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INSIDE THE ETHICS COMMITTEE

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RADIO 4

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TX DATE:听听听听听听听听听听听听听听听听听听听听听听听听听听听听听 THURSDAY 14TH JULY 2011

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PRESENTER:听听听听听听听听听听听听听听听听听听听听听听 JOAN BAKEWELL

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CONTRIBUTORS:听听听听听听听听听听听听听听 DEBORAH BOWMAN

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PRODUCER:听听听听听听听听听听听听听听听听听听听听听 BETH EASTWOOD

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NOT CHECKED AS BROADCAST

Bakewell

Ethical dilemmas present us with heart-breaking choices.听 None more so than when a woman who yearns for a baby is struck down by a life-threatening condition.听 In Anne's case events moved fast and confronted her medical team with issues of life and death.听 It is winter 2009 Anne has a cardiac arrest at home.听 Her husband, James, resuscitates her until the ambulance comes.听 By the time she arrives at A&E she is unconscious.听 She's put on life support but has a second cardiac arrest.听 She's given drugs and stabilised.听 The critical care doctor in charge:

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Critical care doctor

She was admitted to intensive care.听 She was being kept asleep to allow her chance to recover from her heart having stopped and having suffered a lack of oxygen for a period of perhaps 20-30 minutes overall.听

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Bakewell

A few hours later Anne shows signs of responding.听 She opens her eyes, takes some breaths on her own, her reflexes are working - this is good news, indicators that she is not what's called brain stem dead.听 But Anne is different from most cardiac patients in several respects.听 For a start she's only 35 years old.

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Critical care doctor

Anne had been born with a complex heart problem which had necessitated a number of operations during her life. 听So we contacted the specialist centre where she had been treated for advice from them as to what complications we needed to watch for in particular and how we might treat them if they arose.

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Bakewell

Complications do arise.听 The following afternoon Anne starts having seizures.听 She's given anti-seizure medication and some sedation to make her more comfortable.听 The following days are critical.听 On several occasions her medical team don't expect Anne to survive but even so they do not give up.

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Critical care doctor

Younger people have a much better recovery overall than somebody who was much, much older than them.听 If Anne had been an elderly patient and in similar neurological state then we would have aimed to get her to a stage where she was able to breathe completely on her own and withdraw any support for her breathing and not reinstate that, should it be required.听 But because Anne was very young and we were not sure of her long term recovery we continued to support her breathing longer than we might have done.

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Bakewell

But there is another major consideration:听 Anne is 17 weeks pregnant.听 So all sorts of obstetric concerns arise.

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Obstetrician

As an obstetrician my prime care, believe it or not, is actually to the mother.听 We clearly had a major anxiety for Anne's life and Anne's wellbeing in that Anne could easily have another cardiac arrest which would mean that we would not potentially very sadly have to worry about long term care for a baby should Anne die in the next few days or weeks.

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Bakewell

But Anne doesn't die.

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Obstetrician

We were suddenly faced with the realisation that actually Anne was going to live for the foreseeable future.听 We clearly didn't know what her long term prognosis was but we had to make a decision regarding the baby.听 Our main question was how much of an insult the baby had taken in terms of lack of oxygen supply to the baby in the womb.听 We undertook an initial ultrasound scan and the baby was alive, the foetal heart rate was present and at that stage we could not tell the difference between the pregnancy inside Anne's womb and any other pregnancy that was normally progressing and so we were at that stage slightly reassured.

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Critical care doctor

We also, right from the start, needed to consider treatment, medication, for example that might affect the baby, particularly in this early stage of her pregnancy.

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Bakewell

Here the dilemma intensifies.听 While rightly considering the impact of her condition on the baby the doctors are also aware that the foetus itself poses a risk to Anne's life.

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Obstetrician

Pregnancies, unfortunately, are risky businesses, add into this the issues of a potential major maternal cardiac abnormalities and a pregnancy can increase the risk of the mother dying.

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Critical care doctor

On a daily basis we anticipated that there might be severe complications that would lead either to a massive bleed that we couldn't control or another cardiac arrest.听 Because we were conscious of the risks imposed by pregnancy upon Anne we did discuss whether or not we should consider terminating the pregnancy on the grounds of Anne's health.

