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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:So this is another of those "I know better because I'm a doctor" rants. wink



So I'm doing my second month in the NICU (Neonatal Intensive Care Unit) starting tomorrow. When I left the NICU 8 weeks ago there was a baby there who was doing poorly. He's a former 25-week preemie (full term is 40 weeks, 37 weeks is term, you can abort in NY state at 23 weeks) on day of life 180+. He's now two months post-term. He's had every single complication of prematurity you can imagine.



He has severe lung disease and is on a special kind of ventilator reserved for only the most critically ill patients. He has high blood pressure in his lungs and is on digoxin and diuretics. He has terrible hernias that are so far into his scrotum that his penis is hidden. He has had some bowel obstruction and has vomited blood. He has had multiple infections. He has had multiple transfusions. He has had multiple episodes of oxygen deprivation due to his lung disease and likely has SEVERE brain damage. And he has hypospadias, which is where the urinary meatus (the "pee hole") emerges from the underside of the penis due to a failure of proper closure of the penis in development. And his retinas have suffered and he will be severely visually impaired, if not blind.



*IF* he ever survives this, I can say with confidence that he will have no meaningful life. What do I mean by this and who am I to judge the meaningfulness of life?



Well, simply, I reject that a life lived half in the hospital with repeated pneumonias, severe asthma, essentially no higher brain function, and limbs locked in painful contractures is meaningful. In fact, I consider keeping a child alive to live such a life to be nothing short of cruelty.



This has been explained to the child's mother, but she is a deeply religious woman (in spite of having this child out of wedlock) and she refuses to activate a DNR (Do Not Rescuscitate) order.



So every time the baby's heart rate drops, we have to do chest compressions and give him epinephrine. Chest compressions are amazingly painful and break ribs. He requires rescuscitation up to five times a day (although he hasn't needed any in a week now, amazingly).



His mother just doesn't seem to get it. We explain his prognosis to her, she breaks down in tears, and the next day comes in and cheerfully asks "he's going to be normal, right?"



And, although this shouldn't matter, this is a Medicaid hospital. That third of my paycheck that goes to taxes is paying to torture this child. And yes, I consider it torture.



So here's my question: when is it child abuse? When is it abuse period? I've seen patients, both pediatric and adult, kept alive and had amazingly terrible things done to them because the family insisted on "doing everything."



The Oath of Hippocrates does not actually contain an admonition to "Do No Harm," but this is a basic tenet of medicine. I believe we're harming this child by painfully prolonging the inevitable...or by condeming him to a life of sickness and pain.



What do you think? Should doctors have more power to pull the plug over the objections of the next of kin? Or am I being an arrogant ass in a white coat wanting to play God? Or are we already playing God by keeping this kid alive?





-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:Written by: DragonFury

Is it possible that the child will grow and have a worthwhile life? and a worthwhile life to me is to be loved. If the child knows love and feels loved, then to me, they are living.



Does love counteract pain? Many abusive parents love their children so much that they love them to death. Does that make it OK? I see this as a similar situation. Maybe he'd be loved, but does it make it OK that he's constantly sick? That he's in constant pain from his contractures? That he's constantly starving for air and gasping for breath? Is it OK to live a life of misery like that if he's loved?

True love, I believe, is knowing when to let the bird fly free of the nest. And knowing when to let the sick one die and stop suffering.

This child's brain is so damaged that there's no way he will ever be more than a minimally interactive, very retarded child with absolutely awful lungs.

There's another kid in the unit with similar issues. HUGE bleed in his brain. Neurosurgery refuses to touch him because going to the OR to drain the bleed would kill him. Rotten lungs, infection of the bowel (necrotizing enterocolitis...which is about as unpleasant as it sounds), and impending renal failure. He's got issues with four organ systems. He's going to die.

And mom wants everything done. So if he arrests he gets chest compression, epinephrine, everything. I think it's criminal.

