Management of significant illness. Terminal events.

Today was a challenge. 

Having been asked to review an elderly lady admitted overnight it became clear to me that the infamous border between optimism and realism was at my feet. I have at length discussed the ethical and moral concepts surrounding death, but today I was part of the decision making progress to withdraw care. This meant providing comfort and dignity in the face of a perhaps inevitable death.

This lady had been admitted with a severe stroke, the name given to the process by which a variety of mechanisms  can lead to damage or death of brain cells. Strokes have numerous causes, but the classically known are ischaemic or haemorrhagic (bleeding.) The severity of each is based upon the amount of brain affected, which is in turn dictated by location, artery or region affected, time line, basic patient state and another large number of variables.

It is often the case that in medicine we work on principles of risk stratification designed to reduce uncertainty. Medicine, like any science, is limited in its accuracy in scope. Due to the complex nature of the brain, its variant blood supply and function, the effects of the death of certain regions can have somewhat predictable but contextually specific symptoms.

These collections of symptoms, be it a facial droop or leg weakness, are termed a  syndrome and help us form a diagnosis. A measure of consciousness, known as the Glasgow Coma Scale (GCS) is also useful in gauging a patients overall conscious level (with less than 7 being very concerning.)

The use of imaging techniques, such as computed tomograpy (CT), magnetic resonance imaging (MRI) and others help us pinpoint the locations of strokes further, but are of a relatively recent invention. The combination of signs, symptoms and imaging allows us to formulate a diagnosis and initiate management based on our suspicions. This informatio, coupled with documented case histories, allow us to predict possible outcomes.

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In the case of this patient she had severe stroke comprising brain areas associated with basic functions of breathing and bodily control. She had a low GCS and signs of localised brain dysfunction. She was beginning to develop a chest infection. She was not well, and unlikely to become so. Prognostication, the process of estimating a likely future, led to a pessimistic but ultimately realistic view. This was a battle we were unlikely to win.

My review made it clear that any intervention would unlikely prove of reasonable significance to her and after discussion with my team, the decision was made to limit care to symptom control. Sometimes patients get better, sometimes they don’t/

This is  a hard decision to make, and one all doctors will make in their careers, often daily. There is a point where death is likely inevitable,  and prolonging life becomes questionable. The ultimate decision making lies with physiology, we cannot want for life when disease claims it. Decision making around withdrawing care affords us comfort and dignity often refused in sudden death.

As a junior doctor I found it especially difficult being part of this process, with the obvious need to seek senior support in validating my assertions. Although the mechanism of this ladies death was not me, I was part of the decision to withdraw treatment. This decision was made to spare her pain and suffering, only prolonging her struggle. Part of caring means learning to let go.

This is a day that I will remember, not just for the significance of this patient, but also for the normality by which this daily decision is made.  The disconnect between what I would perceive as normal life and my own is growing, and the acceptance of that is what I assume to be growth.  I will hope to approach future cases with this ladies lesson in mind.

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Sources

  1.  http://www.radiologyinfo.org/en/submenu.cfm?pg=ctscan
  2. http://patient.info/health/stroke-leaflet
  3. http://www.nhs.uk/conditions/mri-scan/Pages/Introduction.aspx
  4. http://glasgowcomascale.org/

 

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