Crossing the ‘bright line' – difficult decisions at the end of life

Abstract

-Patients tell us stories about their lives, their symptoms and their interpretation of them. As physicians we try to make sense of the stories, piecing together the fragments that come our way to discern a diagnosis which we then confirm or refute by examination and investigation. Thus was Samuel Gee's life as a physician: with little in the way of diagnostic tools his 'clinical skills' had to be honed finely and his diagnostic nose well attuned. Perhaps we have today lost some of that clinical intuition. We seek the evidence base for all we do, failing to observe subtleties in our quest for hard science. Following Gee's esteemed lead -for he was celebrated for his clinical descriptions -I will unashamedly use doctor-patient experiences to illustrate my points, particularly around end-of-life decisions.

Surrogate Decision Making for Patients With Severe Traumatic Brain Injury

“…The decision-making processes identifi ed in this study were similar to those discovered by Boyd et al 22 Surrogates who had prior conversations and truthful prognoses had an easier time making decisions, consistent with the prior research fi ndings. 7,9,33,34 Surrogates are both observer and participant in an unfolding drama that many fi nd as diffi cult to understand as to direct through their decision making. The 2 surrogates who harbored regrets withdrew life-sustaining treatment for their patients, whereas other surrogates who also elected to withdraw support were steadfast in their beliefs they had made the right decision to withdraw support.…”