Knowing when to stop

So… 4 months in intensive care (working in intensive care, that is) and counting. I can’t wait to get out. It’s a bizarre world, this. Nowhere is the law of diminishing returns more vividly illustrated.
One of the upsides of paediatrics is that the vast majority of children get better without a huge amount of drugs or surgery. It mostly takes a shrewd diagnosis, some sound advice, and sometimes a couple of slugs of antibiotics or, say, 24 hours on intravenous fluid. Occasionally it’s a more chronic or complex condition, but even then, though not cured, they are soon home with their parents.
In intensive care, the sickest children, often with unfixable underlying problems (like a metabolic disease or a structurally very abnormal heart) receive increasingly sophisticated and demanding treatments. Again, the majority of stays are short (and successful), but in the ones who are there for over a week, the outlook just gets worse. The worse they get, the more complex and expensive (both in terms of human and financial cost) treatments get thrown at them, with less and less scientific and humane justification. The things we do on intensive care may be occasionally heroic (one of the more obnoxious consultants has actually had a patient’s baby sibling named after him by the fawning parents), but I think it takes more bravery to take a step back and say “stop”.
These thoughts have been bugging me since my first few days in intensive care, but the recent death of a patient who has been in for that same length of time has really brought them to the fore. I won’t relate that case in full as it contains a possible iatrogenic element, but towards the end, sustaining that patient’s life simply became cruelty. In the last few weeks, I found it hard to meet the parents’ eyes, because I knew how hopeless the situation was, but it wasn’t my place to convey it.


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