The Vasectomy Doctor (23 page)

When you have a decent salmon on a single-handed rod you must make sure not to horse him but to let him run while always keeping in touch, never let your line slack but do not haul on it either. All my fishing companions on this stretch of the Moy are seasoned anglers and are well aware that I am only a doffer. But they kindly take me in. Soon a man is by my side with a landing net at the ready wanting to know if I have ever done this before. When I tell him that this is my first he is full of gratuitous advice and help. Anglers, like all proper sports people, help each other out. After about six minutes, during which time my salmon runs three times but never all that far, the fish flounders and I can lift his head out of the water. At this stage my helper slips the landing net under my catch and we have him on the bank, all five and a half pounds of him. This is a great country and thank you Mayo for my first real decent wild fish.

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During my time living with Joan in Ballsbridge I became involved in a strange way with what was referred to then as the ‘right to die' case. This was during the long hot summer of 1995. But I need to go back to the beginning.

Sometime during the spring of 1972 a bright and pretty young Dublin woman, well-educated and in the prime of her life, was suffering from painful periods or dysmenorrhoea as we call it in this profession. She was twenty-two years of age. About eighty per cent of all young women suffer from painful periods at some stage or other of their lives. Most of these women manage to keep going by taking something like Paracetamol for the first few days of their periods. In about ten per cent of young women however the degree of menstrual cramping can be so severe and incapacitating as to make it impossible for them to keep going and they may have to take to the bed or otherwise rest themselves holding a hot water bottle to their
tummies. Thus they may have to miss out on school or work for a few
days each month. Such young women therefore may need stronger treatment than simple over-the-counter analgesics. This young Dublin woman was such a case. She went to see her GP and he referred her to a conservative obstetrician gynaecologist. This was a bad mistake on behalf of the GP. Some GPs are in the habit of always playing it safe and referring anything more serious than the common head cold to specialists. Our young woman going to see a gynaecologist in April 1972 to treat her dys-menorrhoea was unwittingly heading towards catastrophe. The GP should have been able to treat her himself. This is not rocket science. The standard treatment for severe dysmenorrhoea back in 1972 was then, as it remains to this day, the oral contraceptive pill. By blocking ovulation you can stop painful periods in their tracks. You might think that this kind of treatment was ‘too severe' but remember, if someone has menstrual cramps so severe as to render them incapable of going to school or work for two or three days a month, then treatments like the oral contraceptive pill are absolutely justifiable in the eyes of most reasonable doctors.

Unfortunately her GP did not take this view. Even as late as 1972 there was tremendous resistance among many Irish doctors to prescribing ‘the pill' to unmarried women, particularly to sexually inactive unmarried young women. There was this ridiculous notion abroad that such prescribing could promote promiscuous behaviour. Whether it would or wouldn't is not the point and in fact is none of
the doctor's business. The doctor's business is to treat the painful peri
ods in the safest and most effective way possible. And prescribing the oral contraceptive pill is in most cases just such an approach. But our GP in this disastrous case flunked it and took the easy way out and kicked for touch. He decided to refer the young woman to a gynaecologist – a decision that was to have catastrophic consequences.

Gynaecologists operate. That is their stock-in-trade if you like, it is what they do. So the gynaecologist decided to perform a D&C on her. A D&C, or dilatation and curettage, is an operation on the womb where the cervix is dilated to allow an instrument inside to scrape away the womb's lining or endometrium. As a treatment for dysmenorrhoea, even back in 1972, it was already long outmoded, dangerous, ineffectual and totally inappropriate. But in this case it was to be much more than any of these things: death or, worse still, near death. She never recovered from the anaesthetic. During the operation she suffered from three cardiac arrests or heart stoppages. Each of these resulted in her brain being starved of oxygen for prolonged periods of time.

When the anaesthetic gases were eventually removed and efforts were made to bring her around she did not respond. Instead she lapsed into a deep coma or what is usually referred to as the ‘persistent vegetative state' or PVS. To be strictly accurate about it in fact she was in a near-persistent vegetative state. Because she seemed to have glimmers of cognition in being able to perhaps recognise some of her long-term carers her condition was thought to be something slightly less than PVS. You might think that this was somehow good news. But it wasn't, quite the reverse in fact. It raised the possibility of her being vaguely aware of her predicament, which of course would have made her life intolerable. But things were to get even worse than that.

The poor girl's parents complained that they were given little or no explanation as to what had happened, why it had happened, what they were to expect or what the future would hold for their lovely daughter.

And so this once bright and beautiful young woman lay on a hospital bed sometimes on the flat of her back staring, perhaps unseeingly, up at the ceiling, totally paralysed and motionless except for her steady breathing and the darting movements of her eyes. Her carers had to turn her from one side onto the other to prevent her from developing pressure sores. She had no speech. She was unable to swallow. She could give no signal of thought or feeling other than an occasional despairing moan. She was trapped in her frozen world of deep unconsciousness, alive but unable to move, with no evidence of awareness of self or environment. Her wakeful unconsciousness had no real prospects of any meaningful recovery. To be kept in this state her minders had to insert a urinary catheter into her bladder and a naso-gastric tube down into her stomach through which she was to be fed and hydrated three times a day with a tasteless nutritious soup.

In the very best of medical institutions where highly trained and skilful surgeons and anaesthetists work with the best of nursing staff and where superb ancilliary help is available these things do and will happen. These are the rare but real complications of general anaesthesia. It would be very wrong of me to attempt the proportioning of any blame to anyone in this awful case. Any doctor, even the very best and kindest of them can find themselves in a situation where someone they are trying to help takes a turn for the worse and is left, by complications of treatments, much worse off than they were pre-treatment. Most of us have found ourselves in that situation at least once in a long, active, professional life. It is very much a case of ‘there but for the grace of God go I' and I do not wish to be seen as smug or as pointing the finger at anyone. But I have talked at length to the mother of this young woman and it is clear from my conversations with her that the real problem lay, not so much in the awful tragedy itself, but rather in the lack of any meaningful communications between carers and relatives.

