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

[En0ufh1sEn0ugh39]

I recently started watching Facebook videos and haven’t yet adjusted my preferences for content I want to see. I’ve been bombarded by videos of “feel good” stories. It’s largely about people in the US who have had life changing injuries. So for example, a shot gun wound where they lost most of their face, or someone who has had all of his body below the torso removed because of an accident. In all these cases the person nearly died but was saved by modern medicine.

I want to be clear I am disabled myself (and have a not great quality of life) and I think if people want to have surgeries/treatment they should have them on the NHS and be fully supported by the welfare state if needed. But, is it always ethical to
intervene? And is consent always needed?

I’d be really interested to hear from any medical professionals or people with firsthand experience what they think. Is it possible to put in place something on medical records to say in advance when we wouldn’t want treatment.

My experience is that the NHS/medicine is great at physically saving people but there is very little support for living with the impact of serious illnesses/injury. I assume it’s the same in the US.

YABU-we should always use medicine to save a life

YANBU- it’s more complicated and sometimes it’s kinder to let someone pass

www.nhs.uk/conditions/end-of-life-care/planning-ahead/advance-decision-to-refuse-treatment/

Some people want to be alive at all costs. Some people don't. Doctors can't and shouldn't make that decisions . So unless otherwise stated , life saving measures, even extreme ones should always be taken.

I think if the state sends someone into warfare and they come back in a terrible state, then the country has a duty to revive and repair you and give you the best possible healthcare available.

If someone gets their head blown off because they're an idiot and got into a gang related crime, or were pissed and got in a car crash, you should pay for your own healthcare out of your own healthcare insurance if you want it.

It's not a cut and dry situation. Personal choice should come into it. Our NHS is doomed to fail and is on a path to self destruction as it is. We would all do well to get proper health insurance right now then we can choose.

I don't think the OP is getting at just the financial issues. To my mind there is the moral view of is their a viable relatively contented life for them post surgery.

If I were left unable to care for myself and in constant pain. Would I choose to live and endure major surgery and ongoing painful rehabilitation. I'm not sure.

Thanks for sharing the link that’s really useful.

I find it really interesting although worrying if I’m honest that the default is to treat even in extreme situations. Is this in the hypocratic oath? I suppose you could say that not treating someone but making them comfortable is “doing no harm” whereas extreme and invasive treatment is. Obviously not ideal that decisions should fall on individual drs but from e.g. covid sounds like they do have to make life/death decisions a lot?

Yes@ARealitycheck I was more getting at the ethics of medical intervention when the persons’ quality of life is going to be badly affected if they aren’t in a position to
consent.

I was moved by the story of the young man who had a hemiorectomy (think that’s the word) where he lost his body below the torso. 5 years on his life seemed very restricted (housebound lying down mostly) and most of his friends abandoned him. I think his situation could have been improved with more state support (but this was the US).

I’ve changed my feed algorithm now

@En0ufh1sEn0ugh39 there are so many circumstances and situations that it’s hard to cover them all.

For example, if someone is brain dead they will stop intervention and just keep them alive with machines until family can get there.

The main issue is that doctors have no idea what an unconscious person on the table (with no family or NOK around or with directive) wants or can live with. If there is treatment that can be done, they have to attempt it. Tbh, in many cases , the kind of thing you're talking about ends in death more often than not , anyway.

Do you really want someone else (even a medical professional) to decide for you when enough is enough ? Or put that responsibility on them?

Covid was an extreme circumstance and certain decisions were made based on the "greater good" and maximising chances of survival for the max number of people, rather than the individual themselves. A bit like organ transplants. Many things can bump you down the list or even off it completely. That’s because organs are a precious resource and they do the want to "waste" it on someone with low chances of recovery/high chances of rejection.

I know someone who was brought back after catastrophic injuries. She says she wished she had been allowed to die. She's now terminally ill and very happy about it.

Really interesting, especially to hear more about covid and organs.

I think there should be more awareness and discussion on treatment directives like the one you sent the link to. As to responsibility of medics, I think unfortunately they bear that either way? They don’t save someone they might feel guilt? They save someone who really suffers afterwards they feel guilt? Or is it out of sight out of mind iykwim because the same medics won’t be dealing with any follow-up?

Yes there are documents you can complete as above in terms of what you would/wouldn't want in these circumstances.

In general, in an emergency, the aim will always be to preserve life as;

1. You usually don't know the wishes of the person on the table
2. There is likely no way to tell fully how a person will be affected (physically/emotionally etc). Obviously in extreme circumstances like decapitation or gun shot wounds to the head, a decision will likely be made that the injuries are not compatible with life and treatment won't be attempted/stopped. In other cases, the outcome and the persons feelings around potential outcomes are unknown.
3. It's a little scary when we start to allow doctors to put their own morals/feelings on who should be saved. Many doctors will have different opinions, but who would be 'right'?

Edit to add - sometimes a person is 'saved' when they didn't want to be, which is incredibly sad.

I’m sorry that happened to your friend x

Yes, your point 3 is very difficult. I suppose in the past we wouldn’t have these issues as the interventions weren’t there and people would pass away. I think this is going to become a bigger issue as medical science improves

My parents have recently completed the paperwork to have myself and siblings as their LPOA.
One parent wants life saving measures if required - CPR, but doesn’t want to get into a cycle of constant operations or lots of medical interventions to stay alive.
Other parent wants no medical intervention at all and stated that if they caught Covid they didn’t want to go on a ventilator as they thought a “young person” should get it.

