For better or for worse, trauma surgeons often cultivate the aura of the stereotypical hero surgeon who operates in hectic and fast-paced environments with lots of shouting, off-the-cuff decision-making and fearlessly dragging people back from the brink of death no matter how unlikely the odds of survival. And some surgeons, perhaps egged on by this imagery, do try to live up to it.
We’re now better equipped than ever to salvage the previously unsalvageable patient. People who would have died in the street 10 or 15 years ago are now making it into resus, into theatre and onto the ICU. But at what cost? We seldom have the luxury of knowing what a patient’s core beliefs are and how this might influence the value they place on being fully independent as opposed to paralysed and reliant on carers 24/7. The indignity of relying on someone else for personal hygiene or the loss of the simple ability to take a walk to the park cannot be underestimated. Many patients would rather be dead than lose their independence, hence the enduring allure of Swiss assisted-suicide clinics.
I recall vividly the young man who stepped out in front of a train and was brought into my trauma centre with traumatic bilateral hindquarter amputations. Coincidentally, the incident had taken place at my local rail station where I had gotten the train to work that very morning. As we formalised his traumatic amputations and performed a crash laparotomy on him to gain proximal vascular control, I couldn’t help but think that if this guy was already at such a nadir that he sought to kill himself in such a gruesome way, then how will his mental state be improved by waking up to find he has no legs and a stoma? Of course, there are questions of mental capacity and whether one can truly weigh up the pros and cons of wanting to live or die when in the throes of depression. But what of the young TBI patient doomed to be left in a vegetative state or with locked-in syndrome, never again able to fully communicate their wishes. Despite the emotions involved, the decision to operate can’t be influenced by the clinician’s hunch as to whether a person wants to be saved.
Perhaps all of us, young and old, fit or otherwise need to have in place some kind of advanced directive that states that we should be left to die in the event that a major traumatic injury leaves us with significant disability and a diminished quality of life. Perhaps we ought to engage in this difficult discussion with our loved ones beforehand akin to the way we ought to talk about organ donation. The definition of ‘significant disability’ and ‘diminished quality of life’ is a highly subjective one and therefore must be determined by the patient when they’re of sound mind and body before any tragedy strikes.
Last month the British Medical Association moved to adopt a neutral stance on assisted dying which it had previously been opposed to. Such a paradigm shift is indicative of a gradual change in societal attitudes. It also acknowledges that there is nuance to life and death and that preserving life at all costs may not always be in a patient’s best interests. It’s hard to see how this discussion could be incorporated into to a fast-moving trauma resuscitation scenario, especially when many patients show up in the trauma bay without a name, let alone a detailed précis of their wishes and expectations for quality of life. Furthermore, the extent of their injuries and the long-term sequelae are often unknown in the initial hours and days.
We still must fix what’s in front of us and act in what we deem to be the patients’ best interest, which for most cases (especially the younger, healthier trauma demographic) means pulling out all the stops to keep them alive irrespective of injury severity. However, it doesn’t stop us having the conversations and keeping in mind that life is an experience that means so much more than simply having a cardiac muscle that beats.