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Obstetrician

Having said that there were potential risks of considering termination of the pregnancy.听 She could bleed to death from a termination because of the complex drugs that she was on.听 The alternative is to stop the drugs for her clotting risk increasing her risk of clotting.听 So unfortunately she was between a rock and a hard place at this point.

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Bakewell

So should they terminate the pregnancy to save Anne's life?听 Anne is unconscious so they can't ask her but they can consult her husband James and mother Jane, who's nursed her through several childhood heart operations, they both explain that this is a very cherished pregnancy, Anne and James had been warned the pregnancy would be risky but had nonetheless planned over a year with medical advice to go ahead.听 Seven days after Anne's admission a neurologist comes to assess her brain injury, her doctor stops her sedation to make this possible.

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Neurologist

She was able to open her eyes for an increasing period of time and she had some movements in her limbs but very little.听 She didn't give any indication of recognising her family or responding in any way to anything we did to her.听 We were quite concerned for her long term outcome but we were aware that it was very early days.

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Bakewell

And then just another three days later Anne has a major internal bleed, it calls for a number of transfusions, Anne's life hangs in the balance.听 At this point some of her medical team are uncomfortable with the amount of treatment Anne is receiving, she already has a massive brain injury and life-threatening complications, so what lengths should they go to to keep her alive and how does her pregnancy influence that decision?

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Neurologist

The fact that Anne was pregnant, albeit fairly early on in her pregnancy, led to a number of discussions as to how much we should take that into consideration when we were considering what treatment we would or would maybe not give to Anne and I think it's fair to say at this stage there was already fairly divided opinion amongst staff.

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Bakewell

Here to discuss the dilemma so far are Dr Andrew Hartle, a critical care doctor at Imperial College Healthcare NHS Trust and a member of its ethics committee; Rosamund Scott, Professor of Medical Law and Ethics at King's College, London, who specialises in the legal and ethical issues in reproduction and Deborah Bowman, Senior Lecturer in Ethics and Law at St George's University in London.

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So Deborah, who decides when the patient can't decide?

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Bowman

It's a vex question.听 Occasionally there will be a third party who can decide, so if there were lasting power of attorney, there isn't in this case.听 It may be that there's an advanced decision in place, there isn't in this case.听 So all the team can do, as they're rightly doing, is try and get a sense of what would be in Anne's best interest.听 The ways in which that is done are talking to families, talking to James, talking to Jane - both of whom will know Anne well. 听It sounds as though there's a sense of this pregnancy having been a much wanted pregnancy.听 The other factors are of course the medical implications of what's happening and the clinical risks and benefits.听 And all of those factors are supposed to be weighed to give us some sort of approximation of best interest.

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Bakewell

But family - you know husband, loving mother who's seen her through so many operations as a child - can they make a wise decision?

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Bowman

We're not asking them to make a decision, what we're asking for is a sense of who Anne is and what Anne would want.听 I think most of us would recognise that we exist not as self-contained atoms but we exist within families and groups and we look to our families and friends to advocate us, to support us and we also recognise that they have an investment in what happens to us.听 So perhaps borne of those relationships they have an investment but it's not a decisive role to play.

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Bakewell

Right now Andrew you bring in the medical view of this and Anne is not brain stem dead, what does that mean?

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Hartle

Well brain stem death is a catastrophic brain injury where the patient is unable to breathe for themselves and when the brain stem dies in the Western World that's certainly considered the same as being dead.听 So the fact that she isn't brain stem dead and we know that because she's taking spontaneous breaths, she's moving indicates that although she's had a severe brain injury it's one that is potentially recoverable from but it'll be a long time before we can tell how much she can recover.

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Bakewell

Now there's another phase that crops up around this issue - the persistent vegetative state, PVS, what's that?

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Hartle

A persistent vegetative state is where the patient is unresponsive to their circumstances and that's one of the worst outcomes after a cardiac arrest.听 But because of the brain's incredible ability to recover and because it takes so long to find out one wouldn't be making a diagnosis of persistent vegetative state for months or even years.

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Bakewell

So what you've heard of Anne's state, what do you make of that?

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Hartle

She is showing signs of response.听 I mean after people have had a cardiac arrest and they've had a brain injury all you can say is it's too early to say.听 And I think the point was well made - in somebody of Anne's age that we're not talking about someone in their 60s or 70s, we're talking about somebody in their 30s.听 So none of us could predict how well she will recover.

