TW: death/injury When is it kinder to let someone die?

It seems ludicrous and cruel when someone is clearly terminal and in pain to dither around worrying about "too much morphine" for example.
Well indeed. When my DM was dying, 'too much morphine' wasn't a concept I even considered. I just wanted her out of pain, and if that hastened the inevitable end, I thought it was a fair trade.

Ironic to come across this thread today.

3 years ago I was in the last 48 hours of my DPs life sitting beside his death bed.

He had been in hospital for nearly 3 weeks having collapsed at home from a major brain bleed. He was operated on successfully and even regained consciousness for a few days. He had tested positive for Covid so we weren't allowed to visit for 14 days. I had one phone call and it was clear that he was thankfully high as a kite and he asked me what time it was. I told him and he said "See you at 6" which was when we'd meet after work. At that point it was clear he had some paralysis but they were already talking rehab.

Over the next few days he regressed and another scan found a second massive bleed that wasn't compatible with further surgery. The writing was on the wall. I had long conversations with his devastated father and I knew DPs wishes were not to end up like his DM who has end stage dementia. His career depended on fine motor function, and he would have hated to be dependent on anyone for intimate care, not that it seemed he had any awareness and was in a deep coma. I agreed with doctors suggestions that for the sake of comfort and dignity, we had to let him go.

Some of his close friends were really combative about it, holding out for a miracle of some sort, (as if I wouldn't feel the same) but it was medically and personally ridiculous to keep him "here" in physical terms as his body was shutting down and no miracle could have restored the damage and brought him back as the person he was and would want to be.

It took four months and two post mortems to reveal that he had cancer that had metastised to his liver, lungs and brain. Partly genetic, partly lifestyle and with symptoms that any doctor would have concluded were lifestyle related which is why he didn't seek help - he was trying to address those issues himself and only bother the doctor if they didn't resolve.

So it's a really hard and emotive subject for all concerned.

I'm currently in a position of holding H and W for his mother as he was an only child, and long divorced from his father. She is end stage Alzheimers, unresponsive to a degree, in a care home, muscle contracture in the foetal position, no recognition of people or stimulation for at least five years. In the last three months she has started suffering seizures. This weekend I'm told they are now investigating potential bowel cancer. I am making it clear that she has a DNR and that any investigation is only to determine how any palliative care is administered. Her comfort is to be the only focus, and honestly, I'm willing her to go as quickly and peacefully as she can. She already has no quality of life so if she does have cancer, and I saw what chemo did to my late DM, I will not advocate any treatment bar the highest amount of pain relief possible.

My late DM was diagnosed with ovarian cancer stage 4 after two years of doctors assuming she had IBS and dicking about with the Fodmap diet etc. It was finally picked up in a blood test for HRT to address her tiredness. The first round of chemo bought her about three years. When the tumours started to grow again she was persuaded to try more, and the first lot nearly killed her and put her in hospital for a week. The last six months of her life were devoid of pleasure in food- she couldn't taste it, and she couldn't do activities. Her last month, which I nursed her through at home, we're hell. She only had a syringe driver for the last 24 hours. She wanted to live, but not like that.

I think every case should be considered individually with more flexibility on the part of medics and family to help determine a dignified end when it is inevitable. It seems ludicrous and cruel when someone is clearly terminal and in pain to dither around worrying about "too much morphine" for example. Likewise watching my DP struggle to breathe for two days seems unnecessary when a dose of appropriate drugs might have helped him slip away more peacefully.

My thoughts about disability and premature babies etc - I don't feel I am qualified or have the right to speak for anyone but myself, as these are hypotheticals for which I have no experience or frame of reference. Legislation relating to such personal matters is a huge can of worms and I remain conflicted on assisted dying because while the three situations I have experience of do I think qualify, there are hundreds of different scenarios that are grey areas in my book, and I worry about slippery slopes.

I send love and solidarity to all those grappling with such issues. It's a shitty club to be in.

Yup dnar is literally cpr only isn't performed everything up to that point is performed, if deemed appropriate. Respect forms are becoming more widely used now which covers invasive ventilation dialysis etc and has a space for patients wishes

Tbh advanced directives are vanishingly rare, hence why i recommended earlier in the thread people get them. The only ones I've ever seen in 10y qualified 5y med school have been jehovahs witnesses blood refusal, and they're 100% respected, and they can be petrifying to anaesthetise. I've witnessed one die when would be saved with blood and its really common in haematology if they get blood cancers as they're basically untreatable as chemo = blood transfusion or die :(

Yep I've had many horrific car accidents/stabbings at work that if don't get to theatre with massive blood transfusion within about 15m of arrival they'll arrest

If its valid and correctly signed it should be followed and active treatment stopped. The difficulty is many injuries aren't imminently life threatening and if the initial event isn't fatal can often have a normal "length" of life. Is what I really struggled with when doing my stroke job

I've had it on icu where they've got circulation back post cpr and the family were like he would never have wanted this etc. We dnar'd him then in case he rearrested, but explained that as he was now alive normally we wait 72h to prognosticate to see the impact on brain function to decide if to withdraw treatment or not. They were accepting of that. It was unsurvivable so was paillated then

@ForeverDelayedEpiphany I am so sorry. We're an adaptable species, aren't we? I'm lucky enough to be physically in good shape, but I've lost someone in an incredibly traumatic way that made me think I couldn't go on after that bereavement. But we do go on. Its not the same and it never will be the same, but we go on.

I've lost control of my body in lots of ways thanks to a head injury and post concussion syndrome before being injured by off label antipsychotic that gave me a movement disorder. I also lost my ability to read, and my mind's eye after the concussion... two things that gave me immense pleasure before as a writer and editor.

