According to the Oxford dictionary life is defined as “the condition that distinguishes animals and plants from inorganic matter, including the capacity for growth, reproduction, functional activity, and continual change preceding death”. This definition outlines the simplest form of living, however a common question is often raised- what defines meaningful life? Is a life on machines deemed meaningful and if so are there resources available to sustain that life?
While on my block in neurosurgical ICU, I was exposed to many patients with severe traumatic brain injuries from varying causes who were most often than not ventilated, sedated or comatose due to the severity of their condition. Many of these patients had been given a poor prognosis of severe permanent biological changes and in some cases, very little or no brain activity. Due to this, the patients’ families are faced with the harsh reality of their situation and in some cases, leaving them with the grim task of having to make a life or death decision for their loved ones.
In the South African public health care system, if patients are unable to make decisions or express their wishes regarding their treatment and in some cases death, their appointed representative will make such decisions with the help from various appropriate health professionals (HPCSA, 2008). Clinicians commonly present these representatives with the news that that any further treatment will have no effect on the patient’s condition.
I had an interaction with a patient in the ICU who was comatose due to the severity of his traumatic brain injury and was given a poor prognosis by the doctors. The patient’s family was advised about their loved one’s condition and that any further treatment would not improve the patient’s condition. The family were given 24 hours to make a decision of whether to withdraw treatment. The family members of the patient were very upset and distressed with this news. They felt torn between letting their loved one pass away versus the hope that he might come out of the comatose state. State hospitals do not have resources to keep these kinds of patients alive in the ICU, without a guaranteed improvement of their condition. The family’s only option would be to move the patient to private care, but with such exorbitant costs required, this option just was not possible for the patient. The family’s decision was therefore made for them, and it was just a matter of time and pressure from the hospital to sign the form and withdraw treatment.
This experience brought upon many emotions for me, as it is such a controversial dilemma that so many are faced with, where the life of a person is at hand. The idea of the patient’s quality of life is raised and whether anyone would want to live with such a low quality of life where basic daily functioning is not possible and the individual is fully dependant on another person. On the other hand, however, families have hope that their loved ones will return back to some degree of independence, from such a comatose state. These beliefs are often faith and religiously motivated which lead to the want to continue treatment.
What I find most upsetting is seeing young people in the ICU with severe traumatic brain injuries who, according to my definition, have a very poor quality of life. The young patients still have many years ahead of them to grow and experience life, yet are now seen lying in an ICU bed sedated, ventilated and unable to do the simplest of tasks like breathing by themselves. I do not believe that is a quality of life to sustain. Some people have apposing opinions and definitions on the idea of quality of life and thus, their feelings towards such a situation will differ. Nonetheless, it is terribly emotional to having to see families who are upset at the reality of having to withdraw treatment for their young child, parent or grandparent.
If we look closer in the South African public health system, is there really a decision to be made of “life or death” or just a pressure of time to sign a permission form to withdraw treatment? Despite the patient’s poor prognosis, what happens if a patient’s family wants to keep their loved one alive in their current state? The patient fits the Oxford definition of life to a certain degree with regards to having “the capacity for growth” and “reproduction”. However, is this considered a “meaningful life” when their “functional activity” is limited and vastly reduced compared to their previous quality of life? This also poses the question of whether sustaining this sort of medical state is realistic for the healthcare system, despite definite positive outcomes.
While saying this, in April 2019 an Emirati woman opened her eyes after being in a coma, induced by a serious brain injury (AFP, 2019). This patient was medically monitored for 27 years without the guaranteed chance that she would ever wake up. An intensive care unit comes with various running expenses which exceed that of a normal hospital ward. There is a high demand for resources to ensure the patients are well cared for and have 24 hour monitoring due to their critical state. However, resources are limited for such management to be carried out in the South African public health system. Due to the high cost of running such units, resources are managed tightly and space is limited to only the most critical patients.
In 2015/2016 a study was done in the intensive care units of a central hospital in the eThekwini Health District in KwaZulu-Natal to determine the costs of running an ICU. In that financial year, the ICU had a total cost of R114 055 104. The greatest contributors to ICU costs were human resources (55%) and other direct patient activity costs including clinical support, consumables and pharmaceuticals (24%)(Mohamed, 2019). These resources are reserved for only the most critical patients who show potential for recovery with active treatment.
Due to the limited budget for healthcare in South Africa, scarce resources are available for medical management of those patients with a terminal diagnosis, who will require permanent dependency on the system. This therefore results in the termination of many patients’ treatments, despite the families’ wishes for other decisions. This is the ethical dilemma –intensive patient care is terminated unless there is a known and potential positive outcome. This means that, unlike the Emirati woman, a patient who is not showing hopeful outcomes in the South African health system will not be given the opportunity to be medically monitored for 27 years in the hope of waking up.
