The parents asked if they could take James home. Thankfully for once the NHS worked as it is meant to, and we were able to co-ordinate with James’s GP, the district nurses and our own nurses. James was able to go home and died a day later, comfortable and surrounded by his family. Sometimes we can’t save lives, but as in this case we can still act in the patient’s best interest.

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