Futility, right to die, withdrawal of therapy and the ICU as a medical purgatory.

I knew that it was going to be a long day. It was the morning round, the intensive care unit (ICU) was full, staff were racing around shouting orders at each other, telling me to cancel the cardiothoracic list ‘because we had no beds’ and the night resident began the hand over by stating that the first patient who had just been admitted, intubated, ventilated and paralysed, was an 81 year old man who had ‘terminal’ emphysema. He had had numerous hospital admissions for acute/chronic respiratory failure and had been oxygen dependent for the last 12 months. The last hospital admission was two and a half months ago, requiring a three-week period of mechanical ventilation and a prolonged convalescence in hospital. When he was finally discharged home he remained dyspnoeic and bed-bound. He had given strict instructions to his only daughter, with whom he lived, to ensure that the next time he was admitted he was not to be put on ‘life support’ again. What happened? It seemed that the daughter found her father unconscious after returning home from a brief shopping trip. She called an ambulance and arrived with him at hospital to be asked by an accident and emergency (A & E) resident “do you want your father to be treated actively?” She had been his carer for the past 5 years, she was unmarried and her life revolved around him, he wasn’t a burden to her, indeed she had enjoyed caring for him. To the question ‘do you want your father to be treated actively?’ her response could only be “of course I do. I want you to do everything possible”. The ICU registrar was contacted and informed; “Remember Mr. X? Well he’s back again and his relatives want every thing to be done”. The dye was cast thiopentone, suxamethonium, intubation, all in A & E, and pancuronium 12 mg i.v. ‘to stabilise him for the trip around to ICU’. The rest of the ICU ward round was a little simpler. The remaining four patients who had been admitted overnight had problems that resolved rapidly, and could be discharged to the care of their home team the ‘Cardiac’s’ could now be accommodated, and there was less shouting by the ICU staff. I asked the ICU registrar if she could organise the discharge of patients who were admitted overnight so that I could “sit and have a chat to Mr X’s daughter”. The daughter was rational and reasoned. She understood that her father’s wishes had been contravened, yet when asked ‘do you want your father to be treated actively?’ she stated that she could not bring herself to make the decision to stop treatment. I began by saying that her father was sedated and comfortable at the moment and that we were continuing to ensure that he remained so. However, there was no treatment available that would return him back to health. Her father knew this, and as his life was coming to a close it appeared that it was also becoming unbearable. If he required resuscitation, he had expressed a wish not be put on ‘life support’. We did not have to make a decision; the decision had already been made by him. By withholding or withdrawing ‘life support’ we would simply be carrying out this wish. I stated that it was unfortunate that she had been confronted by a clumsy question of ‘do you want your father to be treated actively?’ because we treated everybody actively. We would provide all that was necessary to allow him a comfortable death. Currently, what we were doing was simply prolonging his death. The daughter felt comfortable with the fact that her father would be taken from the respirator and provided with a peaceful end. She understood that we were adhering to his wishes and was relieved to find that she was not required to personally authorise his death.