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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DragonFury
BRONZE Member since Mar 2005

Draco Iracundia
Location: Adelaide, Australia

Total posts: 784
Posted:if the child is mentally handicapped as you say, then he wouldn't know if he is loved.

as for the second kid, i would OD him on painkillers... though i say that, but i have trouble killing anything that is not a spider.

Do we sleep when we die?

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Patriarch917
SILVER Member since Oct 2005

Patriarch917
I make my own people.
Location: Nashville, Tennessee, USA

Total posts: 607
Posted:Taking decisions about life saving medical treatment for children away from the parents and giving it to anyone else, such as doctors or the government, seems to me to be a bad idea.

Any parent who let a retarded child starve to death or a sick child die in their home by not calling the hospital would certainly be prosecuted. Can we condone the same behavior if it's done in a hospital and 5 doctors say it's ok?

At least in America, a woman would have had the right to kill a premature child if it had stayed in the womb, whether there was anything wrong with it or not. If we are willing to give her the power to take a life, we shouldn't criticise her when she decides, against the odds, to try to save it.

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:So Patriarch, when does it become abuse?

I think condemning anyone against their will to a life of pain is abuse.

People always hear stories about "miracle patients" who are told they'll never do this or that and then do. Most of these stories are apocryphal and the true ones are generally based on doctors not doing the appropriate studies. A destroyed brain is a destroyed brain. I argue that our brains make us human and that without a brain, it is impossible to have a human life.

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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Sethis
BRONZE Member since May 2005

Sethis
Pooh-Bah
Location: York University, United Kingdo...

Total posts: 1762
Posted:Written by: Patriarch917

...would certainly be prosecuted. Can we condone the same behavior if it's done in a hospital and 5 doctors say it's ok?




If I killed someone, I would be prosecuted... can we condone the same behaviour if it's a soldier?

Of course we can, they're trained to do so. Doctors are trained to value life, and to make judgements about the quality of said life.

After much consideration, I find that the view is worth the asphyxiation.
--------------------------------------------------------------------------------------
I may disagree with what you have to say, but I will defend to the death your right to say it.

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Patriarch917
SILVER Member since Oct 2005

Patriarch917
I make my own people.
Location: Nashville, Tennessee, USA

Total posts: 607
Posted:Written by: Doc Lightning

So Patriarch, when does it become abuse?

I think condemning anyone against their will to a life of pain is abuse.





I would agree that condemning someone against their will to a life of pain is abuse. However, if the hypothetical is a prematurely born child with medical problems then that statement does not strictly apply.

First, the mother did not purposefully choose to create a life of pain for the child. If she had her way, I'm sure she would like to give it a life without pain. You can say the child was condmened to a painful life by God, or blind chance, or whatever you like, but you can't say it originated with the mother.

Certainly, the choice to give the baby medical care that will prolong and even add to the agony is the mother's choice, but allowing something to exist is not exactly the same thing as creating it. The question is not whether a mother should condemn a child to a life of pain, but whether a child who is in pain should be kept alive, denied treatment, or purposefully killed.

You also specified that it is abuse if a person is condemned to pain "against their will." I doubt that you meant that many people choose pain for it's own sake. Instead, I infer that you mean me to finish the thought to read something like " I think condemning anyone against their will to a life of pain is abuse, instead they should be denied medical care and allowed to die."

Of course, we are not speaking of someone who has expressed a wish to not recieve treatment. If the child were capable of making that decision, I would probably be content to leave it to the child. Unfortuanately we do not have that luxury. Instead we must give that choice to someone else.

Some, like myself, think the decision should be made by the parents of the child. Others, perhaps followin Sethis' reasoning, think that doctors should be given this power.

It may be abuse to keep the child alive when it is in pain. On the other hand, it may be abuse to deny a child medical treatment and let it die merely because it is in pain.

There is a saying in the legal community that "hard cases make bad law." Essentially, the premise is that if a judge is presented with an extreme case, such as the one we have had in mind. He is more likely to base his decision on emotions and sympathy for the parties in an individual case, rather than judging it by a more appropriate rule.

