Difficult decisions

A Dutch consultant used the phrase ‘sitting in the chair of God’ to convey something of his experience when he has to decide sometimes to resuscitate, sometimes to do the opposite, and how that influences his attitude towards the patient. He says:

I don't feel in control, but due to the medical and technological advances, we are making decisions about life and death. I couldn't live with the idea that I spend my professional life helping people to go on living, and then at the critical point of life's ending, leaving them on their own. End-of-life care is part of what I have to offer as a physician, and it is important to have a range of possibilities to choose from, of which euthanasia is one.

At the other end of the spectrum, we have the comment of a UK physician who, early on in his career, did not even consider that he had a choice:

In terms of death I actually think that the first time as a doctor you have to perform an assisted death is with a termination of pregnancy. I'm pretty ashamed to say I probably did not really consider what I was doing, because I was educated to do what the patient wanted without judging. I was their servant. It never occurred to me that I had a choice. When we qualified, we signed up to medicine being all about preventing unnecessary suffering, and we should not inflict unnecessary suffering either.

Decisions in circumstances of life or death require discernment, skill and experience. They have to take account of what treatments are available and need doctors and nurses to feel confident in their choice. Established protocols, teamwork and collegial support are helpful. Ideas can be challenged and discussed, and there is more wisdom in two heads than in one. There are also patient rights, and from time to time, educated people will say they will take the decision. Sometimes there is little time to ponder. A nurse reflected on her strength and her resilience to cope when her mother died quite traumatically. She felt she managed because she had to, because her father was in the room.

My father woke me, as Mum had accumulated a lot of secretions and was struggling to breathe. I had always been concerned that the moment might come when Mum might not have the strength to cough her airways clear. She had got herself onto the edge of the bed and banged on the table because she was struggling to breathe. I lifted her back into bed, and she died in my arms. I managed that without help, because I had to.

What helped me cope was understanding that I knew she was dying. While I could have tried slapping her on the back, turning her over, at the time, I felt it would have been wrong, really traumatic and to no end. I stayed with her while nature took its course. Subsequently, I have wondered whether I did the right thing, because allowing someone to die is not the same as allowing someone to choke. However, I did what felt right at that moment.

Since that happened, there has been quite a shift in resuscitation training, and the national guidance on 'do not resuscitate' has become clearer. Now, if the patient chokes or if something else happens, it must still be dealt with. That raised something very difficult for me, wondering whether possibly I made the wrong decision at the time. I have to live with that. But I may also have been right and, come what may, I might not have been able to clear my mother's airway. She was dying. It was not nice for her, but it was minutes. Neither was it nice for me nor for my father, but we had to manage and cope.

These are very difficult decisions and it has taken the nurse years before she could talk about it, but now that she can, it is helpful. More often than not, decisions need to be made on the spur of the moment, and the questions this nurse asked herself in hindsight could not be reviewed at the time. A physician had another story showing one never knows what is coming!

I was sitting reading a book when the train slowed down to twenty miles an hour and somebody spoke on the intercom, asking whether there was a doctor in the train, and if so, could they come to the front. As no-one else was getting up, I walked to the front, and the guard there said the driver had taken ill.

When I got into the cockpit there were two drivers and one of them was slumped unconscious in his chair in cardiac arrest. The other was pale and frightened, gripping the steering mechanism tightly. He explained how, when the main driver was unwell, he had taken over the controls and slowed the train down. I knew the slumped driver had no chance of recovery, because it was too long from the time it happened to the time I got to him. His pupils were widely dilated, which is a sign of irreversible brain anoxia. I decided to support the other, very scared driver. Trying to resuscitate the first driver in the tiny cabin would not be feasible. I decided my job was to talk with the second driver, helping him to stay calm until we got to the station, where he halted the train and they took off the dead man.

This doctor, too, had to make a spur-of-the-moment decision. When he walked back through the train, no-one seemed to have noticed anything. Maybe this was a confirmation of him making the right choice? Soon another pair of drivers had been found, and they continued on their journey as if nothing had happened. It had been a challenge.

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