Joseph Ting: Final decision

THE man who arrived in the resuscitation room was in dire straits. His body seemed to have been drained of its lifeblood, his pulse fast and barely discernible, a quiet yet vivid fear writ large on his sweaty face.

As an emergency physician, this scenario is not new, and I frequently encounter time-sensitive dilemmas about whether to initiate life-preserving resuscitative therapy.

With limited initial information, I usually adopt the safer default approach, which is to commence treatment until a definitive management plan can be calmly mapped out in consultation with the patient and their loved ones.

Life support can then be withdrawn in the intensive care unit if the patient fails to respond to optimal management or it becomes clear that their quality of life before catastrophic deterioration was already severely impaired.

This is why it is crucial that hospital staff have ready access to background health care information about patients who come into their care — including end-of-life care preferences — that allow better decisions to be made.

Patients in these situations can, at best, achieve a return to the level of health or function they had before they became really sick. If they were previously bed- or housebound with significant cognitive impairment, I would be reluctant to start aggressive treatment and then have to deal with the difficult decision of whether to continue.

I have been involved in many end-of-life decisions, made after speaking with the patients and their partners and families. For patients with terminal illness, these decisions are often consensus-based.

In most of these cases there is all-round agreement that symptom alleviation, with a focus on pain reduction, maximising physical comfort and support of the psychological well-being of both patient and family, is the clinically rational and humane course to pursue.

Before the acute worsening, and in consultation with their usual treating physician, partners, children and families will have had to opportunity to discuss and contemplate at length a fundamental shift of objective to comfort care, preservation of dignity and symptom palliation.

There is usually time to come to a realisation that premorbid or disease-related quality of life is poor and more aggressive treatment would be futile. Leadership from the doctor is not required then, just gentle guidance.

However, unexpected critical illness and the possibility of death for which loved ones and relatives are unprepared leads to upheaval and is destabilising.

In time-constrained settings where patients and their families have not had end-of-life discussions about the use of aggressive treatments, doctors face difficulties with overwhelmed and unprepared patients and families. For these distressed families, it is difficult to raise the option of limited treatment in the first instance. After acquiescing to a decision against full resuscitation they may feel like their loved ones have been short-changed.

In our urgent haste when life hangs by a thread, it is hard to see how all the pieces of the jigsaw puzzle will best fit. The path taken in the decision-making and consent process needs to deliver the best appropriate clinical care, take into account the belief systems of the patient, family and doctor about life and death, respect patient autonomy and wishes, engender mutual trust and importantly be guided by clinical leadership that is empathetically free from coercion or paternalism.

Partners and families should be told honestly about the prospects of meaningful recovery even with maximal treatment. Life and organ support therapies involve invasive painful procedures and often require mind-fogging sedation to be tolerated.

A calm rendition of realistic chances does not equate to paternalism or coercion towards a palliative treatment trajectory. We need to arrive at a decision together — one that is in the patient’s best interest as far as is possible — moderated by humanity, dignity, beneficence and non-malfeasance.

The critical situation of the patient described above had been a shot out of the blue. He had recently travelled from London and was visiting family in Australia. I had a long chat with his bewildered wife – the wife of a fit and healthy man who had an acute collapse. The patient was rushed to surgery on life support that we had initiated in the emergency department.

Amid the tears and upheaval, she valiantly tried to resist the grim prospects for the recovery of her loved life partner. Was there something she could have done to prevent this, perhaps called an ambulance earlier, or heeded earlier symptoms, she pleaded.

No, I said. Sometimes life and death are in the lap of the gods.

Dr Joseph Ting is adjunct associate professor at Queensland University of Technology’s School of Public Health and Social Work. He is also a clinical senior lecturer in the division of anaesthesiology and critical care at University of Queensland Medical School and consultant emergency physician at Mater Health Services Brisbane.

See our news story ‘Make advance care plans routine’ about making advance care planning and end-of-life care discussions essential in routine clinical practice