Tuesday, 2 September 2008

When do we stop? Should we stop?

Posted by: Dr. Thunder

It's 2pm, and the emergency pager goes off. "Emergency, ward 4" flashes up on the screen.

We all drop what we're doing and run to ward 4.

When the emergency team arrives we're greeted by a flurry of nurses running around little Dylan, a 6 year old boy with severe brain damage. Monitors are beeping loudly, there are tubes everywhere, and Dylan looks crap.

He has pneumonia. For the 6th or 7th time this year. This time it's really bad. This happens to him every few months without fail. Now that it's winter, he suffers a lot more than usual.

The problem this time seems to be that he has very severe pneumonia and is struggling to keep his oxygen levels up. After examining him, it becomes obvious that he's punctured one of his lungs now, and it looks like some of the bacteria in his lungs have made their way into is bloodstream, causing septicaemia.

He's a very sick boy.

So, we stick a tube into his lungs, through his chest wall, to drain out the excess air from his punctured lung. We give him a lot of fluids intravenously to help with his low blood pressure. We give him lots of oxygen. We pump some more antibiotics directly into his bloodstream.

This all helps, but it's not enough. Dylan is really struggling to breathe now, and he needs to go on a life support machine. This involves putting a tube into his mouth and pushing it into his lungs, allowing us to take over his breathing for him.

We managed to stabilise him where he is, and transfer him to intensive care. He stayed there for a number of days, and is now back in his old ward. He still has his pneumonia, and he's still very sick. He'll be in hospital for a while. When he goes home, he'll be back within 6 weeks.

The reason I bring up this incident is because there's a number of staff who don't think we should have resuscitated Dylan. This kind of thing happens to him several times a year, and he's always pulled back from the brink.

But in the interval, Dylan has really no functional capacity whatsoever. His mum think she can make out when he's trying to smile, but that's about is. He has no speech. He can roll his eyes around, but he's mostly blind. He gets fed through a tube in his stomach. He can move a bit, but not much. He has seizures most days, and they are almost impossible to control.

His mother remains very calm when he gets sick. She's been asked whether she wants all these intensive measures when he gets ill. She does. But there are a number of people who believe that this choice should be taken out of her hands.

They argue that, in the last few weeks, he's taken up a hospital bed for 4 weeks, and intensive care bed for 4 days, aswell as a stack of staff-hours and medication costs.

Personally, I don't like getting into the realms of deciding who's worthy of resusciation, and who's not. Dylan is a good example of how there are differing opinions. So, I just get on with it, and try not to think about it too much.

But I was just wondering what people thought. Should people like Dylan have a right to the same healthcare as the rest of us? Should the final decision rest with their parents? or does there come a time when the hospital should step in and call time?


  1. Ouch! Difficult one.

    There will always be arguments on both sides but I think that ultimately, the decision will lie with Dylan. His poor little body can't continue on that roller coaster for ever... can it?

    If it were my child and in those circumstances, I'd like to think that I'd give permission to withdraw treatment but maybe that would all change if/when my protective instinct kicked in?

    A good thought provoking post.

  2. I know of a child like that at my hospital.... it's a difficult difficult thing and a major topic of conversation everytime they represent.

    I think in these sort of circumstances where there is no meaningful life (especially if the child has little to no development at all) there should be an ethics committee of sorts that can step in an make recommendations... It would be a difficult thing legally and ethically, but I think the parents are just grieving so much that seeing people doing something for their child makes them believe all will be okay... I'm not sure....

    Nice to see you back by the way Dr T!

  3. Ah, ethics.
    It shouldn't be up to us to make moral decisions.
    Dylan should have exactly the same right to healthcare as everyone else; however, eventually these decisions have to be taken by medics, objectively. If he has no hope of meaningful recovery, then questions should be asked about the value of continued resus.

  4. Problem is what constitutes meaningful recovery? I'm not going to make him into a fully functional little boy again?
    The issue is a simple one in a world with infinite resources.

    But when resources are scarce, and people are denied treatment on the basis of cost, then this is unfortunately where the waters get muddied.

    Dr. T

  5. Having no children of my own I cannot really put myself in this mother's shoes, but I would hope that were this my child I would see:

    a) although his cognitive ability is low, he must surely be in pain

    b) his chances of leading any sort of pain-free life seem to be minimal

    c) the resources you mention could be used to treat others who may stand a better chance of making full recoveries

    If I were the parent I would hope I could find the strength after these repeated circumstances to say "enough is enough"

    I suppose it's almost like organ donation - if you choose to donate, your actions potentially save / repair lives. If you don't, you can never help (this makes me think I should sign up for one of those cards when I come home in July).

    At present, and without a "committee" to help decide, I think the decision rightly rests with the mother (so long as she is of sound mind!) though her actual reasons for keeping her son in this seemingly-awful perpetual limbo should be addressed and possibly counselled ....

    My 2p anyway. Sorry for extreme lateness of posting, I've only just started reading your blog, having seen your comments a bunch of times on Dr Crippen's blog.