Not infrequently I’m called upon to help care for critically ill, frail and elderly patients. Challenging ethical problems often present themselves in these instances, as can be appreciated by the case of Mrs Kathleen Baynesfield. I was called to the casualty department late one night to see an 87 year old lady with a colon perforation caused by diverticular disease.
This is when a small, age-related pressure bubble in the colon wall gets infected, bursts and causes severe infection. She would need to undergo urgent surgery if she were to have any chance of survival. Unfortunately, Kathleen had a prohibitive risk for anaesthesia and a big surgical procedure – she had advanced coronary artery disease.
She wasn’t amenable to intervention, she was on Warfarin, which inhibits blood clotting because her heart was contracting poorly, and her kidneys weren’t functioning well at all. Gently, but frankly, I explained her position to her and her family. Her two daughters and their husbands accompanied her as she’d been a widower for five years. As I gave them the news, she appeared at peace. It’s my subjective experience that terminally ill patients have some kind of primal knowing when their time’s arrived, whereas their family members are often less ready to accept the inevitable. Her one son-in-law asked me whether I wasn’t legally bound to at least try to, “Save her life”.
It was fortunate that Mrs Baynesfield was still completely clear-headed and able to verbalise her wish to, “Only be made comfortable and be allowed to die with dignity and minimal suffering”. This settled it because she was able to speak for herself. I softly pointed out to him that in these extremely hard situations people are often blinded by their own fear of death, it’s easy to lose sight of what may be best for the patient. It’s most definitely not a doctor’s calling to prolong life indefinitely, but rather, to put your patient’s well-being first. At times this may mean not prolonging suffering and the indignity of a tortured, drawn-out departure.
Experiencing death at close quarters allows one’s perspective to change from believing it to be the final, dark enemy to someone kind who, provided they come at the right time, is a welcome, long awaited friend. South African law, in my opinion in a naive, misplaced interpretation of human rights, place the burden of end-of-life decision-making with patients’ families rather than with the team of treating doctors. This sometimes leads to an untenable situation where distraught, subjectively involved non-medical people’s decisions override a team of objective, experienced doctors who are in a better position to judge futility. Kathleen was placed on a Morphine-drip, she was given fluids and oxygen and she was placed in a private room. Her children spent her final hours with her, stroking her hair and holding her hand. She died peacefully in the morning. The patient’s name was changed to protect patient and family confidentiality.