RickInOz

Props to Faithless for the superb Insomnia for the post title this time.

I’m on nights again. The unit has been unusually busy and so I haven’t had much sleep for the past couple of nights. I still have two nights left, and at this rate will be exhausted by the end. The reason we are so busy is that we have a large number of sick patients who shouldn’t really be on the unit. In the UK ICU beds are a limited resource and demand is high. As such only patients who are expected to do well are admitted. Anyone with serious pre-existing diseases, poor functional status or malignant cancer tends to be refused. Some might argue this denies treatment so patients, but given an ICU patients costs the taxpayer upwards of £1000 a day, it makes sense not to waste money on those who have a poor prognosis and little chance of survival.

Here the system is different. There are far more ICU beds available and the admission criterion is much lower. This means we tend to have a lot of patients who do badly and languish on the unit for far too long before we eventually realise how futile the situaton is and withdraw treatment. This is very frustrating as I sometimes feel we are not really acting in the best interests of the patients. It is entirely reasonable to provide high quality palliative care, ease suffering and hence avoid an unnecessarily protracted decline.

The reason we have so many unsuitable patients is that the hierarchy of consent is inverted. In the UK the patient has the first right of say as to how they are treated. If they are unable to state their wishes (if they are unconcious for example), the doctors make decisions on their behalf. The family are consulted and asked for an opinion, but have no legal right to dictate management. This is why there have been high profile cases of families having to seek a court order to override the doctors. Here the patient still gets first right of consent, but the second tier is the family. This means even if doctors disagree with the family’s wishes, they must accede even if clinical reason says the family is wrong. This is a fundamentally flawed system as it demeans the role of the physician. Inevitably if a family is asked what they want they will ask for “Everything”, to avoid accepting the guilt of pulling the plug on their dearly beloved.

There is a realistic, better and more humane option. Pity it isn’t available to us.