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We did the right thing – but for who?

Writing competition illustration entry No.5 
BMA News

The aftermath of a young woman's suicide attempt was characterised by bedridden convulsions and despondency which ultimately ended in death. BMA writing competition highly commended entrant Lloyd Bradley describes the difficulties involved in dealing with such a case

The young woman had travelled a long way to die. She had written a note with a blue Biro on plain white paper.

It was neatly folded beneath the pile of belongings she had left behind on the beach. She kept her shoes on to walk into the sea.

The tide was coming in and she probably had to walk for around 200m to reach the point where her feet were lifted from the shingle and she was carried about in the swell.

Although winter had passed the water would still be cold. Perhaps this cooled her brain so that the lack of oxygen didn’t completely destroy her central nervous system. When she was pulled out of the sea she had no pulse and no respiratory effort.

Lifeguards pumped her chest on the seashore and in the lengthening shadows forced air into her sodden lungs. And now here she was, lying in the intensive care bed.

An arterial line had been placed at her wrist below pale crisscross razor marks which decorated her forearm up to the elbow. A pulse oximeter capped her forefinger and her nails were broken and chipped. There was a tattoo of a red rose curling above the neckline of her blue-green gown.

Even with the ventilator, the inotropes and the nasogastric feed, she was struggling. The irregular electrical discharges from a swollen confused brainstem would set her blood pressure soaring, her pulse racing, then dropping. With no motor cortex, her legs and arms clenched and writhed reflexively responding to the gentlest touch. Jumping and juddering to an unexpected sound from the world around her.

Sometimes her eyes were open. Staring ahead not moving or changing to light or shape. Nights and days passed appearing all the same. An electroencephalogram picked up slow waves, possibly some background activity but no response or reaction. The CT scan she’d had on arrival to hospital was reviewed again and repeated. Loss of grey-white differentiation. These were the facts shared with a hushed and frightened family later on in the relatives’ room.

Her mother was able to tell us that her daughter had been up and down for a few years now, but she’d recently got a job and had a partner who she loved.

Reading the note filed in the brown cardboard notes on the ITU (intensive therapy unit) trolley at the end of her bed it was clear that she wanted to die. There has been no pre-warning and she’d found herself a lonely stony beach on a late March afternoon. Her mother wanted to know why we couldn’t let her go. It was what she had wanted to do.

Could we stop her nasogastric feed? Where could she die? How should she die? Now the conversations begin. We will try and find out what the evidence base is for prognosis. We will read the lengthy email that the trust legal department has sent. We can listen to what the ITU consultants tell us. We could even have a second-hand conversation with the palliative care team. Everyone has their ideas, but no one can make a decision.

She stayed on ITU, grimacing and twitching as opinions came and went. Days became weeks. She began to make noises, guttural groanings and yelps as her endotracheal tube came out. The consensus had been reached. Now able to hold her own she was transferred off the ITU on to a care for older people ward (no one else would have her) awaiting a plan and a future. Transfer to a specialist unit for a more detailed assessment of her low awareness state; a raft of assessments and meetings were planned.

There she lay on ward seven for two more months, becoming ever more curled into herself, her limbs fixing into rigidity: gnarled angular shapes. Her eyes, not fixed now but moving and flickering, her face screwed into a mask of the person she was. According to the specialist unit’s protocols she required a secure means of nutrition, and so a percutaneous feeding tube was pulled into her stomach and a dietician dutifully prescribed a feeding regime and requested further blood tests. Other patients, often frail, came and left the beds on either side of her, easily twice her age. Her mother stopped visiting.

Spending another four months on the specialist unit, she was deemed to be not quite vegetative but minimally responsive; an apparently important distinction. She was moved on to a nursing home nearer to her mother and died the following year from a chest infection. Her left buttock was worn to a red fleshy crater and the skin in her elbow creases macerated and raw. Her head was twisted and flexed, stuck as if staring forever at the red rose on her chest.

All the guidelines had been followed correctly.

Lloyd Bradley is a consultant in rehabilitation medicine based in West Sussex. He won the BMA writing competition in 2014.

Read the winning entry and runner-up entries