‘He’s suffering so much. Please do something, doctor. You wouldn’t treat a dog like this.’

 This post and the next deal with the sensitive subject of terminal illness, dying, assisted dying and euthanasia. It is necessarily emotive, and some readers might find it distressing. Please don’t continue if you think you might be affected. 

 Few subjects generate stronger opinions than euthanasia, assisted dying and limiting patients’ access to medical and surgical interventions. People hold deep personal views on one side or the other of the divide, often influenced by religion, philosophy or life experience, such as the memory of watching a loved one die. For once, I’m not going to tell you how it is in this post. I won’t tell you what to think. Instead, I’ll explore some key ideas, arguments, medical realities and the UK legal position with you.

 This topic is another two-parter. In this post, we’ll define exactly what we’re talking about and read several clinical vignettes, which I hope will give you plenty to think about. In the next post, we’ll delve a little deeper into these issues. Doctors and nurses have to deal with them all the time. Hopefully, you will never have to, either as a patient or as a patient’s loved one.

 Let’s kick off with some useful definitions to help us navigate this controversial area.

 Euthanasia

 The word is derived from ancient Greek and means “Good Death”. Sometimes referred to as “Mercy Killing”, euthanasia is the act of one person deliberately ending another person’s life (killing them) to relieve their suffering.

 Assisted Dying

 This term refers to a medicalised process whereby a person with a terminal illness or an incurable condition that causes them severe pain and/or distress is helped to end their own life. There are two distinct forms:

 Assisted Suicide – an appropriately registered healthcare professional prescribes a lethal dose of medication, which the patient self-administers.

 Voluntary Euthanasia – an appropriately registered healthcare professional sets up the lethal dose of medication, for example, an intravenous injection, at the patient’s explicit request. However, the patient still has to activate the syringe pump.

 Limitation of Treatment

 A medical decision to limit specific medical or surgical interventions when they are not deemed beneficial to the patient. That is to say, the interventions have no realistic prospect of making the patient better and would only serve to draw out the process of dying with all its attendant pain, suffering and distress. Once again, there are two distinct forms:

 Withholding Treatment – a medical decision not to commence a new intervention. Perhaps the most well-known example is the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.

 Withdrawing Treatment – a medical decision to stop an ongoing intervention because it is no longer deemed to have any realistic prospect of improving the patient's condition.

 Palliative Care (End of Life Care)

 A package of clinical interventions aimed at ensuring that a patient’s death is as comfortable, fulfilling, dignified and pain-free as possible.

 Thinking Caps On

With those definitions in mind, read the following four clinical vignettes. They are all based on true events and are described in more detail in my books. Ask yourself which of the concepts defined above are operating in each case. Were the decisions made justified in your view? How might we have acted differently? Do you think we should have acted differently? If you had been in charge, what would you have done?

 Stan

On my very first night on call as a surgical house officer, I admitted an 89-year-old man called Stanley Worthington. He was in bad shape. Very bad shape. He’d perforated his large bowel, developed acute peritonitis and was in septic shock. The view of my surgical registrar was that Stan would die without urgent surgery. The problem was that my registrar also thought Stan was too frail, with too many other things wrong with him, to survive a major operation. After a quick phone call to the on-call surgical consultant, we decided all we could do for Stan was make him as comfortable as possible. From Stan’s point of view, the most pressing problem was the unbearable agony he was suffering. I gave him a large dose of morphine, and he appeared to settle.

My bleep went off in the early hours. ‘It’s Night Sister. Can you come right away? One of the patients is in terrible pain. I’ve given him the prescribed dose of morphine, but it hasn’t touched him.’

Stan was moaning incoherently when I arrived in his side room. His sunken eyes stared blankly at the ceiling from a deathly pale face. The room had an odd smell I couldn’t place, but would later recognise as the stench of death. Although I hadn’t thought Stan was conscious, he sensed my presence. ‘Pain. Pain. Please, please help me.’

I injected a syringe full of morphine, but Stan continued moaning and groaning, shifting restlessly from side to side in his bed. I injected a second syringe of morphine. Now Stan did settle. His rapid breathing slowed down. I watched his taut body relax. I was about to leave when Stan’s eyes snapped open. He grabbed my right hand tightly and whispered, ‘Thank you, doctor.’ Stan took a deep breath, held it for an age, and slowly exhaled. I watched, waiting for the next breath. And waited. And waited. ‘Stan! Stan!’ I shook him more roughly than was strictly professional. There was no response. I felt for his carotid pulse in a wild panic. Shit! I’d killed him. No, wait a minute. He had a pulse, surprisingly strong. Stan snatched a deep, rasping breath. He was off again. Thank God. I’d almost killed him. I said two silent Hail Marys. One for Stan and one for me.

