Only a miracle

So now the Telegraph is reporting that the doctors caring for Michael have told his family that “only a miracle can save him”.

1) doctors, no matter their spiritual bent, do NOT talk to patient’s families about miracles saving anyone. Ever. From a practical viewpoint, this gives a patient’s family absolutely NO useful information on which to act. It provides hope, yes, but not for anything with any medical reality. And this hope will then cloud all subsequent decision-making.

A statement like this is more than ambiguous – it lets each recipient interpret it in his or her own context, the opposite of clear precise information. What would the care team mean with a statement like this? Are they saying “let’s wait a bit more for the miracle”? Or are they saying “miracles don’t happen in reality so we’re pretty much out of hope”?

I can only guess that what this report means by “save” is “recover sufficiently to have meaningful interactions with his loved ones”. So you see why this is kinda a dumb thing to say. And why it is impossible for me to imagine doctors EVER communicating like this with a grievously injured patient’s family.

If something like this WAS said, I can only try to “reverse engineer” it, and from there consider what they were saying and how it’d be said.

1) If there is now clinical, radiologic, physiologic and other data that leads to the conclusion that a resumption of any meaningful consciousness at all is impossible (see? no mention of miracles), they would be VERY unambiguous with this. In a situation like this, there must be no guesswork – NONE on the part of the medical team, who need to put the data together and reach an unquestioned and unquestionable conclusion. In this situation, ANY ambiguity in communication with the family is disastrous. They will often cling to any hope left, and this conversation is going to be, tragically, THE conversation that finally (and gently and compassionately) needs to remove all hope. This is crucial. If the message is misunderstood, it will almost inevitably lead to major problems, conflicts and tension subsequently.

Let me just say here that medical ethics allow, and virtually require, doctors to refuse to provide treatments they reasonably consider to be futile. My neighbour cannot show up at the hospital and demand that a surgeon remove her appendix. And in the above situation, where there is incontrovertible evidence of damage so severe as to make resumption of consciousness impossible,  doctors can certainly undertake the process of “therapeutic de-escalation”. Even if the patient’s family insists that “everything be done”, if there is NOTHING left to be done, there is no requirement to do anything more. At that point the patient’s family can make other care arrangements. It’s obviously critical to avoid this kind of situation, so once again you see the need for perfectly clear, concise information, with no ambiguity. Families need time to accept this, whether it’s in intensive care, or oncology, or genetic anomalies, and so on. But with open honest and clear communication, this will happen.

Please note that this is NOT the situation for a patient in a persistent vegetative state, at least not necessarily. This is the situation for a patient whose condition is even WORSE. The essential point is that the impossibility of recovery has to be as certain as current medical science can be AND that this certainty be transmitted to the family.

2) if the clinical situation is desperate, but not without all hope, the family would be told this, with as close to numerical precision as possible. In a situation where there is hope, it mustn’t EVER be taken away. On the other hand, families need to know, at the most basic level, that most patients like this get better, or that a few get better, or that really VERY few do. That 60%, or 20%, or 1% get better. No talk of miracles.

As I mentioned a few posts ago, if this conversation has happened, if Michael’s family has been told that it is extremely unlikely that he recover “satisfactorily”, then it is quite possible that the “several steps of separation effect” between hospital personnel and the press could have led to this kind of language appearing in these articles.

And again, despite a day during which we’ve been told Michael is breathing on his own AND that it would take a miracle to save him, we know nothing more than we knew yesterday or the day before.