Through this, we could arrive at skewed principles such as "if a child is in a lot of pain, we should let it die rather than give it treatment." Certainly, some would agree with the outcome if this rule were applied in this case, but we would all probably agree that it is not appropriate for a child with a broken leg!

We can shape the rule, adding details such as "if the child is going to die within x number of days, if the child's brain will be damaged x amount, if the chance of recovery is x..." but for any of us to draw a bright line and condemn the choice of the mother based on our rule is a bigger undertaking than most of us realize at first.

I am not ready to condemn this mother whether she keeps the child alive, or whether she pulls the plug. I am also not fully convinced that going to school and having a medical liscense makes you more likely to make the right decision than the child's mother.

Whether our default position should be life, death, parent's choice, or doctors choice, I'm not sure. All I can say is that if I had to decide, I would give the choice to the mother.

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onewheeldave
GOLD Member since Aug 2002

Carpal \'Tunnel
Location: sheffield, United Kingdom

Total posts: 3252
Posted:Some mothers make the wrong choice- especially if they're in the position of being so emotionally bound that reason becomes impossible.

The examples Mike is talking about are not just about a child in pain- they are extreme examples of a pointless life devoid of any kind of happiness- extreme physical and mental disfunction.

A mother choosing that for her child is almost certainly not being realistic or facing up to the true consequences of her actions.

Part of societies function is to protect individuals (ie, this child); for example, it questions the right of a religious mother to deny her child a blood transfusion which she sees as against Gods will (and make no mistake, in that situation she is truly choosing what she sees as the best for her child, as, in her eyes, the childs immortal soul takes precedence over it's earthly life).

Parents do not always know best.

It's not as if the medical system is taking away her child and murdering it; it's simply withholding treatment on the grounds that it is not in the best interests of the child, or the other patients who could benefit from the medical staffs valuable time.

"You can't outrun Death forever.
But you can make the Bastard work for it."

--MAJOR KORGO KORGAR,
"Last of The Lancers"
AFC 32


Educate your self in the Hazards of Fire Breathing STAY SAFE!

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:

Written by:
You can say the child was condmened to a painful life by God, or blind chance, or whatever you like, but you can't say it originated with the mother.





It's interesting that you mention "God, or blind chance, or whatever you like." The child isn't condemned to a painful life by God, is he? He's condemned to it by doctors. Thirty years ago, the child would have died. Nobody would have even tried to intubate him or resuscitate him.



Written by:


You also specified that it is abuse if a person is condemned to pain "against their will." I doubt that you meant that many people choose pain for it's own sake. Instead, I infer that you mean me to finish the thought to read something like " I think condemning anyone against their will to a life of pain is abuse, instead they should be denied medical care and allowed to die."





I disagree with the bit about "denied medical care." It is appropriate medical care to provide palliative treatment to a terminal patient. As it happens, we did withdraw care on one of my patients yesterday. We did not, however, deny her medical care until we declared death. My last orders were:

'Morphine Sulfate, 1.2mg IV push, please have additional dose on call x1'



It was not a lethal dose. It was the maximum recommended dose. Our final act of medical care for this patient was to keep her comfortable and allow her to go.



Written by:






Some, like myself, think the decision should be made by the parents of the child. Others, perhaps followin Sethis' reasoning, think that doctors should be given this power.



I am not ready to condemn this mother whether she keeps the child alive, or whether she pulls the plug. I am also not fully convinced that going to school and having a medical liscense makes you more likely to make the right decision than the child's mother.





I agree that it should be up to the parents to make the decision in the best interests of the child.



However, I believe strongly that these decisions should be informed ones. In a few cases in the NICU, I don't believe that's the case. In both cases, pysicians have clearly told two mothers that their children's brains are badly damaged. In one case, the child has severe bleeds in his brain, is unable to breathe without a high-frequency ventilator, has short-gut syndrome because he required a bowel resection for necrotizing enterocolitis, and has a bad infection in his abdomen that we're having trouble eradicating. The mother was told that if the child ever survives this, he will never walk, never speak, and may never breathe on his own.



Her response is "He's strong. He'll be OK."