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Bakewell

Now Rosamund Scott you deal with the moral concerns about this, how much has Anne's pregnancy influenced the decisions that are being made by all her medical staff and advisors?

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Scott

That's a very good question and obviously this is an incredibly fraught scenario.听 Perhaps it's helpful to start by separating the legal and the moral and what might be thought to be a rather curious thing is that foetus itself doesn't have any legal status or legal personality and that means that its interests can't be legally asserted against Anne.

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Bakewell

Does that apply throughout the pregnancy?

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Scott

It applies throughout the pregnancy and the reason the law has taken that position is essentially to avoid coercion of pregnant women in a variety of contexts because once you have the position that the foetus is a legal person it's possible for people to try to assert the foetus's interests against the mother and the law has taken the position that that's not a wise thing to do.

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Bakewell

So a mother has the transcendent identity?

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Scott

That's absolutely right and she has - I mean if she were autonomous and able to make decisions here she would be able to make decisions which even potentially compromise, in the treatment context, the foetus.听 But of course the difficulty here is we know is she's not actually making any decisions, she's unable to do so and so we're thinking about how, if any, how the foetus's interests might be taken into account and the only way in fact that they can be taken into account is if they form part of Anne's best interests and if we decide that in some way it's in Anne's best interests that the pregnancy continue and that might be on the grounds that we hope she might recover to the extent of being able to appreciate a child, a baby, that she very much wanted.听 Alternatively if it's the case that she doesn't - there isn't the prospect of recovery well we'll have to see but it might be that we think it's still in her best interests because it's something she very badly would have wanted, so thinking about her beliefs and values and so on.

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Bakewell

You had mentioned the moral rights of the child.

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Scott

Yes, there are a range of positions one might hold about the foetus's moral status - you might think that a foetus has moral rights from conception as an embryo, you might think it has some kind of increasing claim at the point of viability, when it has the possibility of surviving outside the womb.听 You might think that the foetus has a greater claim when it has the ability to experience pleasure and pain and so on at sentience, approximately the same kind of time as viability.听 Or you might take the view that birth is critical and there are no moral claims before then.听 And finally you might take the view that the foetus's moral claims increase throughout the pregnancy but there's always going to be an issue here also about what moral duties are owed to Anne.

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Bakewell

Now the issues about - for the ethics committee - about moral rights are entirely subjective aren't they, they're often the subject of religious convictions and very personal decisions.

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Bowman

What you're trying to do is think about the range of ways of thinking about the foetus but more importantly really what you're trying to do is get a sense of how Anne understood it.听 I mean ethicists and others will tie themselves up in knots about these arguments and become very excited but what we've heard is this is a woman who very much wanted to become a mother and I suspect she's never even thought about when personhood begins.

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Hartle

And the ethics committee have the advantage that they're not treating Anne, they're not as involved.听 They're allowed to take a step back without the emotion involvement you inevitably get when you look after a sick patient.

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Bakewell

So at this point is anybody considering termination?听 Would you?

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Hartle

Yes.听 If the on-going pregnancy may make it less likely for Anne to survive then you have to seriously consider whether you should end the pregnancy.

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Scott

The big worry is of course, as Andrew said, the impact of the pregnancy on her, as long as she's not being compromised the pregnancy might be allowed to continue provided that we think that's in her best interests, we think it's what she would have wanted and there is some evidence here, as you pointed out at the beginning, that she contemplated that there were risks for her in this pregnancy.

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Bakewell

Well the medical team decides - yes it is in Anne's best interests to keep treating her.听 And given her wish to have a baby they should do everything they can to keep her alive even when complications arise.听 But a contradictory dilemma exists - should they terminate the pregnancy in the interests of Anne's survival?

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Obstetrician

The role of a doctor is rule number one do no harm - we would have felt terrible had we undertaken a termination of the pregnancy, which Anne potentially wanted, and then ended up with a complication of that termination which ended in hastening the end of Anne's life.听 And we decided not to go there.

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Bakewell

By now Anne has been in intensive care for nearly three weeks and both family and staff are starting to notice changes in her responses.

