Monday, 12 March 2007

Living wills, comas and life after death

News comes from America this week of a woman who has been in a coma for the past six years, following a heart attack. Last week she woke up and spent three days chatting to family and friends, before slipping back into a "minimally conscious state.” What is stranger is that this is not the first time she has surfaced. Will she wake again? No one seems to know.

Earlier this year a court ruled that a woman in a coma should, despite her family’s wishes, be given the drug Zolpidem, which can briefly wake such patients. The family argued that it would be cruel to wake her; that she would be confused and frightened to wake and realise what had happened to her. In the event the pill didn’t work and a judge allowed doctors to let the woman die.

Further back a husband fought with his in-laws. He said his wife, Terry Schiavo, wouldn’t want to live in a persistent vegetative state – her parents insisted that she would. The husband received death threats, the Supreme Court was involved, the family was ripped apart. Visits to the Living Will Registry shot through the roof. In the end Mrs Schiavo’s feeding tube was removed and she died.

Would a living will or advanced directive have helped in these cases? Since we don’t know how it feels to be in a permanent vegetative state how can we write something now about what treatment we do or don’t want if we end up in such a state? Easy to say now “I’d rather die” – but suppose once in PVS you are aware of loved ones, have wonderful dreams and memories and are certain you will wake again one day. It’s too late then to change your mind – you’ll have no way to tell people that you are happy as you are and don’t want to die. Recent research suggests that families of patients with “living wills” are happier with the end of life care received than the families of those without such documents.

The GMC has guidance on patients in persistent vegetative states We have books in the library that discuss this and other ethical issues. Wikipedia has suggestions for further reading and a list of PVS cases. The UK Clinical Ethics Network has a discussion on ethical issues at end of life. The BBC has legal and ethical information on living wills and some information on how to draw one up.

There are no right and wrong answers here, and every case is different, because every case is a human being and a family. Every clinican should be prepared by thinking the questions through, challenging your own assumptions and being prepared to change your mind as new information comes to light.

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