How Do You Know When To Turn Somebody Off Support And How Does An Anaesthesiologist K

**RonaldoVII** · 06-10-2009, 12:48 AM

How Do You Know When To Turn Somebody Off Support And How Does An Anaesthesiologist Know How Much To Give?

See, last weekend I had the opportunity to view some areas of the hospital. I was shadowing a consultant and some scrub nurses. It was on Friday night and a patient presented to the A&E with serious head wounds and flail chest after his car swerved out of the way of a drunk driver and hit a tree at 60mph.

At the time, the consultant was busy in surgery. I followed the patient get ready for surgery. The doctor I was with had to begin unsupervised because there was only one consultant on so I was wondering does this happen often? Are you expected to somehow know what to do even without completing training? This doctor was apparently in his first year of trauma training btw.

This is where the anaesthesiologist question comes in. How did the anaesthesiologist know how much to give? He hadn't met the patient previous to that, he swanned in and simply waved his magic wand. So, do anaesthesiologists have some kind of magic power?

The next day I followed the same consultant and the patient was officially brainded. They had explained all this to his family, and they agreed that they would rather have their husband/father/brother being whole than a braindamaged shell that didn't recognize them.

I know the basis that you're supposed to turn the life-support off when the patient becomes braindead, basically to free up beds because the managers are the ones that really run hospitals.

But, if your relative was braindead, would you let them turn off the life support?

I'm sorry that this is more of a rant, but these questions still remain unaswered and are irritating me. But, they are genuine questions.

**House Jr.** · 06-10-2009, 01:26 AM

when you turn off life support ,its called euthanasia or assisted suicide. i'd personally not turn it off but interesting story.

**Spencer Wells** · 06-10-2009, 01:40 AM

Originally Posted by House Jr.

when you turn off life support ,its called euthanasia or assisted suicide.

You're talking absolute rubbish. I suggest you look up the definitions of both in a dictionary mate.

A doctor is only obligated to offer medical treatment that they feel is necessary and in a patient's best interest. If artificial ventilation is not felt to be necessary or in the patient's best interest then there is no legal or moral obligation to carry on treatment. Withdrawing unnecessary treatment that is not indicated is no different from me not offering someone with a cold antibiotics.

**Leo2004** · 06-10-2009, 02:09 AM

Originally Posted by Spencer Wells

A doctor is only obligated to offer medical treatment that they feel is necessary and in a patient's best interest.

Well said!

A very core idea in medicine, imho...

**House Jr.** · 06-10-2009, 02:13 AM

Originally Posted by Spencer Wells

You're talking absolute rubbish. I suggest you look up the definitions of both in a dictionary mate.

A doctor is only obligated to offer medical treatment that they feel is necessary and in a patient's best interest. If artificial ventilation is not felt to be necessary or in the patient's best interest then there is no legal or moral obligation to carry on treatment. Withdrawing unnecessary treatment that is not indicated is no different from me not offering someone with a cold antibiotics.

sorry my bad, wasn't really paying attention. but i guess it would be some form of euthanasia.

**Leo2004** · 06-10-2009, 02:26 AM

HouseJr,

Euthanasia is when you do something like decide to end someone's
life based on a criterion (cf. the nazis t4 euthanasia programme) or
as a doctor when you decide to give someone a dose of morphine
with the intent to end their life.

Assisted suicide is when someone lets you know they want to
kill themselves and asks you to help them, and you do it.

Turning off a ventilator (a.k.a "life support machine") if a patient
is brain dead and no further treatment is in their best interests,
is not euthanasia.

Hth

**Spencer Wells** · 06-10-2009, 12:07 PM

Originally Posted by House Jr.

sorry my bad, wasn't really paying attention. but i guess it would be some form of euthanasia.

Euthanasia is taking an active step to end someone's life. Withdrawing treatment is passive (because you not starting something, like injecting a morphine, you're stopping something - a ventilator).

If you think switching off life support is euthanasia, House Jr. and therefore "bad," do you propose that we do absolutely everything we can for absolutely every patient in order to keep them alive? Do you not think that for someone in immense pain dying of cancer this represents cruel and unusual punishment? How do you propose we fund such a system?

Everyone dies at some point. It is a certainty. Prolonging the inevitable is something that can actually cause more harm than good.

**PeteG** · 08-10-2009, 02:17 AM

To answer a couple of RonaldoVII's questions, the amount of anaesthetic given for the induction (and indeed maintenance) can either be calculated on a mg per kg body weight, or can be given according to effect - that is, when the patient is asleep, you stop giving the drug (this is a skill only gained by doing plenty of anaesthetics). The amount of drug needed varies quite a bit between individuals and depends on various other factors, including what other drugs have been given, the age of the patient and factors like alcohol intake. In the situation you describe I'm fairly sure that a gentle anaesthetic was all that was needed but that drugs were given to try and obtund the laryngeal response - this means that the increase in blood pressure that occurs during intubation was best avoided in order not to increase the intracranial pressure. Maybe you should find the anaesthetist (or any anaesthetist) and ask them what was going on.
With regard to the issue of brain stem death, you really need to look up the specific criteria that defines this condition. Far from being a "shell" that wouldn't recognise relatives the brain stem dead individual has absolutely no level of cognition and in fact cannot breathe on their own because the part of the brain that governs this no longer functions. Their body will cease to function once ventilatory support is withdrawn. You don't "free up beds" by withdrawing treatment, you simply allow nature to take it's course because there is no treatment available that will change this situation.

**andy2** · 11-12-2009, 04:27 PM

Pete is correct - adjust the dose to the patient, involves a bit of judgement and titrating drugs to response.

Brain death is death, as surely as one's heart stopping is death - ceasing to treat a dead person is not 'freeing up resources', its just stopping doing something utterly pointless. This is different from withdrawing care - if someone is alive but very unwell it may well be decided that further therapy is pointless, as it will not alter the final outcome (death) and involves placing further burdens on the patient (Intensive Care is not a nice place to be). Indeed withdrawl of organ support is one of the commonest modes of death in intensive care, just because we can keep people alive does not mean we should. This is not the same as actively killing people as in the case of euthanasia or assisted suicide, it is withdrawing therapies which are no longer effective.