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Critical care doctor

We noticed that she seemed to be becoming more alert for longer periods of time - her eyes were open, she would look round the room although not necessarily focusing on anyone or anything, it's always very difficult to tell.

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Bakewell

And some of the nursing staff at her bedside are becoming hopeful.

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Nurse

That was like a golden moment, should I say, because you kind of hope she wakes up.听 She would stare at the ceiling or state in the corner or state at something but she would not give you eye contact so you kind of kept your fingers crossed and hoped for the best.

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Bakewell

So how much is Anne aware of what is going on around her?听 The enigma is how is anyone to know.听 Her mother, among others, feels she is aware but they can only speculate and watch for signs.听 Anne's family talk to her, show her pictures, play her music.听 Medical staff also form their own opinions.

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Nurse

You more or less went by her body language and try to make sense of how she might have been feeling.听 For example like when you gave her her bed bath you would have to roll her on to her side, sometimes she would extend her arms and other times she would make a facial expression - something like ooh - but with her eyes open, so you would think is she in pain or is the baby kicking.

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Critical care doctor

She would seat profusely at times, her heart rate would go up and down, which is often a sign that somebody is reacting to something and suddenly her blood pressure would go up and down.听 But it wasn't clear that they were linked necessarily to anything particularly that had been done.听 But sometimes different manoeuvres - simple things like holding her hand or stroking her hair - she would seem to become more settled which perhaps was an indication that maybe at times she was distressed and that the very basic human responses to touch or voice etc., helped comfort her at times.

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Bakewell

As weeks go by it's not surprising that the staff become increasingly attached to Anne.听 They are watchful of her advancing pregnancy, which is now beginning to show.听 Her obstetrician:

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Obstetrician

Anne required a huge amount of nursing.听 With a pregnant woman they have to be nursed on one side or another because the womb is getting larger and the womb can lie on the major vessel coming back up to the heart and in someone who is not breathing for herself they are at an increased risk of infections, particularly when they are not standing vertical for a lot of the time.听 Therefore when she got a little bit better we tried to sit her out to try and mimic reality really a little bit more because pregnant woman don't lie in a hospital bed.

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Bakewell

The baby, having been deprived of oxygen during Anne's initial cardiac arrests, continues to grow and the medical attention begins to focus more and more on its welfare.

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Obstetrician

The features we were looking at were the growth of the baby, the movement of the baby, the fluid around the baby, the heartbeat of the baby.听 The ultrasound scan appeared to show no structural abnormality in the baby, which was fantastic and the baby appeared also to be growing along the line that we would expect it to.

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Bakewell

By this time Anne has been in hospital for three weeks and she is 20 weeks pregnant.听 There are now real fears that Anne's precarious health could be exacerbated by her advancing pregnancy, at times she looks distressed, so sedation is given to calm her.听 Is she aware of what is happening to her?听 The agony for her family and for her doctors is that no one knows.

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Critical care doctor

People did repeatedly ask were we being kind, for want of a better expression, were we being kind to Anne by continuing with treatment.听 Clinically we had no reason not to continue with treatment.听 We knew she did open her eyes and she did move, she was responding to treatment and therefore from our perspective we were doing what we would do for any patient in a similar circumstance.

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Bakewell

And the neurologist must take the long view, he needs to wait at least six months to make a proper diagnosis.听 Anne is now 23 weeks pregnant.听 Her baby is just one week from being able to survive outside the womb.听 Staff and family are starting to come to terms with the fact that Anne might deliver a live baby.听 They know it's a boy.听 And an MRI scan of the baby's brain appears normal but they can't be sure.

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Obstetrician

It was going to be virtually impossible to confirm that the baby was not affected, she had had, we guessed, around two 20 minute down times from an oxygen supply to the baby.听 There was very little information in the medical literature.听 None of us had been in this situation before.

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Bakewell

And the advancing pregnancy is putting an increasing strain on Anne's heart and raising the chances of another cardiac arrest.听 So Andrew, suppose there is another cardiac arrest, should she at that point be resuscitated?

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Hartle

Oh quite clearly yes, you should certainly try to resuscitate but the very presence of the baby will make resuscitation very difficult and in fact the standard teaching now is that in cardiac arrest in a woman over 20 weeks if resuscitation isn't successful over three minutes you need to do a caesarean section within five minutes to save both mum and baby.