Losing those alongside gaining a movement disorder was horrendous, and devastated me for a long time. It's only been through having my children that I've kept going and not lost the will to live at times.

Its cos post transplant they'll need to be on s handful of drugs to prevent the transplant failing, if can't manage their psych meds the same would be assumed of the transplant meds so can't deem an organ that is in so short supply to failure

This is referring to something different than attempting hemicorporectomy as a treatment, as happened to the young man in the U.S. who survived. It means if someone has been - well, not to put too fine a point on it - bisected - at the site of an accident, say by explosion or heavy machinery, nothing is to be attempted and in most jurisdictions paramedic can certify death in absence of a doctor, as they would for say, decapitation. It doesn't mean surgical hemicorporectomy is considered unsurvivable, as we know - a (very few) people have survived it and are alive to this day. I agree, that story made me uncomfortable. I don't know how to feel about it. Apparently he wanted the surgery to be attempted, so good, I guess?

I'm a trained swimmer and the best endorphins I know are the feeling after an hour's hard swim in cool water followed by a hot shower. If you know you know: its like all the good parts of being drunk, without the bad parts, and the added bonus that its actively good for you rather than bad for you. That feeling has saved my mental health in the absolute worst times in my life. If I lost it - initially, I'd be devastated, but I would still have reading, music, and my work. If I lost it and also lost the mental ability to perform and enjoy those things....nah. I think I could live with one of the other - losing a chunk of my mental faculties, but still able to swim at a high level, or being paralyzed but brain intact. But not both. If I stood to lose both, I'd want no treatment.

I can comment from an A+E practitioner perspective. Sometimes people arrive in such a state and with minimal history/documentation so treatment is started and questions asked later. However, once it is clear there is an advanced directive I'm personally very comfortable stopping treatment and giving comfort care / palliation instead if this is what the patient has declared they would want. I've noticed this feels less comfortable for more junior staff, litigation is probably part of it but lack of recognition and acceptance of the dying process also. It's shocking to me regarding previous comments that it was ignored by staff, if a frail patient attends the ED I make it my business to find out what their end of life wishes are as we are all encouraged to do. However difficult, it's the last kind thing you can do for a person if that is what they would want.

Both parents and grandparents in my family have opted for no further treatment in the months before their death.
Some times even then it is not straightforward. My FIL opted in advance, for no treatment that would prolong his life. But on a few occasions he chose treatment that did prolong his life simply to ease symptoms he was experiencing. Nobody wants their last few months of life to be painful or difficult.

One thing to note about hemicorporectomy - the type classed as incompatible with life is traumatic hemicorporectomy - where the lower body has been severed in an accident, for example.

The young man in the US who has a social media presence sustained severe crush injuries, but his hemicorporectomy was surgical (as his pelvis was completely crushed). Despite media reports that he was "cut in half" by the accident, it was a clinical decision taken after he was stabilised (to a degree).

In an incoming trauma situation, it would be very difficult to ascertain the extent of internal injuries before stabilising a patient.

Interesting.

I read an article some time ago about a young woman who had tried to commit suicide with a gun, and instead ended up alive and with terrible facial injuries. She was very bitter about the whole thing, including the loss of her good looks (I guess that's what happens when you shoot yourself in the face, eh?) I did feel that the medical care and the compassion and support of her parents were wasted on her, but I suppose you can't know that in advance.

Life for the very elderly who would have been dead long ago without modern medicine is another can of worms. I know at least one who is sitting there just willing the Grim Reaper to come knocking; but I knew another who loved life right up until a few weeks prior to his death in his mis-90s.

My grandmother was in remarkably good health for most of her life. In her elderly years, the only healthcare of any significance she required was a double hip replacement when she was around 83. When she was 93 she very sadly had to watch her son (my dad) predecease her, having had to endure the death of her husband several years prior. She lived independently with occasional carer visits until she was 96 when her symptoms of dementia started to pose a safety risk. She was devastated to have to go to a home, devastated that the family house was being sold and, from what I understood of the things she said, devastated at the thought of having to continue in a world where she had outlived her husband, her siblings, all of her friends and one of her children. On arrival at the care home she told the staff she didn't intend to be there for very long, six months at most. Six months turned into seven years, when she died aged 103 after she stopped eating. It was heartbreaking to see such a strong, witty, elegant and charismatic woman slowly consumed by Alzheimer's disease. For her sake I'd rather she had gone much sooner. My dad's illness was related to a specific organ and she pleaded with his doctor to take hers so that it could be used to save him. If only it could have worked out that way.

I might be mistaken but as far as I understand it DNR is about no resuscitation/CPR rather than treatment. So if he had a cardiac arrest due to his illness that would be a no CPR /resuscitation, but antibiotics to treat the infection would be ok. That’s without an advanced directive that describes what treatment is refused and in what circumstances or no NOK available to advocate for the patient.

Happy to be corrected.

My FIL had advanced Alzheimer's and was in a nursing home.

On Boxing Day he was taken to hospital with a chest infection, and though he had a DNR they still wanted to treat him with antibiotics etc..

Dh talked to the consultant (helps that Dh is a doctor) and instead he was put on compassionate care only in the adjoining hospice and he died 8 days later. Gently and peacefully with his partner by his side.

There comes a point for everyone when there's little hope in going on. He hadn't recognised his son in 2 years and spent his days asleep. He died, and though we're sad, we're not sorry. It was his time.

We shouldn't be afraid to choose not to treat. Sometimes that's the right way to go.

Ignoring an advanced directive is wrong . As far as I know, in the US is classed as assault and a doctor could be criminally charged, not just civilly sued, not sure about here.

I would hope that it is assumed that anyone with the sort of terrible injuries you mention would be treated as well as could be, and it not assumed that they would want to die instead. Otherwise that is a slippery path to go down.