Withholding and withdrawing in real life

With an average of one patient deceased every six hospitalizations, in my 25 years as an intensive care doctor I have been often forced to face death. Many times, I found myself deciding whether and when it was appropriate withholding or withdrawing life-support treatments when they proved futile. As any Intensive Care physician or nurse, I was trained in the use of extracorporeal prosthetic techniques, which replace vital functions. In ICU we continually use mechanical ventilation, extracorporeal circulation systems, dialysis, and many, many drugs. Death can be postponed to a limit that was unimaginable a few decades ago. During my years as a resident in anaesthesia and intensive care, I absorbed an alternative way of seeing the functionality of the organs. Working shifts in intensive care are very long; doctors in training and their mentors live in strict contact, in a closed system that is constituted as a whole world of experiences, full of objects that are not part of everyday life. This “unnatural” condition, the availability of advanced technologies that prolong life and the contemporary and frequent contact with death, make it very difficult an open and conscious discussion of end-of-life decisions with other doctors and with relatives. I am sure that the greatest difficulty I have encountered in my work is the impossibility of speaking or communicating in any way with my patients, to be able to cure them according to their free choices on the therapy to be undertaken. Unfortunately, the vast majority of patients who die in ICU are not able to express their wishes in relation to invasive care. In Italy, the so-called “living will” or “early declarations of treatment” is not a widespread practice nor is it an imperative for the doctor who treats a patient who is not able to express his consent or his will. The ICU doctor, young and inexperienced or full of experience and responsibility, must try to “guess” the will of the person who cares and, to apply those choices that she or he would have shared if they were able to express their will, can only address his/her family. In Italy, relatives do not exercise any legal right to decide in place of the patient but are considered witnesses of the patient’s will. With Mr. Antonio’s daughter, this kind of approach did not work, to the point that two Carabinieri showed up on Friday night to check that all of us, doctors and nurses, were not abusing our power over life or death. Mr. Antonio, immobilized in his bed with a decidedly poor prognosis for more than a year, had already been the object of