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Thursday, July 07, 2005

Not to harm - Medical Ethics (IV)

When I walk down the corridors of the hospital, I often get cornered by relatives of patients who want to discuss their loved one's condition and options for treatment. Many of them struggle with making difficult decisions, and one of the topics I am often asked about is the concept of Euthanasia.

Now, anyone who is asking more information about euthanasia, is usually in a rather delicate frame of mind. Perhaps they have a relative suffering from end-stage cancer or a debilitating condition like multiple sclerosis or parkinson's disease. Perhaps they have been asked to make decisions about treatment plans. I still find it very difficult to discuss treatment options with patients and with relatives, because I need to be very clear in what I am trying to communicate, whilst remaining sensitive towards them.

Euthanasia, as I understand, means 'good-death'...but nowadays it points towards the intentional killing of a person because of the suffering or illness endured by that person ('Mercy-killing' or 'Physician assisted suicide' are other common terms). This is totally different from withdrawing 'life-prolonging' treatment.

Now there are many stages of hospital treatment, which I categorise as follows:
1. For cardio-pulmonary resuscitation (CPR)
2. For Active invasive treatment
3. For Active conservative treatment
4. For Passive/supportive treatment

Stage 1 treatment is all about bringing someone who is 'dead' back to life. A person who requires
cardiopulmonary resuscitation is someone who has no pulse and has stopped breathing - so we start chest compressions to try to keep blood flowing to the brain, and breathing into his lungs to keep oxygen in the blood (until someone comes along with the defibrillator and yells 'STAND CLEAR!' and tries to jumpstart the heart with 200J of electricity).

In a normal, young and healthy person, CPR has a 4 out of 10 chance of restarting the heart and breathing, and on average 2 out of 10 patients will survive long enough to leave hospital. The odds really are not bad at a young, fit and healthy person. But what about an elderly, sick person with lots of problems? CPR is not a kind, gentle procedure. It is rough and ugly and very painful.

More than once, I have felt ribs snap under my hands, and I have seen patients come back to the living after CPR, but die a few days later, spending their last moments drifting in and out of pain and consciousness, hooked up to machines.

The decision whether or not to perform CPR on a person is a joint decision made by the patient, the patient's family, the doctors and the nurses. The patient, of course, gets the last say - which means, anyone between stages 2-4 can also be for CPR if they so request it.

Stage 2 is active, invasive treatment. By 'invasive', I mean treatment that is painful, which usually involves either cutting open a person (on the operating table) or the use of anaesthetics to keep a person asleep and paralysed.

For this stage of treatment, you need to know there is a small chance that the person involved might be able to be weaned off the tubes or survive the surgery or wake up once the anaesthetic has been withdrawn. There is no point in performing invasive procedures on a person who is more likely to die faster from the procedure than the disease that they have. Active, invasive treatment is usually for life-saving procedures.

For example, I will cut out the lung cancer, and I will put tubes down your throat to help you breathe but if your heart stops beating, I won't try and restart it with 200J of electricity.

Stage 3 is active, conservative treatment. This is treatment that involves either very simple instrumentation (like the insertion of a small needle into a vein or small tube into the bladder) or medication that can be swallowed, inhaled or injected or extracorporeal intevention like radiotherapy. This is usually for life-prolonging treatment.

In this sort of treatment, I may give antibiotics through the vein to treat your chest infection, I may do blood tests on you to make sure you are adequately nourished, I will give you chemotherapy but I won't cut you open to remove your underlying lung cancer.

Stage 4 is passive or supportive treatment. This is the treatment of symptoms only - like pain, dehydration or discomfort (eg. muscle spasms, nausea, dry mouth, difficulty breathing). At this stage, life-prolonging treatment is seen to be futile, because under natural conditions the person would already be dead. At this stage, the patient understands that death is coming soon and is unavoidable. This is usually more difficult for a patient's family to accept than a patient. Everybody knows that death comes to all living creatures but that concept just never seems to be realised.

In stage 4, I will keep you as comfortable as I can with fluids/oxygen/medication, I won't keep jabbing you repeatedly with needles, and if you pull out your nasogastric tube (tube we put down the nose into the stomach to give liquid foods), I won't force it down again.

You can see how stepwise the withdrawal of treatment is. Physicians do not actively assist suicide, we do not overdose you with a lethal injection but we also do not keep your body alive just for the sake of keeping it alive.

If you are dying and we know there is nothing we can humanly do to stop that then we let you slide away slowly or allow you to go home to be in a friendlier environment. We try to keep you conscious as long as we can so that you can sort out your affairs or say goodbye to the people who matter most to you. And when you are delirious, we try to keep you relaxed and out of pain. We will withdraw treatment at your request, but we will not reinstate treatment that is futile and would only speed up your demise. We try as hard as we can to respect your decisions, wherever possible.

It's hard for doctors, too, because we also need to come to terms with the fact that there is nothing more we can do to make things better for you, because we have reached the limits of our capacity to help.

It is in this time where doctors step back, realising that for all that we try to do, only God is the true Healer.



Blogger Jennifer said...

I can empathize with your role - being a nurse I have been witness to these decisions and discussions with families. They are always difficult, never easy and usually emotional and complicated.

I really enjoy your site - take care and keep writing!

10:28 am  
Blogger tscd said...

Jennifer: Thanks for your encouragement! Nurses are so indispensible to the 'breaking bad news' process - so many times I've had to go away and leave the nurses to the damage control.

5:41 pm  

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