Get something in writing stating what you want your wishes to be.
We all feel like we know where we stand and are better able to deal with difficult medical decisions as they arise.

I completely agree with your point and I've always said prolonging life for the sake of it - for me - would be unpalatable.
But I, in no way shape or form want a doctor to decide what I may or may not be happy with - there's too many unknown factors. I suppose that's where the idea of assisted dying comes in. Say I'm in an accident and have all my limbs amputated. After a period of adjustment I should get the right to say actually no thanks this life this way isn't for me give me a huge dose of morphine (or whatever would be the least painful way out).

I think people need to be clear with their loved ones about what they would want in situations where traumatic e.g. brain injury or severe physical damage is caused. DH and I have been very clear with each other at what point we would each do all we can to ensure the other’s life support gets pulled and we aren’t patched up and forced to live with a profound and life altering disability.

Equally, whilst medicine might be able to keep a profoundly disabled baby alive, I think it’s unethical to carry a pregnancy to term knowing that the child is going to be profoundly disabled. It’s one thing to be determined to live a full life and make the best of what you have if you become disabled in life, or if a disability is undiagnosed prior to birth. But to knowingly choose to subject another human being to a life of struggle and pain and disability that they have no choice over and which you wouldn’t ever want or choose for yourself? I can’t countenance that.

I used this to do a living will and handed it in to my GP

compassionindying.org.uk/how-we-can-help/living-will-advance-decision/

If I have dementia, or a massive brain injury I don't want any treatment

I've said it before but I sat watching my mum die like.. this is ridiculous. She has dementia and sepsis, she's actively dying and we have to just wait? Yet you would be charged for cruelty doing that to an animal? Why does she have to go through this process when we could end it?

I disagree with this. If a person is 98 years old and terminally ill, but insists the NHS provide extreme and very expensive treatment to keep them alive no matter what, do you really think that's the best use of limited healthcare resources?

Unpopular opinion with some, but I feel the same way about babies born with anencephaly, trisomy 18 and other severe birth defects that are incompatible with life. They should not be subjected to unnecessary torture and the healthcare resources should not be taken from children that actually have a chance.

That’s an interesting idea. Not sure what’s happening with the assisted dying bill now

From my experience last year I saw that if you’re over 70 they seem to think it’s curtains and write you off. Nana had suffered her fourth massive brain bleed. They said she’d die within hours. She lasted nearly two weeks. In that time they stopped all feeds and kept her alive with saline.palliative care were lovely but.

Thanks for sharing the link x

It's probably a strange thing to say, but I often think of assisted dying and if I'd be happy going somewhere that it's legal.

I had a head injury and post concussion syndrome before being injured by an off label antipsychotic prescribed for severe insomnia and anxiety and it gave me a permanent neurological involuntary movement disorder called tardive dyskinesia. This is a bit like Tourette's and Parkinson's disease combined, but in some ways more bizarre: the antipsychotic made my dopamine dysfunction so I get involuntary movements of various parts of me so my tongue and mouth move on their own, and my brain sometimes actually feels like it is vibrating inside my head. Yes, these are genuine symptoms and pretty distressing at times. I've had it for a decade and adjusted somewhat as it's in remission, but there's every chance new symptoms might develop or come back.

Not having control over my body is horrible, but I can be ok with it at the moment, and if you met me then I am sure you'd never know I had it. If I was injured or disabled in some other way, I might be more distressed living with another type of health problem too. I'm going through perimenopause at the moment, which isn't great, but luckily my movement disorder symptoms are ok.

I think if there was a way of knowing how much my health might change in future, it would make it easier to say how much medical intervention or not I might need in dire circumstances 🤔

I don’t know how this works in practice-can medics comment? Do the NICE guidelines kick in where treatment is only funded to a certain level based on years of quality adjusted life expectancy?

I’m so sorry. Do you think they should/could have done things differently?

I was an A&E sister. We were situated between two underground stations so people who intentionally went under trains was a not uncommon occurrence. Many were in a horrendous state when brought in and huge attempts were made at resuscitation and were obviously not going to lead anything like a normal life if resuscitation was achieved. I frequently wondered why we were making these heroic attempts and questioned the morals of our actions.

Yes I think knowing what treatment options there would be plus better support/care through the NHS for living with disabilities would make a difference. In my experience, NHS great for emergencies and patching people up but there’s very little state support to help people with disabilities etc live a full life

I've worked with a lot of people who've had heavy facial reconstruction, some from gunshot wounds including self inflicted, some people go on to be very grateful (including those with self influcted wounds), some struggle. When faced with someone who's potentially unconscious then how can you make that decision for them?

And its often not going to kill them. At least not immediately. Essentially you'd be talking about euthanasia.

The way healthcare works is someone will come into A&E with life threatening injuries. They will be resuscitated, different teams do get involved but it's not really a facial surgeon deciding if the patient lives or dies. Once the patient is stable the various teams will get involved and do their bit. It becomes complex if you've got to get all the specialties into an MDT before you decide if it's worth saving that patients life. The patient would probably die before a decision was made.

So essentially once the patient is stable your then talking about euthanasia if you say "this person's quality of life is going to be too poor so let's not bother reconstructing their gunshot wound". In the moment of deciding to resuscitate or not I don't think in many of these cases the team would be able to gain enough information to make an informed decision in the time frame