Night Sister bleeped me again a couple of hours later. ‘Sorry to disturb you, Dr McCluskey. I’m afraid Mr Worthington has died. Can you come and certify him, please?’

 Alma

 It was nearly midnight when my bleep went off. ‘Dr McCluskey to Ward 6 urgently. Dr McCluskey to Ward 6 urgently.’

 I ran to the ward and pushed through the gap in the curtains to find three nurses, two doctors, a defibrillator, and an emergency drugs and equipment trolley. Alma Pearson, lying prostrate in the bed, was the centre of attention. She’d just had a respiratory arrest, and one of the doctors was bagging her. The other doctor began telling me the sorrowful tale of another no-hoper with end-stage COPD. He was nearing the end when I heard coughing and spluttering. The figure on the bed moved. Skeletally thin arms came up to pull the mask off her face. The doctor who had been bagging Alma jumped back in fright, shocked by his patient’s sudden resurrection.

 I wasn’t wholly convinced we’d witnessed a miracle, however. ‘Where am I?’ croaked a weak voice. Alma looked about her blearily. ‘I could murder a nice cup of tea.’

 After making sure Alma probably wouldn’t peg it before enjoying her nice cup of tea, I set off to find the Pearson clan. After spending some time with them, I took a deep breath and prepared to tell them what I thought. I would try to convince them that ICU admission wasn’t in Alma’s best interests. That it would be better to aim for a comfortable and dignified death rather than to torture her in the ICU. A bit strong, perhaps, but it was what I truly believed. I opened my mouth to speak, but before any words emerged, Barbara, Alma’s eldest daughter, interjected. ‘Doctor, I think we’ve all realised for some time that Mum’s health has been failing. She’s deteriorated so much in the past year or two. We've talked about it with Mum as a family more than once. She always said, “Barbara, when the time comes, don’t send me to hospital. I don’t want those doctors and nurses prodding and poking me. I want to be left alone. I want to die in the comfort of my own bed with my family surrounding me.’

 Barbara had panicked when her mother had collapsed and phoned for an ambulance, anyway. We agreed that as it was late, Alma would stay on the ward for now. At nine o’clock, only a few hours off, Sister would try to get Alma home with an end-of-life care and support package. When I left the ward, Alma was sitting up in bed, enjoying a second cuppa, chatting with her family and looking for all the world as if she were hosting a tea party.

 After I handed over the ICU to one of my consultant colleagues at eight o’clock, I rang Ward 6 to find out how Alma was getting on. ‘She passed away peacefully about an hour ago with all her family around her,’ said Sister on the other end of the line.

 Darren

 ‘Dr McCluskey, it’s Sister Dawson in the ED. We’re expecting a 50-year-old male with 100% burns. ETA five minutes. Can you come down immediately, please?’

 The mortality of a severe burn injury is related to the body surface area involved. A rule of thumb we learnt as medical students estimated the death rate from severe burns as being roughly equal to the percentage of body surface area directly affected plus the age of the victim. You didn’t need to be Pythagoras to work out that the patient was stuffed.

 A nightmarish vision of hell assaulted my eyes in resus. My patient was recognisably human, but barely. Most of his clothes appeared to have either burnt away, fallen off him or melted into his flesh. His age and sex were impossible to gauge from his appearance. He was bald-headed, but whether that was his natural state or the result of flames consuming his hair was hard to say. He had no discernible eyelashes or eyebrows. Strips of charred, blackened skin hung loosely from his arms and legs, obscenely wafting in the breeze while he was transferred from the paramedics’ trolley onto the resuscitation bay trolley. Bare skeletal muscle, ligaments, tendons and even bone were visible. Where his skin hadn’t turned black, it was a livid red. Worse even than the horrific sight, though, was the acrid, upsetting smell of charred meat. It stuck in my throat and made me want to heave.

 It didn’t seem possible that anyone so severely injured could still be alive, but the man moved weakly, trying to push his carers away with what remained of his hands. Severely burnt as he was, the man wasn’t screaming in agony as might have been expected. His body was in a state of severe shock. His central nervous system was awash with endogenous enkephalins and endorphins, natural hormones that act at the same receptors within the brain and spinal cord as morphine and heroin.

