What we talk about when we talk about death: a case

An elderly man, the precise age is immaterial, is admitted from home having had a fall. It is quickly determined that he has a chest infection, and antibiotics are started. We are optimistic that he will recover. On the second day he appears confused, and the amount of oxygen he requires goes up. Sometimes people get worse before they get better, and the antibiotics have barely got into his system…we carry on. We know now that despite his jovial character and bluff attitude, he was not in such good shape at home. He managed on his own, but the neighbours did all the shopping and he was rarely seen out of the house. He smoked two packs of cigarettes a day, always had done, as evidenced by his yellow hair, leathery skin and walnut coloured fingertips. His lungs are overlarge, expanded, most of the air-sacs within broken down and useless.


On the third day we begin to worry. A blood test that is used to track the progress of an infection (CRP, not infallible) has gone up, from 60 to 150. We ring the microbiologist for advice, essentially for permission to use a stronger antibiotic. These are commonly effective, but bring with them the risk of Clostridium difficile, a potentially lethal diarrheoa bug. We prescribe it.


We haven’t seen any relatives, but I ask my team to make sure that his next-of-kin, whoever it is, knows that things are not going so well. On the fourth day he looks a little better, on the fifth worse. He isn’t eating well, and we worry that poor nutrition will hinder his recovery. I ask a nurse to insert a feeding tube, but he pulls it out half an hour later. Another is inserted, carefully taped down, but he wriggles a finger underneath and yanks it out. Third time lucky…we secure the tube with a ‘bridle’, a small clip that attaches the tube to a piece of string that runs into one nostril and out of the other. It is now impossible for him to pull out the tube without traumatising his own nasal septum. The bridle is a standard technique, and not as unkind as it sounds. Thankfully, he stops pulling the tube and starts to receive proper sustenance.


On the sixth day we are told that his oxygen levels have fallen again. Another x-ray shows that the white shadow, the patch of pneumonia, has enlarged to occupy half the left lung. The new antibiotic has not worked. We make a decision – on the ‘ceiling of care’. We must decide, for the benefit of all who might be called to see him ‘out of hours’, how far things should go.


We have a high dependency ward, where he can be more closely monitored and receive assisted ventilation with a portable machine. The next step, should that fail, would be intensive care. That is a big step. It is run by another group of doctors the ‘intensivists’, who must agree that the patient is a ‘good candidate’, ie. has a reasonable chance of surviving. The treatments they can provide are often miraculous, but they are also invasive. In cases of severe pneumonia the only real option is to sedate the patient, insert a tube into the trachea, or windpipe, and do all the breathing for them. But to recover from this period of complete physical dependence one needs a reserve of bodily strength. Patients weaken on ICU and to admit someone when you know that the chance of recovery is slight is hard to justify. Not only do they need to be strong enough to survive the actual infection, they must have enough lung function left to allow the ventilator to be detached before it causes its own complications. Then they must be able to get back on their legs and back home to live a tolerable life. This is no easy judgement, and must be done without bringing your own set of values to their projected quality of life. It is safer to just concentrate on the physical recovery and whether they will survive or not.


We make a decision that going on a mechanical ventilator is a step too far. He is transferred to the high dependency ward and a tight mask is placed around the nose and mouth so that the portable ventilator can push oxygen enriched air into his lungs under pressure. We review all of the blood results and cultures and see if the culpable bacteria can be identified, but there are no clues. There are stronger antibiotics out there but we keep our faith with the second line choice.


Next day he is barely conscious. For some reason the chest infection has advanced through the lung despite everything we have done. I begin to wonder whether the ‘burden’ of treatment is justified if the truth is that he cannot survive this illness. And this is where we begin to discuss end of life management. If it is clear that he cannot survive based on the fragility of his lungs and the rapidity of the advancing infection perhaps it would be kinder to stop pretending that we can reverse things and start to think about his comfort.


We meet with his son has now come down from the north of the country. It is clear that the relationship is not a straightforward one. He has not seen his father for 18 months, and the interaction is not a particularly loving one, I can tell. Not all families function according to the ideal. The son is clearly uncomfortable during the discussion, as though we are asking him what to do. That is not the intention. We need him to understand the reasons for our decisions to make sure that he does not strongly object, and to allow him to tell us what his father might have wanted. He agrees with our plan.


So at the end of the 8th day we surrender, on the patient’s behalf, to the illness that was once called ‘old man’s friend’. A nurse detaches the mask and rests his head back against the pillow. We look at the drug chart and cross off the antibiotics that were intended to save him. He has a small tube one of his wrist arteries and I instruct the nurse to remove it. We request that he has no more blood tests and that the only injections he receives are those that make him more comfortable. I write up small doses of morphine and midazolam, a painkiller and sedative, to be used if he appears to be distressed. If his cannula comes out he will not have another one inserted, even if this means he does not get any extra fluids. His veins have become thready and bruised, it would take the junior doctor four or five attempts to get one in. The drugs that he may need can be injected under the skin.


We start the Liverpool Care Pathway. In this way any doctor or nurse asked to see him overnight will not have to guess at our intentions and conclusions, but will know that active or ‘heroic’ treatment is not appropriate. He is, of course, made DNAR…for after all, we have accepted that his heart will soon stop and any attempt to restart it would be indefensible. But even at this point I ask myself – are missing a chance to save him? He was clearly a tough chap. A week and half ago he was living alone, happy, doing the things that amused him. He hardly ever saw a doctor, as shown by the slim medical folder that has been retrieved from records. The cigarettes had never really bothered him. Perhaps if we continued to treat, or if we reached for the even stronger antibiotic, we might yet reverse the infection. Nothing is certain. Would the patient want us to continue with this aggressive policy in the face of almost certain failure? Would he want his sore nose and chin to be continually rubbed by the tight mask, to have blood tests twice a day, the feeding tube in his nostril, if the chance of success is only 5%…or less? I don’t know. His son doesn’t know. We make the decision because we have seen this situation hundreds, thousands of times.


Perhaps, by stopping the antibiotic, we will let the infection progress more rapidly still. Perhaps, by stopping the fluids, his blood pressure will go down and his heart stop a little earlier. Perhaps the tiny dose of morphine that he receives overnight will slow his breathing even more, bringing forward the final collapse. It is possible that he may survive another four days if we continue aggressive therapy, but only one day on the LCP. But those extra days will be full of discomfort, and that suffering will achieve nothing. Those three days will represent the prolongation of death, not life.


[This case is fictional]


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