Our Patient's Requiem Mass Was Held Long In Advance

Occasionally, a patient in our care in the Critical Care Unit (CCU) is expected to die imminently no matter what we do. Others may have had a good chance of recovery if admitted to the Critical Care Unit, but then no bed is available for this new patient. Limited resources impact on CCU admissions. Situations in the CCU are often fluid, the medical condition of each of the patients may be stable, changed or perhaps hopeless. The rapid pace of unchecked technological advances enables prolonging life by maintaining some patients on a ventilator even for years even where prognosis is poor or guarded, some even with 'silent' Do Not Resuscitate [DNR] orders. There may be no clear policy on DNR existing in any Kenyan hospital as yet. This dilemma often occurs in the Critical Care Unit. Profound ethical questions confront the CCU personnel as they watch and wait helplessly. Apart from the relatives the critical care primary nurse bears the greatest psychological trauma.

Its depressing and stressful to see, manage or care for the brain dead patient. The society has become less prepared for death and has come to rely on high tech medicine to work miracles...ACLS has become one of the techno age's primary end -of -life rituals, but it falls short of filing the gap left by the loss of life affirming community and family bonding ceremonies... Adds Borgatti Joan an ethics consultant in an article First Do No Harm that family experience of death of a loved one ought to be more binding for their family than disintegrating.

'Though technology has improved the quality of life for many people, it can also be burdensome, and its use at a patient's end of life is particularly distressing for many nurses', remarked Urlich Connie, author of Nursing Ethics In Everyday Practice.

CASE STUDY

ZX (not her real name), a 56 year female patient has been ventilator dependent by tracheostomy in a Kenyan public hospital. She is a retired civil servant, married and a mother of 3 children. She was admitted with ascending paralysis which started on the lower limbs progressively to affect respiratory muscles. Could not feed, move or breath without help (mechanical ventilator) .Working diagnosis of Gullaine Barre Syndrome (GBS) or its variants [never became conclusive]. Went in and out of depression many times, was managed by the psychiatric with counseling and antidepressants without much improvement. At one point after one year she summoned her three children to the bedside. Patient was only able to move the eyes. Not possible to ascertain what exactly she communicated to them. Around the same time, a memorial service was held in CCU, a joint effort between CCU staff and the relatives. The opinion of experts from three medical disciplines; neurosurgery, anesthesia and internal medicine (physicians) was that the condition was irreversible; it was only expected to deteriorate until death. That is, she wound never be able to live without total life support with ventilation, nasogastric tube feeding, turning and cleaning. ZX was very close to the CCU staff, they knew her likes and tastes; she was fond of pediatric patients who got admitted the CCU bed next to hers.

She had been moved through all the six CCU beds slots at different times of her stay. Her cognitive functions remained intact most of the time. She made friends even in that state e.g. whenever a staff went for annual leave one desire they had was 'to come back and find ZX still alive'. She was resilient and could pull through odd and ends circumstances including multiple drug resistant organisms in her spectrum etc. A silent attempt for 'less aggressive care' was contemplated in a conference to discuss way forward. The family was divided on this; however they consulted their lawyer who constrained them against seeking to terminate life.

At times stress levels could get very high among the nursing staff on advocacy and primary nursing. Nursing care was performed professionally-the patient was suctioned, put back on ventilator, bathed, fed, turned, and her dressings were done. A written order was issued by hospital management to resume full support.

Efforts were even made for fundraising for a portable mechanical ventilator to use at home. ZX went into deep coma 3 months to her death after 1 year 4 months in CCU she succumbed, possibly due to complications like hospital acquired infection. She had accrued a Hospital Bill of nearly Ksh 3 Million (US$37,500). A support group was founded in her honour.

This case is comparable to Terry Tchiavo and Richard Rudd only that these two had given advanced directives on what should happen in case they ended up in vegetative state while ZX (above) had not given any such directives. Anecdotal evidence also shows that many Kenyans don't give advance directives or living wills.

Conclusion

There will probably be more situations like these in Kenya. There is no Law or guidelines in Kenya on the issue, therefore ethical issues and dilemmas are inevitable. Health Care providers ought to seek out resources early, care and support the carers as they strife towards a positive and dignified outcome for the patient. The European and American cases quoted in the text though setting precedence for our courts are only of persuasive not binding authority so our courts can ignore them if they wish.Ethical rules do not have the weight of the law, but may be relied upon by the courts as guidelines to determine whether a health care professional has acted unprofessionally in litigation. The Ministry of Medical Services in collaboration with professional bodies like Nursing Council of Kenya and their legal advisers should legislate (subsidiary legislation) on this matter urgently to issue pragmatic policy guidelines to safeguard the health care providers.

References

Donchin Yoel, The Intensive care Unit May Be Harmful to Your Health

Bogner S. Marilyn, 2004: Misadventures in Health Care -Inside Stories, Lawrence Erlbaum Associates

Herbert Vander Lugt, 1981:A Matter of Life and Death, Radio Bible class,USA.33-43

Campion Catherine, 1998 Death Rites for the Techno Age, Nursing spectrum ,Vol.2, No.15, http://nursingspectrum.com Borgatti Joan

Urlich, Connie, 2012: Nursing Ethics In Everyday Practice, Sigma Theta Tau Intl http://digg.com/News/Science/Terry

'Between Life And Death,' BBC television documentary, 13th July 2010 http://bbc.co.uk/