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Bakewell

Now Anne is 23 weeks pregnant, so where does the foetus figure because it's becoming more and more a consideration isn't it?

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Scott

Well I mean it's obviously becoming more and more visible and apparent and more of a possibility and a reality and some people might think it has stronger moral claims.听 But at the same time we do owe duties to Anne and that mustn't be forgotten and I think it's very difficult to think that the foetus could have some kind of moral claim which would override our duty to Anne here.听 And of course in any event we have the comfort, if you like, of the background legal position, which tells us that we can only do things for this foetus if they are thought to be in Anne's best interest.

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Bakewell

As part of Anne - the baby's part of Anne.

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Scott

As part of Anne - as part of Anne, either what she would have wanted or what she might be able to experience in the future.听 If we thought it wasn't in Anne's best interests to continue to treating her and clearly they're saying at the moment they did think it was in her best interests it would actually be unlawful to continue to do so, it would constitute a battery, an unlawful touching.听 So the foetus's interests can only be accommodated as part of Anne's best interests.

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Bakewell

Now Deborah, there is the interesting side concern here which is that if the foetus were to come to term and survive but in the process Anne were to die Anne who has longed for a child would not be there to parent.

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Bowman

We can't prospectively in pregnancy begin to think about the ways in which people might parent, whether they'd be available, whether they'd be a good parent but nonetheless, at this stage, in terms of changing the outcome, it couldn't be a determinative factor.

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Bakewell

Andrew.

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Hartle

Although throughout we've said that it's too early to say how well Anne can recover we are now several weeks into this process and the best response that she's shown has been eye opening and some response to stimulus.听 We can begin to say that it seems unlikely, if not impossible, that Anne will make a full recovery to independence.听 The best recovery it looks like she's going to make is to a very dependent state.听 So her ability to care for this baby, assuming the baby is born and the baby is normal, will be very, very limited.听 There is, of course, the outcome that we could also consider that the baby could also be born severely disabled and require constant care.

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Bakewell

So where does the medical team come in that assessment Deborah?

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Bowman
It's part of the debate, it's part of the weighing up of the interests but also at this stage I think you do want to be thinking about things that are not necessarily medical, so things like suffering, things like dignity, the integrity of the person in front of you.听 And I think that that's why this becomes a different, broader, more morally contested issue at this point.

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Bakewell

And it's clearly involving the staff on a very emotional level isn't it, how do medical staff deal with their rising attachment to the whole story?

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Hartle

With difficulty and being conscious of them.听 I think the crucial thing here is it's very clear that there's been really good practice, lots of involvement, no one's making decisions on their own and that the multi-disciplinary team are meeting regularly and consulting regularly.听 And you do get very emotionally attached.

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Bakewell

It is an enormous strain, Rosamund, isn't it on everyone living through this episode.

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Scott

I think it's completely mind blowing in terms of what the staff are going through.听 One thing that I think is reassuring at this stage is that they have said if Anne were not pregnant there is still no reason not to continue.听 And one of the comforting things about that I think is that Anne's interests and the foetus's interests are nicely kind of in alignment at this point.

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Bakewell

Right, so while they're treating Anne like any other they're actually saving her life when she has a crisis which they wouldn't do if she wasn't pregnant.听 So where are we here in terms of decision making?

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Scott

That underlines the point that we can never get away from the fact that she is pregnant here in the sense she's not like any other patient.听 I think two things I'd probably say about that.听 One is I'd want to be increasingly sure the more interventionist they are that we really have some reason to think this is in her best interests.听 The second thing to bear in mind is that there is another legal issue which is the question of the duty of care that's owed to Anne and that involves the duty not to harm her by the way they are treating her.听 What about the foetus one might ask and do obstetricians not owe any duty to the foetus?听 Well the curious thing is that they owe a duty to the parents regarding the foetus and of course that ultimately must be so that the foetus's interests can't trump the mother's in precisely this kind of scenario.听 So I think the implication must be the duty of care not to harm her, not to be negligent in treatment of her, has to override at the end of the day any duty of care that is owed not to injure this foetus.

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Bakewell

Deborah.

