Ethical Questions….
on Shona in Sierra Leone (Sierra Leone), 22/Jun/2011 19:25, 34 days ago
In a resource poor setting, it’s one of the most difficult decisions to make. How much time should I spend with one child? There are so many sick children, not enough staff and not enough equipment or drugs. How do I (and the other staff) prioritise which children I (we) spend more time with?I gravitate towards sicker children because that’s always what I’ve been trained to do. There comes a point though, when I have done everything within my capabilities and within the constraints of the resources. Then it becomes a bit of a waiting game. Will this child get better, or will they deteriorate despite everything we can do? And if they deteriorate to the point where they are gasping – will anything that we do make a difference to the final outcome? Or will it just prolong the inevitable? Are the medication and fluids that I am prescribing killing them just as much as their disease? We can’t monitor electrolytes, there is no potassium to add to fluids and we can’t check gentamicin levels. Will they just die during the night anyway when they are not getting monitored? (On a separate issue – is this why it can be so difficult to motivate the staff to do things at times? – do they know the child will die anyway, sowhy bother?)There are many children here who would be ventilated in a (proper) PICU or neonatal unit at home. At what point do I think, nothing I can do here will make any difference–would it be kinder to this child, this family, (and very sadly, a better use of resources) to withdraw care and allow the child to die with dignity?Yesterday morning when I went into the S-C-B-U one of the babies with presumed septicaemia had deteriorated markedly overnight. He was profoundly jaundiced and had bruising on his body. He was febrile. He had irregular respirations and occasional gasps. His heart rate was good. He was unconscious. After assessing him and checking his blood sugar (which was normal) it seemed that he had a very poor prognosis, given the limitations of our resources. His parents told the nursing staff they wanted to take him home with them. They knew he was really sick and would die quickly without his oxygen and IV dextrose. I don’t know how much longer he would have survived with it. I could understand why they wanted to take him home. His father put a thumb print to sign he was discharging his son against medical advice. They left.How long should I keep going with resuscitation? Also when I arrived yesterday morning one of the nurses was bagging a baby (this was all going on at the same time). This baby had been admitted yesterday, with a history of meconium aspiration. His saturations were about 60% for most of yesterday. I expect he had PPHN (sorry about the medical chat– translate this as “he was very sick”). Mohammed had been bagging him for about half an hour. He was gasping only intermittently and had made no spontaneous respiratory effort in response to the resuscitation. However, his heart rate was still good. How long should we keep going, knowing thatthere is no ventilator, no inotropes, no nitric oxide, no ECMO? As it turned out, his pupils were fixed and dilated (i.e. he was brain dead). Mohammed and I decided, after speaking with the relatives that we should stop bagging and allow his heart to stop.Another baby (it was a busy day!) has been admitted since Thursday. His mother died two days after he was born. She was 18 years old. To be honest I’m amazed the baby survived the weekend. He has presumed septicaemia and “birth asphyxia”. Yesterday he was really sick again. He needed a blood transfusion. His father, the poor man having already lost his girlfriend, was too underweight to donate blood. So I took him back to the blood bank to get some emergency blood (amazing what a white face and a bit of advocacy will do). The father was extremely grateful to me. The baby was still alive today. But deteriorating massively. I spent quite a bit of time going back to review him. But there are 20 something (I haven’t counted) other patients on the ward all needing attention. Five or six admissions (I lost count after a while). None of them quite as sick. Still most of them would be classed as intensive care babies in the UK. But all of them with probably a better chance of survival. What do you do?I don’t know the answers to these questions. I try to do as much as I can given the limited resources of equipment and personnel and my own limitations in knowledge and skills. For withdrawing care or stopping resuscitation, I use my best judgement at the time; take advice from the nurses and local doctors about what is culturally appropriate. In the UK we would have more fancy tests to help us come to a decision to withdraw care, and professional guidelines aiding the ethical decisions. And I wouldn’t be making the decision by myself.Baby number three was still alive when I left this afternoon. Despite the terrible prognosis, I haven’t given up hope for him, not yet. I won’t be surprised if he dies during the night. But miracles happen. Sometimes.