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The patient was 95 years old and in resus on a trolley.
You’re picturing a frail older man, one with hollow cheeks and skin like paper.
If that’s not the image you had in your head, it is the image I had in mine. I poked my head around the curtain and was met with something else; sturdy, solid and too tall for the trolley. He had those large square hands that I have come to recognise, they are hands that have served for decades and still managed to retain their presence.
This man seemed the sort that never went to hospital because there was never anything he wanted to bother anybody else with. Now he was confused, owing to respiratory failure and required some non-invasive ventilation.
I sat down to speak to his son and explained I had come to see if his dad might benefit from admission to intensive care. We talked about his day-to-day life, working through those seemingly arbitrary questions…
He does his own shopping, but how does he get to the shops?
If he stops walking, is it due to breathlessness?
Then we talked about what his dad might think would be acceptable to him at this time in his life. If I said we thought there was some chance that intensive care could help him, but there was also a chance that he might die there, what do you think he would say?
His dad had just ordered the flowers for his summer garden. Somebody was coming to help him put them down.
The son said if it were him in that position he would say that sort of care wasn’t for him, but he thought his dad would say yes.
I tell him then that we felt continuing some treatment on intensive care might help his dad, but that we would not escalate to intubation and that we would not do CPR.
‘So, I’d like to take your dad on to my ward and see how he gets on, does that sound reasonable?’
He said it did, but he added that he didn’t want to be selfish, because he knew resources were limited and he knew his dad’s age.
I tell him that there are some general points; that we need to feel that his dad has a reasonable chance of benefiting from intensive care, that we have some chance of achieving an outcome that is acceptable to his dad and that we are acting, to the best of our knowledge, within his dad’s wishes.
Then I tell him this; that his dad is entitled to all the care that he can benefit from.
I am sad that I have to make this point clear to this son, sat beside his father who had worked well into his seventh decade and up until now, asked for very little from his national health service.
I wonder what has made him feel like this, what ‘NHS in crisis’ article, perhaps, has stoked those thoughts. As a doctor, of course I want people to appreciate the health service, I don’t want the pressure and deficits to be ignored but I don’t want my patients to feel like that. Being critically unwell is burden enough.
He was entitled to all that he could benefit from.
By the Secret Doctor
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I do feel exactly the same.
This is an ethical dilemma. The patient did not have capacity to make his own autonomous decisions. The decision to treat has to be based on his clinical assessment and on what would be his best interests as well as taking into account his wishes and preferences. The aim should be to avoid harm and increase his suffering. The issue of justice and the cost-effective use of resources is so difficult because there are limited resources in healthcare and we live with rationing everyday. In this situation an advance directive or advance statement of wishes and preferences of the patient would be helpful. The former is legally binding. Perhaps the use of the new ReSPECT form may help in the decision-making process. It is interesting to note that his son indicated that his father would like to be treated. This introduces the view that the patient's values should be taken into consideration even when they do not have capacity. Autonomy, beneficence, non-maleficence and justice come into consideration with any ethical dilemma. People need to know that there is a resource issue in the NHS and that needs addressing by those who make the decisions.
There was evidence that the patent, if capable, would have wished to be treated. The doctor believed that the patient was likely to benefit from the treatment. Where's the ethical dilemma? Resource considerations may come into play later but should have no place at the immediate doctor/patient interface. The final sentence says all that needs to be said.
CPR and intubation not advised. So the treatment may well be for symptom control perhaps. It appears that he has advanced lung disease. What is the goal of treatment?