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Bowman

We can't really have it both ways, we have to be honest about it and say if we are continuing to treat Anne, as Rosamund says, we have to do so in her best interests.听 It may well be that continuing the pregnancy at all costs is in her best interest but the more it becomes at all cost the most discomforted I become.

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Bakewell

Well let's see what happens.听 Anne's 24th week of pregnancy is a landmark moment for everyone.听 From now on her baby can potentially survive outside her body.听 But the medical staff could have an extremely premature baby on their hands, so as Anne's life hangs in the balance they're desperate to keep the baby in her womb.听 Then Anne has another major internal bleed with the need for more transfusions - is it time to deliver the baby?

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Obstetrician

We really did not want a baby before 28 weeks if we could manage it and therefore at that stage the decision was that if her life was at risk or if the baby's heart beat was going down she would be delivered as an emergency.听 Believe it or not the baby's heart beat did not flicker.听 We didn't appear to be able to show that there was any problem from the baby's point of view.

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Bakewell

Given Anne's risk of premature delivery she's given two steroid injections to help mature the baby's lungs but the bleed Anne has suffered creates a new problem for her.

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Obstetrician

Because she had bled once we had to stop these blood thinning medications that she was on and in doing that we were increasing her risk of another complication, that of thrombosis.听 So you have to balance up the level of bleeding with the risk of clotting in a pregnant lady.

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Bakewell

And the clot they feared happens - a clot in Anne's left leg, a clot that could break off and move towards her lungs.听 So Anne is put back on her blood thinners with all the risks of further bleeds.听 By now staff are divided - some question whether given the extent of Anne's brain injury keeping her alive at all costs is still in her best interest.听 Others feel everything should be done to keep Anne alive for the baby.听 The critical care doctor and the obstetrician.

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Critical care doctor

Our treatment was directed to treating Anne.听 It was in the baby's best interests as well as Anne's best interest for Anne to be our primary focus.听 And we did consider the fact she was pregnant, mainly because we knew how much this pregnancy had meant to her and therefore we couldn't or for some of us it was difficult to disassociate her being pregnant from her best interests in any way.

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Obstetrician

We were really facing reality that one day this baby was going to be born and we had no idea on which day she was going to require immediate delivery.

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Critical care doctor

We made plans very early on for all eventualities, this included the need to consider an emergency caesarean section at the time of the cardiac arrest.

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Obstetrician

And the decision had been made that we would not transfer her in an emergency situation to theatre, that she would physically be delivered in the intensive care unit in her single room.听 There is no doubt that resuscitating mothers is much easier, I hate to say, when they are not pregnant and therefore if she had been to arrest, for whatever reason, the first thing would be to deliver the baby to enable resuscitation of the mother.

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Critical care doctor

And we had to consider the possibility of delivering a baby if Anne died in intensive care, which engendered a good deal and I think fear is not to strong a word in all staff.听 We had to bring in special equipment and most important of all we put everyone who might potentially be involved through training.

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Bakewell

The team is now in overdrive, the nurses stand ready to help deliver a very premature baby in intensive care.

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Nurse

Suddenly all this equipment appeared in the room that she would need should she have to deliver the baby on the unit and I think that became more scary.听 Then we started doing practises of how we would do the delivery in an emergency situation and a dummy with a baby inside it, wrapped up in cling film, and what position we would need to get Anne in in order to deliver, what things you needed on hand to be able to do it, what you needed to open in what order, what position she had to be in.听

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Nurse

It was very worrying because it was unchartered territory, so to speak.听 You sort of prepared yourself mentally and made sure that all the equipment was checked or plugged in, fully charged and that everything was there and ready to go if anything was to happen.

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Nurse

And we also didn't know what the baby was going to be like because of the drugs that she'd had while she was on a ventilator and the heart attacks and what damage that might have done.听 And I think everybody was just really concerned that at the end of it we all wanted a positive outcome but we might not get it.

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Bakewell

Anne is now 25 weeks pregnant.听 As the baby's chances of surviving outside the womb increase priorities are shifting to accommodate him.听 The paediatrician takes a view.

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Paediatrician

In a mother who'd had two cardiac arrests then the prognosis would have been very poor.听 If we could get the baby to a higher gestation, maybe 28 plus, then we'd need to review it week by week but I think as an aim we should have been aiming for 38 weeks to give the baby as good a chance as possible.听 The pressure became greater to get the baby out because people didn't want to end this situation with a dead baby and a mum in a persistent vegetative state. 听I think people wanted to see some kind of positive outcome from what was really a very poor situation.

