Thursday, January 25, 2007

Have you an answer ?

Correct me if I'm wrong.
I am in turmoil.
It stems from the issue of knowing when to treat and when not to.

Mrs HB came into hospital yesterday. Her GCS was 7/15 (all she was really doing was responding to pain). She was examined (as no history could be gleamed from her) and she was diagnosed as having had a stroke. Also as she might have a chest infection, she was started on intravenous antibiotics (although her chest was clear, and her chest x-ray of such poor quality, very little could be seen). And for good measure, as she was too unresponsive to eat, she was written up for intravenous fluids.
She was seen by one of the stroke physicians on the post-take ward round. He reckoned that she would be a poor candidate for the stroke unit: ie little rehabilitation potential.
I saw her today when she was transferred to my ward. A CT head this morning confirmed a large cerebrovascular accident in the territory of the right middle cerebral artery (not good). She was a little more responsive: her eyes never opened, and she did not speak, but she was able to lift her right hand when asked to.
My SHO said that she should have a SALT assessment (checks swallowing) - if she failed this, we were to insert a nasogastric tube, and feed her that way. His plan included continuing with antibiotics and fluids. He also wanted me to call the stroke unit and find out whether they would take her.
The consultant agreed.
I did not.
She is able to respond, but I don't think she is alert enough to have her swallowing assessed.
I do not think that she will leave hospital. I envision her being kept alive by all means possible, only to die of the umpteenth infection that she fails to fight off.
And then there are other factors to consider: she is 92 years old. She had been living with her son prior to Christmas, but has been in a nursing home for a month, as she deteriorated. She has been going downhill. This is just part of the picture. Surely at that age, one should be allowed to die in peace, without being poked, prodded and jabbed?
Later on, commenting on her, someone said that were they to have a stroke, they would rather have one that was so massive it killed them right out. And quite a few others agreed with this sentiment.

I do not understand.
Is that why I, the most junior of the team, disagrees? Do the others know something I have not learnt yet??
I can understand doing one's utmost for a patient. But for me that includes knowing when enough is enough. A dignified, painfree death is just as much an achievement as is a pneumonia cured, or a cancer driven into remission.

Where am I going wrong?


Addendum: Mrs HB passed away peacefully, five days after her admission. The main cause of her death was identified as a stroke, with ischaemic heart disease being a contributing factor. May she rest in peace.

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