Personal views: There must be a better way
Authors: Jonathan Koffman
Journal: BMJ (1998)

Some years ago I became the custodian for my grandmother’s care, a woman with progressive multi-infarct dementia, congestive cardiac failure, and a litany of other medical problems, the common currency of older people. Remarkably, she coped at home, with the help of a sympathetic and pragmatic community psychiatric nurse who visited her regularly. She rarely ventured out of her second floor flat, although by all accounts residential care with regular day care sessions in the local community hospital would have been better for her. But she was stubborn and independent, and among many other more amenable qualities were the reasons we loved her. 

Recently my grandmother fell while trying to negotiate her way to the bathroom. I called for her general practitioner to attend, and he organised for her to be admitted to a local teaching hospital. It quickly became clear, while we waited in the accident and emergency department, that her condition was far more serious than I had previously imagined. She had sustained a bad fracture to her right neck of femur (no doubt as a result of osteoporosis). In addition, she was suffering from a chest infection and constipation. 

Although I was familiar with the natural consequences of falls and fractures, her rapid decline from her first night in hospital onwards shocked and frightened me. A dramatic transformation had occurred. She slipped into a semiconscious state and her confusion exacerbated. Ideally, an immediate operation to set her femur followed by a period of rehabilitation would have offered some hope for a good prognosis, but no operation would be performed while her chest infection persisted. Instead she remained in traction and we all waited. 

In the days that followed her condition worsened still further. Her periods of lucidity became less frequent and the window of opportunity to operate looked more and more remote. Her kidneys began to fail and she looked visibly distressed. She was giving in. Several unsuccessful attempts were made to place a central venous pressure line in her neck to monitor her fluid levels which were now a source of concern. 

I discussed her condition several times with the senior registrar and junior doctor allocated to her in order to determine what their care objectives were, as the goal posts seemed to have changed so much since her admission. They suggested that a new antibiotic should be tried for her chest infection followed by a strict regimen of physiotherapy. The pursuit of an operation continued. 

I hesitantly began to question the care she was receiving from a dedicated and professional medical team. This culminated during one visit in my pleading passionately with a junior doctor that any active treatment be terminated and that her condition, and importantly her pain, visible in her distress, be palliated and controlled. I wanted nothing more than for her to be comfortable, and I believed unconditionally that she would have wanted the same. I was warned that the progression from milder forms of analgesia for her fracture to stronger opioids might repress her breathing and quickly kill her off. My requests were ignored. 


My grandmother’s last few days were a nightmare. Visiting her, already distressing, proved to be intolerable. She contracted methicillin resistant Staphylococcus aureus and was placed in a single room, isolating her from the rest of the ward. Her last day in particular was tragic: she spent the best part of it travelling in lifts, waiting in anonymous corridors, the end result of which was to have a line placed in her chest. I believe the intervention was misguided and proved to be futile. I arrived in the early evening and helplessly viewed her last moments of life. As I sat silently I was overcome with feelings of guilt and anger. My grandmother had been denied a good death, not as an act of charity but as an act of justice. The junior doctor who certified her death some time later that evening looked awkward and quickly left the room. 


“My grandmother’s last few days were a nightmare”



I believe death in acute settings is often viewed as an enemy and a failure on behalf of healthcare professionals. Recognising that death is a reality and often a welcome friend must gain wider acceptance, and with it greater support for those patients and their families and friends who require a different language of care and set of skills. Understandably, problems do arise because the prognosis of dying is often made after exclusion of all reasonable interventions. Thus the moment at which death can be predicted with certainty is often closer to the actual event and there is a shorter time for the provision of more appropriate care. This, however, should not be an excuse not to act in the patient’s and family’s best interests. The status quo has the potential of being iatrogenic to all involved. 

It has been argued recently that care and management of symptoms in dying patients need to be reframed, whereby all elements of treatment and care of an individual are systematically taken apart and scrutinised in order to determine their usefulness or ability to hinder healing, adjustment, or alleviation. The patient’s situation is then looked at afresh, and new and different approaches—for example, palliative care—introduced where necessary. The need, as opposed to the want, for this pragmatic philosophy of care in acute settings is clearly evident.