听

Bakewell

The pregnancy progresses - 26 weeks, 27 weeks.听 Anne's doctor has new concerns.

听

Critical care doctor

Anne was having a lot of unusual heart rhythms so we were very concerned that having got this far it would be terrible if Anne had a cardiac arrest and we lost both her and the baby.听 So from an intensive care point of view we were anxious that delivery should be considered to be sooner.

听

Bakewell

The obstetrician.

听

Obstetrician

When we got to 28 weeks I decided to do foetal heart beat tracings on a daily basis.听 I decided that if there was an abnormality on that I was going to electively deliver her from the baby's point of view at that stage rather than from her point of view.听 But funnily enough at 28 weeks she seemed to stabilise off and the baby did not seem to have any problems. So we were slightly reassured.

听

Paediatrician

My thoughts at the time were that if we didn't need to deliver a baby at 28 weeks then we shouldn't do that.听 There was no medical reason to deliver it from Anne's point of view, therefore I thought that the safest place for this baby was to stay inside Anne, who was being monitored constantly.

听

Bakewell

Among the nurses and the medical team tensions are rising.

听

Nurse

Every week that baby was still in there the better chance it had.听 And even though you knew that there was still a little part of some staff wishing that it was over.

听

Nurse

When you went into her bed space you hoped and prayed to god please let it not happen on this shift.听 If something happens and we lose the baby we would have felt like we had failed her and her husband and family and ourselves as well because we had put so much effort into all this.

听

Nurse

Our nerves were running out, we were very worried that having got this far we absolutely did not want to lose the baby.

听

Bakewell

Well we've got a really complex ethical dilemma now.听 Anne's best interests are central but when should the baby be delivered?听 Deborah, we've got a sort of conflict here, not literally a conflict, we've got paediatricians and obstetricians with different points of view.

听

Bowman

And that's not surprising and indeed that's what they're there for - to give their perspective from the position of a specialist, an expert.听 However, what they're doing is focusing on the medical, it was telling to me that the paediatrician said there was no medical reason to deliver now but best interest is more than that and actually if you step back and start thinking well what about suffering, what about dignity, what about Anne's interests in a much broader sense it might not look like such a conflict.

听

Bakewell

But Andrew we've come a long journey haven't we, how are we now, from the medical point of view, balancing the risk to the baby?

听

Hartle

It's also balancing the risk of the baby to Anne.听 Anne's heart was damaged before she become pregnant and she's now had two cardiac arrests, so the on-going growth of the baby is putting Anne's heart under greater and greater stress and making the chances of a cardiac arrest higher and higher.

听

Bakewell

Are you surprised that it's arrived at this point so late in her pregnancy?

听

Hartle

I'm pretty surprised yeah, it's quite remarkable.听 There's almost a temptation to deliver the baby now.

听

Bakewell

Rosamund, you're nodding.

听

Scott

Well I'm thinking about the fact that things are becoming increasingly critical.听 Again I sort of come back to this notion of gosh we have to be really sure here about her best interest.

听

Bakewell

Let's speak though of the foetus because by this time we're talking about a baby.听 There is a dilemma, isn't there, because we're coming up to听 30 weeks now and I have a sense that the moral status of the foetus has shifted, is that so in your view?

听

Scott

Personally I do tend to think that the greater the gestation the greater the moral claims of the foetus.

听

Bakewell

But still not legal.

听

Scott

Legally absolutely not, nothing changes in that sense, yes.

听

Bakewell

Let's examine what you mean by the moral status of a foetus.

听

Scott

Well it means that it has an increasing moral claim on us and also the pregnant woman, so its interests or its needs would need to be taken into account.听 Now in relation to an autonomous woman the idea would be she would need to have an increasingly serious reason to justify harming a foetus - for instance by refusing treatment or whatever - because of that growing moral claim.听 But here of course the big dilemma, the big problem, is she's not an autonomous woman, she's a woman who actually is an extremely critical condition and our moral duty is to her I think, absolutely mustn't be lost sight of.听 It would be quite difficult for the foetus's interests to trump hers.