I am not suggesting for one minute that the management of near PVS is simple and straightforward because it is no such thing. Diagnosis can never be absolute and prognosis is always fraught and uncertain. People have been in these states for several years and been known to recover at least partially. But today we know that the relatives of the person in a PVS simply have to be brought into the equation. In as far as possible an explanation should be given as to why it happened and what, if anything, went wrong. There must be no attempt at a cover-up or of anything that might be construed as a cover-up. In addition to this the relatives must be involved in a management strategy and in the decision-making as to how long treatment should go on and to what lengths they should go to keep the sufferer alive. But in this case none of this happened. The young woman's parents were kept in the dark and excluded from all decision-making.

On several occasions the patient developed urinary tract infections as a result of her having to have an in-dwelling catheter. Each of these was treated with antibiotics without discussing it with the family. After twenty years it was decided to insert a gastrostomy feeding tube under general anaesthetic. This was done without discussion with the family. This tube fell out on two occasions and was replaced again without reference to the family. But what was worst of all is that on no occasion were the parents and siblings of the young woman brought into a room and sat down and allowed to express their concerns and to be given a chance to have an input
into an overall treatment plan that might envisage eventual closure.
That simply never happened. The carers' only plan was to keep the patient alive for as long as ever possible. They claimed to have had an ethical duty to do so.

The family eventually felt that they had no option but to seek legal advice. The first thing they were advised to do was to make the young lady a ward of court. As a ward of court her future would be decided, not by the carers anymore, nor by the family but by the courts of the land. Or, in other words, the courts would stand
in loco parentis
and decide what was the best line of action, what was in the patient's best interests – to go on being fed and hydrated through the artificial means of a gastrostomy tube or to allow for the discontinuation of this method of forced feeding and allow the patient to die? The request to make the patient a ward of court was granted in 1994. From here on in, during court hearings, she was to be referred to simply as ‘the ward'.

The next High Court hearing was held in-camera during May 1995 and on 10 May Justice Lynch delivered his verdict, the essence of which was as follows:

– Allow for the discontinuation of feeding via the gastrostomy or naso-gastric tube.

– Allow for the non-treatment of infections and other pathological condition save where pain relief might be required.

– Authorise the family to move the ward to another institution where withholding nutrition was not held to be unethical.

But the carers and the institution where the ward was being cared for decided to appeal this High Court decision to the Supreme Court. On 27 July the Supreme Court delivered its verdict which was essentially to uphold the High Court decision from earlier that summer. I attended all of this hearing as a medical journalist with the
Irish Medical News
and it was at this stage that I first became aware of the family and the long tortuous journey that they had all made over the previous twenty-three painful years. And it wasn't over yet.

After all of this, having had to watch their precious daughter or sister suffer on needlessly for twenty-three long and agonising years at the hands of well-meaning if somewhat blinkered carers, having made her a ward of court and then going through the distress of a High Court hearing followed by an equally stressful Supreme Court hearing, after all of this they were still not out of the woods. No, now they could not find an institution that would take on the case and carry out the legal discontinuation of the tube feeding. Nobody wanted to know about it. It was at this stage that the ward's mother, to know if I might be able to help through my good offices at Clane General Hospital, approached me.

To be honest I did not want to ask my colleagues in Clane Hospital to do something that they may not have been comfortable
with or to put them in a position where they may have had to say no.
In any case at this stage both the family and I were coming to the same conclusion. The only way and the kindest way forwards was to bring the patient back to her own home where I was to remove the gastrostomy tube and allow her to die surrounded by her loving family. And that's what happened but it wasn't before there
was to be a final glitch, this time emanating from the Medical Coun
cil.

This whole right to die case attracted huge media attention as you can imagine. In the immediate aftermath of the Supreme Court ruling journalists approached some of the more conservative members of the council's ‘fitness to practice' committee. At least one of them, speaking I think to be fair about it on his own behalf, opined that any doctor who would co-operate in the discontinuation of nutritional support for the ward might be deemed guilty of serious professional misconduct and be struck off the register. But I had to balance these kinds of threatening rumbles coming from high quarters with the facts on the ground as I saw them at the time. Those facts were that here was a mother and family who had suffered twenty-
three years of the most terrible anguish and pain imaginable,
largely at the hands of the medical profession. Now the highest court in the land had at last declared it legal to bring closure and peace and an end to their suffering. If there was anything I could do to help them then I felt duty bound to do so.

Three days after I deflated the retaining balloon and with shaking hand withdrew the gastrostomy feeding tube from deep inside the comatose woman's abdomen, she passed away peacefully and quietly, surrounded by her family and those fantastic nurses who lovingly and so professionally cared for her during her final hours. May she rest in peace.

* * *

My children are now adults living independent lives away from home while Joan and I happily rattle around in this hopelessly impractical old Georgian house. I have sold my general practice to younger blood. At this stage vasectomy has become more or less a full-time job and I certainly do not need the stress and hassle of GP work anymore. People are congratulating me on my ‘retirement' and I am at pains to point out that, just because I have given up general practice, this does not at all mean that I have retired. In fact I do not believe in or like the concept of retirement and believe that a man needs to have a good reason to get out of bed every morning. It's either work or wilt and I'd prefer to work. So when well-meaning people congratulate me while mistakenly thinking that I had gone and done something that, as it happens, I do not believe in, they are in effect being mildly offensive – without meaning to be of course.