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

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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

My MiL developed a chest infection when she was in the late stages of Alzheimers. We had to take the decision that it was better to make her comfortable and allow the disease to take her.

Not one person thought we'd made the wrong decision.

I was the one that told them to remove my DDad’s oxygen. He died very (shockingly) soon after.

It felt like a huge thing to do, but it was so pointless making him suffer.

You are right, it was selfless.

It sounded from PPs that this isn’t practical for emergency cases (e.g. car accident) where decisions have to be taken very quickly?

It's such a difficult area. It seems to fall into two broad areas: how we deal with catastrophic injuries, and how we handle the elderly or others coming to the ends of their lives.

With catastrophic injuries, it can be so difficult to tell. A friend's baby had a birth injury, and she was told that her child would never walk or talk and would need to be tube fed. None of that turned out to be true: yes, ongoing health issues, but also rides a bike and did (and passed) GCSEs.

With the elderly it often seems that some treatment isn't necessarily in the best interest of the patient. It doesn't help that people's stated wishes aren't always take into account. MIL, with advanced Alzheimer's, was supposed to be on palliative care only, but when she got a chest infection, the nursing home doctor pumped her full of antibiotics and she lived, miserable, frightened and in pain (arthritis), for another year.

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.

This is such a difficult subject. I work in primary care. I’ve seen complaints against a GP because they gently suggested that offering antibiotics for their demented, bed ridden, incontinent, frail 88 year old mother may not be in her best interests. Apparently the GPs were trying to kill her.

And we give Covid and flu vaccines to similar patients in the nursing home, because the family request it and give consent on their behalf. I’ve vaccinated 98 year olds, and I frankly wonder what I’m doing as dying from flu or Covid would be the kindest thing for them.

As a clinician I can only sympathise with the doctors as it’s horrific having to make those decisions.

Yes it sounds very hard, especially as the family of the person might have a very different preference to the person. Also sounds like even if people make their wishes explicitly known these may be overridden, as the experiences PPs have talked about show. I wonder if anyone who has had their explicit written wishes overriden has ever sued.

(Although depending on the severity of their injuries/condition they may not be able to.)

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.

From the PPs it does sound that giving treatment of all available kinds is usually the default in an emergency where consent from the patient can’t be given, although one poster did find a protocol online about a couple of situations which are seem to be considered incompatible with life and where no treatment would be attempted in the UK. These are pretty extreme cases (decapitation and hemicorporectomy) but the latter has been carried out in the US.

I hear what you are saying about slippery slope. From the opinions expressed in the thread this is a very difficult area and some people would like to be kept alive at all costs but to others being kept alive in certain circumstances would feel like a violation.

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.

That’s interesting. I think a PP mentioned that solicitors here are very cautious about the legal standing of these documents, although I don’t know anything about this personally

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.

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.

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.

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.

@DuesToTheDirt That’s probably the least kind thing I’ve ever read on MN, and it can get quite heated in the chats. I’m assuming if she tried to commit suicide she was in a very bad place and maybe had severe mental health issues. She presumably felt so bad she wanted to die but instead lived and was severely disfigured. So I’m sure that only added to her distress-why would you expect someone to be cheery in those circumstances?

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.

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.

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.

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.

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

That makes sense about the difference thanks for explaining that.

what would happen if a patient was stabilised and then their NOK presented a directive which said the patient wouldn’t want to be treated? Just a hypothetical, let’s say they were not elderly but had decided in advance that whatever the injuries were was something they didn’t want to live with?

Thank you for sharing, this is a really interesting perspective

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.

@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.