The other case is similar, and that mother just keeps saying "He'll be normal, right?" And we tell her that no, he'll never be normal. He's almost six months old and is still on a high-frequency oscillating ventilator, digoxin, aldactone, and furosemide, an experimental nitric oxide protocol, and we're even considering an experimental protocol with sildenafil (VIAGRA) to get his pulmonary blood vessels to dilate. And then the next day she says "He'll be normal, right?"



In these cases, it is the mother's psychopathology (extreme denial) that is keeping these children alive, not informed consent. Countless cases such as these have plagued NICUs the world over. One made national headlines last year when a baby born with a uniformly fatal disease (I forget the name of it, but it's a collagen disorder where basically the bones fail to form) somehow managed to survive childbirth and was kept alive at Texas Children's. Texas Children's had tried to withdraw care based on a rule that they could withdraw care if they felt the case was futile and no other center would accept the patient (40 other hospitals had refused the patient), but the courts would not allow the patient to withdraw. The mother had stated that "Sun (the child's name) will never die. As long as the Sun shines, Sun will live!" He finally did, of course, die.



Any parent can attest that the moment they discover that they are to be parents, a "Fantasy child" is born in their minds. Long before the child is born, the parents fantasize about future graduations, weddings, and such. It is a devastating blow when one's actual child cannot live up to that. And these kids can't. In cases such as Down's syndrome, where the child can live a happy life, even with his disability, the parents must adjust to new expectations. But in cases of severe brain damage and marginal viability, parents often can't cope with this.



After all, as long as the kid is alive, a miracle might happen, right?



So a new question arises: in a case like this, is the mother still fit to be making decisions? Maybe that's a question that should be addressed.

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:Written by: onewheeldave

Some mothers make the wrong choice- especially if they're in the position of being so emotionally bound that reason becomes impossible.

The examples Mike is talking about are not just about a child in pain- they are extreme examples of a pointless life devoid of any kind of happiness- extreme physical and mental disfunction.

A mother choosing that for her child is almost certainly not being realistic or facing up to the true consequences of her actions.


Exactly. OWD put it more succinctly than I did. In this case, it isn't the mother's interest in the well-being of the child, but rather the mother's psychopathology.


It's not as if the medical system is taking away her child and murdering it; it's simply withholding treatment on the grounds that it is not in the best interests of the child, or the other patients who could benefit from the medical staffs valuable time.



And this is another very important point. There is the ancient concept of "triage" where the sickest patients were left to die if they were beyond help. We seem to have lost that concept in modern times and even those who are beyond help are still kept alive. The modern ICU has brought about this question of "just because we can keep someone alive, should we?"

Are we really helping the patient by keeping someone alive when the patient will never be free of very highly invasive medical care?

But more than that there is the issue that health care resources are finite. Many times we have had to transfer patients to other hospitals because our PICU was full. One of these babies has been sitting in his isolette for SIX MONTHS. He's used literally millions of dollars of medical care and in the end, he's going to use hundreds of thousands, if not millions more...and for what? So he can live as a vegetable and die, if he ever makes it out of the NICU?

In this case, it's clear to me that the good of society and the good of the patient are both being sacrificed to this mother's denial.

It's one reason I could never be an intensivist.

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:Post deleted by Doc Lightning

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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Doc Lightning
GOLD Member since May 2001

Doc Lightning
HOP Mad Doctor
Location: San Francisco, CA, USA

Total posts: 13920
Posted:

Lest anyone here think I can't handle this or that I'm complaining, I want to show you a picture of what could be one of my patients (this is off a parent's website):




Non-Https Image Link




This looks to be a 26-week preemie. The patient is intubated. You can see the IV in her left arm. My guess is that this patient would weigh between 600 and 700 grams.



I've seen kids like this have great outcomes. For those kids, I've poured blood, sweat, and tears into their care without a moment's hesitation.



But there are other times when I feel that I'm morally reprehensible for continuing to work on some of these kids.

-Mike )'(
Certified Mad Doctor and HoP High Priest of Nutella

"A buckuht 'n a hooze!" -Valura

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