Turning off to life support

“Unfortunately he has suffered severe brain damage and he is not going to make a recovery.” So they said about John Thompson, who was comatose, unresponsive and unable to have his eyes opened manually. What happened next was a recovery story that will remain a rare event since the NSW Supreme Court decision last Wednesday.

John Thompson was a 37-year-old left in a coma after a heroin overdose. After the doctor’s negative diagnosis, he was taken off antibiotics and prepared for palliative care. The hospital staff had pressured the family, kept information from them and even moved John to a transplant ward in order to harvest his organs, as well as putting a “not for resuscitation” order on him. After the court ordered the hospital to maintain treatment, he almost made a complete recovery. This was the happy ending of the Northridge case in 2000.

Last week Isaac Messiha died after the NSW Supreme Court ordered that it was in his best interests not to continue treatment, despite the family’s strong convictions and his relatively short time in a coma. Although the facts aren’t as extreme, the story of Isaac Messiha seems to echo that of Northridge, except for the court’s decision. Isaacs’s son complained of staff playing with his mind and telling him “what you are doing to your father is cruel”. He was told the hospital had to cancel two operations because of his dad. Although the doctors consulted with the family and even sought an alternate opinion, they mentioned that other patients were awaiting treatment.

Did the family have any real choice? On a few grounds, the court decided, no.

Although medical opinion showed that Isaac’s condition was deteriorating, the family gave evidence that he was partly responsive, seemed to be improving and even opened his eyes. This didn’t matter.

The court also decided treatment should be discontinued, as it was intrusive. The fact that treatment was “intrusive” surely cannot be certain. My three-year-old brother received stomach pumping after ingesting two glasses of wine, and I can tell you that it’s pretty intrusive. But we did it anyway. His life was still considered worth living, and despite 75-year-old Isaac Messiha’s case being far more serious, his family thought the same.

The culture of pressuring the family to switch off life support is not so much a result of practical problems such as bed shortages as the attitude expressed in the medical profession and now the courts that certain lives are not worth living. Dr Edward Freeman, a medical consultant for the National Brain Injury Foundation, noted in the Northridge case, “the discarding of people with severe brain injury by the health care system in Australia, unfortunately, is very similar ... and very frustrating”.

While claiming that it wasn’t making a value judgment of Isaac’s life, or ignoring the wishes of the family, the court was satisfied that the “decision as to whether appropriate treatment is being made in the welfare and interests of the patient, is principally a matter for the expertise of professional medical practitioners”. Why are we so inclined to entrust the medical profession with the determination of a patient’s best interests? How can busy doctors with waiting patients - and perhaps a more detached importance on the individual whose life they see as futile - make a better decision than others? Surely the best judges of this are the closest members of the patient’s family. Isaac Messiha’s story is a case in point: Since when was it in his best interests that hospital staff ignore his family’s wishes and remove treatment after a four-week coma?

The Supreme Court decision is a big move for the NSW jurisdiction. For the first time it sanctions medical opinion as more competent to judge best interests than the family of an individual. It seems that the law is slowly moving away from what Northridge held as its role “to prevent the withdrawal of such treatment, support and sustenance where the withdrawal may put in jeopardy the life, good health or welfare of such unconscious individual”.

In modern medical decision-making, personal choice is upheld as the highest good, to be forever defended, at least when the proposed outcome is death. The individual has choice to refuse medical treatment, and the family or guardian of an unconscious patient has choice to withdraw all medical treatment, with fairly low thresholds of proof. Yet it seems a family cannot choose to keep alive their loved one for a few days in the hope of a recovery.

For people who have never been in the position of Isaac Messiha, we tend to make quick assumptions about “quality” and “futility” of life. We assume that everyone values “quality of life” as first priority. Throughout life, people generally do, but in the end of life process, quality of life is often surrendered early on.

While doing our best to relieve suffering, let’s not hasten death so soon. Some people want to see out the illness and fight on, even if it eventually leads to death; some people want to prepare for what may come after death; some may just want time to reflect, and to say goodbye. Oh ... and some may even get better ...