听

Bakewell

Deborah.

听

Bowman

I think it's to the team's tremendous credit that they have really sought to put themselves in Anne's position and to take account of who she was before this happened.听 It's incredibly difficult.听 I think that does change as the picture changes and it's not that Anne's desire recedes but I think other factors, other variables, necessarily become part of the equation and I think that's one of the things that makes it increasingly discomforting that the less obvious the benefit to Anne, indeed the less there is signs of tangible progress the more it seems that she is effectively a vessel for the foetus inside her.

听

Bakewell

Andrew.

听

Hartle

I mean the baby is of no direct benefit to Anne and it seems less likely that Anne will make a significant recovery and therefore to benefit from motherhood.听 So the wellbeing of the baby isn't in direct benefit to Anne in that it's what Anne would have wanted and it's a benefit to James because it's what Anne and James wanted.听 So the direct benefit to Anne is getting less.

听

Bakewell

Are you at this stage, as a medical team, able to assess the wellbeing of the baby and whether the baby might have suffered any damage in the cardiac arrest?

听

Hartle

That's going to be the dilemma because all the tests of foetal wellbeing are incredibly crude.听 So we could yet deliver a baby with a severe handicap.

听

Bakewell

I'm putting you on duty now, the ethics committee, what advice would you give at this stage?

听

Bowman

At this stage I think that Anne's interests have to be re-evaluated, given all the variables and the unknowns I think we need to focus on the least harm to Anne and that probably means at this stage delivery.

听

Bakewell

What about you Rosamund?

听

Scott

I tend to think given there is a chance of this baby surviving and given the increasing risks to Anne I think I would probably err on the side of delivering.

听

Bakewell

Andrew, what advice would you give?

听

Hartle

I think the team should start considering delivery in the next couple of weeks, maybe not today but at the first sign of trouble for Anne deliver the baby.

听

Bakewell

So what happens?听 Anne is 30 weeks pregnant, 31 weeks, 32 weeks, Anne reaches the 33rd week of her pregnancy.听 The decision is made to deliver Anne's baby by caesarean section at 34 weeks.听 But a few days before this in the early hours of the morning, while the nurse is on night shift, a sudden emergency.

听

Nurse

Anne's lights were switched off so I could monitor her from outside and I could see on her sheet there was like a dark patch, so I went into find out what that patch was, I was hoping oh god please let it not be, but it was blood.

听

Bakewell

At once she alerts the nurse in charge, the duty consultant arrives, comes and looks and rings the obstetrician on call.听 The whole team comes together - surgical staff, nurses, paediatrician, obstetrician.

听

Obstetrician

I got a call from the anaesthetist and he asked me Anne has developed low blood pressure and she's internally bleeding and the baby is in distress.听 My registrar is on site and can you ask him to come and start caesarean and I will join.听 God forbid is she died then I should be there to take the responsibility rather than my junior.

听

Nurse

I concentrated on the sedation, the pain relief, suctioning, ventilation.听 I was autopilot.

听

Bakewell

And the critical care doctor is also woken by a call.

听

Critical care doctor

I just knew immediately that it must be Anne, so I didn't bother to answer it, I jumped into my clothes and my car and drove as fast as I could to the hospital and arrived just as the baby was delivered.

听

Nurse

I sort of put my head outside the bed space to get a syringe and that's when I realised baby has been delivered because I could hear the baby was crying outside and that's when I realised oh it's over now.

听

Critical care doctor

The time that Anne had decided that she was going to promote this unexpected and early delivery was actually just as the nursing shifts were changing, so there were two sets of nursing shift on duty and I don't think there's ever been so much joy on the ward, as I walked on everyone was just delighted.

听

Bakewell

Anne is discharged to a long stay hospital.听 Several months later it is decided that she is in a persistent vegetative state.听 Her son, Marty, is being raised by his dad.听 He celebrated his first birthday in the spring of this year.听

听

Critical care doctor

To see the baby now and to know that he's here because of a lot of decisions that were made is very important really but it's nevertheless tinged with a huge amount of sadness that our hopes that Anne would recover to a degree have not been fulfilled and that is very sad for all of us.

听

Bakewell

Very sadly Anne died six weeks ago after contracting a chest infection.听 Her son is healthy and thriving.

听

ENDS