 My job as the anaesthetist was to manage my patient’s airway and breathing. ‘Let me through, please,’ I commanded, elbowing my way through the crowd and stationing myself behind the man. One of the paramedics began a handover. ‘This is Darren Small, male, aged fifty. He was doused in petrol and set alight in the middle of the street at about half eight this evening after falling out with his pals in one of the local drug gangs. We’re not sure exactly what…’

 I raised my palm in front of the paramedic’s face to shut him up. I had been distracted by Darren’s lips moving, but I couldn’t hear what he was saying. ‘Can everyone please shut the fuck up for one second?’ I appealed over the general din. Silence descended as everyone stopped what they were doing. I bent down to listen in. The stench was overpowering at such close quarters. I made a concerted effort not to gag while concentrating all my faculties on my left ear, which was touching Darren’s lips. Even so, I couldn’t make out what he was trying to say. ‘I’m sorry, Darren,’ I said, speaking directly into the remnant of his right ear. ‘Can you repeat that?’

The meaning of the words Darren uttered was crystal clear even if their volume was barely above the threshold of human hearing. ‘Please. Kill. Me. Now.’ I reeled back in shock.

 ‘What did he say?’ a voice from the crowd asked. I shook my head. ‘I couldn’t hear anything clearly.’

 Now that the need for quiet was over, the general hubbub ratcheted up again. I picked up the bag-valve-mask apparatus and began preoxygenating. Darren shook his head from side to side. Was he saying no? The harder I tried to convince myself I had misheard him earlier, the more clearly I heard his words echoing in my head.

 ‘I’m going to drift you off to sleep, Darren,’ I called out in a loud, clear voice. ‘It’s nothing to worry about. You’ll wake up in a few days when you’ve recovered.’ It sounded plausible, even if it wasn’t true. Darren entered a medically induced coma and died a few hours later on the ICU.

 Jack

 Jack Birch was an 82-year-old lifelong smoker with severe COPD who became breathless whenever he thought about exerting himself. He was on home oxygen and had a stairlift. He never ventured outside the house except to attend outpatient appointments, which were varied and frequent, or to be admitted to hospital in an emergency, which had occurred four times during the previous eighteen months.

 Jack’s family called for an ambulance when he collapsed in his chair. He arrived in the ED in extremis and was rapidly transferred to resus. Jack had stopped breathing. An ED nurse was bagging him. ‘I know he’s a poor candidate for critical care, the ED registrar said, ‘but the relatives were pressuring me to refer him to you even before his respiratory arrest. Actually, it’s just one of Jack’s sons, but he’s pretty keen that everything is done. Aggressively keen, actually. I thought he was going to deck me.’

 I was certain that Jack would not survive this illness, whether or not I admitted him to the ICU. It would be better for him, better for his family, better all round, to aim for a peaceful, calm, pain-free and dignified death. Time to run the gauntlet of Jack’s family and get them to see the sense of my plan.’

 It turned out that my plan did not meet with universal approval. ‘I’m not fucking having that,’ thundered Peter, Jack’s eldest son, a fine mist of spit showering my face as he invaded my personal space and poked his forefinger aggressively into my midriff. ‘Dad has a perfect fucking right to go to your fucking intensive care unit. You’re not fucking giving up on him. I demand a second opinion.’

 ‘That’s a good idea,’ I agreed, nodding vigorously, relieved to discover we saw eye to eye on something. ‘I’ll go and call my consultant.’

 Peter was so aggressive with Dr Glenn, my consultant, that he concluded discretion was the better part of valour and reluctantly agreed to admit Jack to the ICU for a short assessment period. Three weeks later we assembled in the ICU relatives’ room. Jack had made no progress. He was stuck in limbo on a mechanical ventilator, unable to breathe unaided, suffering all the while, distracted by pain, confused and disoriented. Peter demanded his father be resedated and put back on full pressure support from the ventilator, shouting out for all to hear in the ICU, ‘You wouldn’t treat a dog like this.’

 Dr Glenn explained in detail that despite everything we had tried to do for Jack, the situation remained that he was still dying. Nothing would change that. It was time to let him go. Everyone nodded and murmured their agreement. Everyone except Peter, who announced he would be contacting his solicitor to ‘Sue the arse off the lot of you,’ before storming off.

 Straight after the discussion with Jack’s family, Dr Glenn did increase Jack’s sedation. Jack immediately lapsed into a peaceful slumber. However, instead of increasing Jack’s pressure support, Dr Glenn switched it off. Jack was on his own. A few hours later, Jack slipped quietly away, his loving family surrounding him. With one notable exception.