On the other hand, if medically monitored, what quality of life is being sustained? This is a complex dilemma that will not easily be solved in South Africa. Unfortunately patient’s lives are being lost on a daily basis because of it. Some may see this as a better way forward due to the patient’s critical condition, while others are torn by the inability to sustain a low quality of life in a state system. Every person has their own beliefs of what is right and wrong in regards to this situation, therefore making this a complex dilemma that cannot be easily resolved. In saying that I would not want to be kept alive by a ventilator and reflecting on quality of life would be an important deciding factor.
References:
AFP. (2019). Sunday Times. Woman wakes up after 27 years in a coma: family. Retrieved 21 May 2019, from https://www.timeslive.co.za/news/world/2019-04-24-woman-wakes-up-after-27-years-in-a-coma-family/
HPCSA. (2008).Health professionals council of South Africa. Guidelines for the withholding and withdrawing of treatment. Retrieved 23 May 2019, from http://www.hpcsa.co.za
Mohamed, S.(2019). SAMJResearch. Cost of intensive care services at a central hospital
in South Africa. Retrieved 23 May 2019, from http://www.scielo.org.za/pdf/samj/v109n1/11.pdf.
3 thoughts on “A matter of life or death”
Content:
Dear Emma-leigh. I think a lot of us as student physiotherapists or even qualified clinicians ask the questions that you are rising in this writing piece. I like how your first paragraph ask what is meaningful life, as this is a very common question to ask ourselves as we face ethical dilemmas on a daily during practice. In South-Africa we are often so rushed due to scarce resources that we ask the question that your are asking in paragraph 3; is there really a decision to be made of “life or death” or just a pressure of time to sign a permission form to withdraw treatment? It feels like if we withdraw treatment then there is an opportunity for us to help another patient with more potential.
Therefore I definitely think that the content of your writing piece reflect the content of the module due to you discussing meaningful life and scarce resources.
Clinical practice:
Paragraph 2 you state that while you were on your ICU block you were exposed to many patients with TBI and how they present. This makes it easy for us to understand your clinical experience, but is there maybe a specific case that stood out to you? Something that triggered you emotionally? If you include a more in depth case then it will make your argument even stronger.
Art:
I think if you want to make your writing piece stand out you can add an art piece that reflects your writing. Consider adding a picture that reflects life on the one side and death on the other. Here is an example: http://favim.com/image/446184/
Evidence:
You have used appropriate literature to support your claims and it make your argument very strong. Good resources used and incorporated.
Language:
The reflection is really well written. The introduction and conclusion makes it easy to follow your thoughts and discussion.
Digital literacy:
You have used hyperlinks for your reference list which makes it easy to go read up more about the topics discussed in your writing. I would suggest however, that you add tags such as; meaningful life, meaningful death, scarce resources. Also you can add the image/art as previously discussed above.
Thank you for sharing
Agatha
Thank you Emma for your piece. I enjoyed it. My next block is at ICU neurosurgical and it gives some idea what kind environment it is and what to expect.
Content: The content is good. I have not personally gone through something like this but I understand where you come from. In a country like South Africa where lack of resources are our biggest problem. Some health professionals, especially doctors have to make that difficult decision of who gets more of the resources. Luckily we as students are not involved in making that decision. Sorry in the beginning I was a little confused at what the ethical dilemma was. Is the dilemma what is considered a meaningful life for patients in the ICU? Who can’t make that decision themselves? Or is it lack of resources in the South African healthcare system to sutain all lives in the ICU setting. Or is it does resources play a decision in what a meaningful life is? Maybe you can make it clearer in the beginning. I liked how you used a example a woman who woked up after 27 years in a coma. That is very interesting. However, I feel that if we did have enough resources and used it on all patients who had a poor prognosis. There is that possibility that some of the patients won’t be as lucky as that patient in the example. You did include a clinical experience but it is more of a generalised one. To bring more emotion to your piece you could maybe put in a more personal experience. That made you think of this ethical dilemma.
Writing style: It is good. The grammar,punctuation and spelling are all correct.
References: You have good references. You have good references to back up your claims. You could just add when you retrieved them.
Hi,
I think a lot of students is faced with this question”what is the meaning of life?”and death. I liked how you introduced the topic, it was clear and related to the module content. In our country we are often so rushed to treat and make decision related to the patients health due to limiting resources that we ask ourselves the question that you ask in your writing piece. This is a very controversial topic where a persons faith can be compromised by medicine, look at the example of the lady that woke up after being in a state of coma for 27 years. A family might have a strong belief that their family member will come out of this state of coma but medicine will encourage permission for withdrawal of treatment, but is there really a decision to be made of “life or death” or are clinicians just pressured to terminate treatment and take away the little bit of hope the family might have had? I liked how you incorporated your clinical experience in ICU, however I feel it is very broad maybe you can add a personal clinical experience.
Your writing style was good, the piece was written well and all the grammar and spelling was all correct.
Referencing: Thank you for hyperlinking it, to assist if we maybe want to go read up on the topics. The referencing was relevant and up to date.
Thank you for sharing, all the best with the final writing piece.