The end of a life

How do doctors decide when to withdraw treatment, and how can one person's death save another life?
21 September 2015

Interview with 

Dr Ari Ercole, Addenbrooke's Hospital


Sometimes life-saving procedures aren't enough, and there comes a time when a Organ Donor Carddecision has to be made to withdraw treatment and allow a person to die peacefully. Dr Ari Ercole is doctor in the intensive care unit at Addenbrooke's hospital, and he explained to Kat Arney how this decision is made.

Ari - So, these are incredibly difficult and very emotive thoughts and concepts. Intensive care is all about keeping the body alive while treatment succeeds hopefully to sort out the underlying disease, not just trauma but other life threatening infections and various other diseases. Sometimes those diseases are too severe and things become futile. Under those circumstances, that's relatively straightforward if it's clearly futile and the patient isn't going to survive then we shouldn't proceed. There can also be quite difficult situations when in fact, actually, what we may be doing is going against the wishes of the patient if we're not careful. So for example, some patients may arrive at a state of acute or life threatening illness after a long period of chronic illness. Generally speaking in medicine, what the key priority for us as doctors is to think about the autonomy of the patient, what it is the patient would want. Generally speaking, we would never offer or enforce a treatment on someone that they didn't want. The difficulty in intensive care of course is that many of our patients, in fact, most of our patients are unconscious because the disease whereas the necessary treatment induced in coma. And so, what we then have to do is think a little bit about try and understand what patients would find acceptable in terms of their treatment. It's pretty tough being critically ill and it's not necessarily for everybody. Now, the only way we can really find that out is to speak to family, try and understand that particular patient and formulate an opinion of what they were like, what they would want or they would not want.

Kat - In terms of the clinical signs and symptoms that you're looking for, are there particular things where you can say, "I think we should stop now."

Ari - There are some situations. They're probably in the minority where it becomes very obvious. So for example, brain stem death, we know there is no recovery from brain stem death and therefore, we really have to stop. This person has died, their heart may be beating. We're getting oxygen into them because of the life support system, but they cannot recover. But those are probably the minority. One of the difficulties in medicine, it is very often difficult to know exactly what the final outcome is going to be. So, this can pose us with real clinical and ethical decisions. The main thing we have to consider is what that patient would have wanted if we can possibly ask them.

Kat - Once that decision has been reached, that we've come to the end of the road. It's time for this person's treatment to be stopped, what actually would happen then? What sort of processes? I assume that it is not just like you pull the plug out of the wall. What actually happens?

Ari - No, not at all. I think that's the really important point. So, the way I like to look at it is really, we're changing our attention from - we've been trying to prolong life. We've come to a point at which we've realised that actually, what we're doing is we're prolonging death instead of prolonging dying process. And then what we really want to do is change our attention from that physiological support, that life support to thinking very hard about how we can keep people comfortable in the last minutes or hours, or sometimes days of their life. So, it's very much about changing from technology and keeping the patient alive to palliative care and controlling symptoms and keeping them as comfortable as possible.

Kat - And  to end on a slightly more positive note, obviously, we do hear a lot about stories of organ donation when people have ended up in this situation, and have become organ donors, tell me a little bit about that process. How does that decision get made and what happens? Why is it so important?

Ari - Yeah. I mean, for a lot of people, the decision to donate their organs is one that may give some meaning to a death and actually, can improve the quality of lives and survival of a great number of people. So, the organ donation originally arose from sort of brain stem dead patients as donors. These are patients in whom whilst their brain has irreversibly destroyed or damaged, the heart is still beating and with life support, oxygen can get into the lungs and the organs are still well perfused, and survive very well and may be very healthy. In recent times, there've been huge advances in so-called donation after cardiac death. The problem with the heart stopping is of course at the same time that it stops blood getting to the various organs and the organs then also subsequently die. But in situations such as in intensive care where life support is being switched off, and we have some idea about the timing of the heart stopping, it may be possible to organise things in such a way that organ donation may still be possible.

Kat - And sort of very briefly, to encourage people to become organ donors or to think about it and look into the process, what should people do if they think, "Yeah, if the worst should happen, I want to help"?

Ari - There are lots of resources out there and particularly, we've had some huge numbers of different resources. I think more than anything, the most important thing is to make your wishes known, discuss it with your friends and families. If you do feel that you would like to donate your organs then ensure that you're in the donation register.

Kat - We've had a tweet in from listener (Ed Wilson) and he raises a really interesting question. Are organs ever unacceptable for donation if for example if people have been given certain drugs or treatments?

Ari - I would say, that's almost never a consideration whilst it is true that some drugs can cause organ damage, that's almost never severe enough to preclude organ donation.

Kat - Are there any circumstances that do save certain diseases or illnesses that would?

Ari - Some diseases such as cancer can prevent people donating some of their organs. But again, everything is dealt with on an individual basis so it's a matter of looking at each person as individual...


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