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No easy answers.

The medical team was making bedside rounds when the member of the Ethics Committee caught up with them. They were shocked at the report. Mrs. R. could be removed from the ventilator, hydration and nutrition discontinued, blood draws stopped, and moved to palliative care. The Committee had just convened, the neurologist presented the medical findings, the patient’s children provided written and oral testimony, the legal standard had been met. The senior resident, certain that there was a mistake, considered the recommendation premature. Shouldn’t we wait? She had been involved in the ethics process and removal of life support before, and while it had not been easy to do a terminal weaning, she understood it is something a doctor does for her patient. This was different. Emily was more alert, responding to voices, tracking with her eyes. She had not been able to do this since the stroke. She was able to do it now. In fact, the resident had asked the stroke team to reevaluate the patient yesterday and the patient was even more alert today. Shouldn’t we wait? Why rush into something so irreversible when the medical picture is still evolving. The medical student, not constrained or encumbered by knowledge or experience, speaks for the group with an authority that is authentic, and sincere. ‘‘She’s getting better, there is improvement. She’s yet to respond to verbal commands but that might come soon. She certainly can’t be removed from life support now.’’ He is challenged about his expectations of the patient’s purposeful response to a command. ‘‘Like raising her hand,’’ he says, as he demonstrates with his own, ‘‘Soon she may be able to do that too.’’ The team is told of the neurologist’s report, the family’s testimony, and how the committee reached its decision. The family would soon be at the bedside to be with their mother when she is removed from life support and her wishes are honored. ‘‘Did the neurologist see the patient today?’’ the medical student asks ‘‘His PA saw the patient, but has the neurologist examined the patient? He should come now.’’ Medical house staff do not command the appearance of an attending. This brash medical student does and the clarity of his position and assertion in his voice are unchallenged. While he may not be following the acceptable medical etiquette and protocol, he is speaking for the group as it struggles with a life and death decision that has engendered ambivalence in some and disagreement in others. The Ethics Committee meets to hear testimony, determine if the legal standard has been met, and make recommendations to the doctor about the plan of care. The patient’s son and daughter speak for their mother now that she cannot speak for herself. The burden is theirs. The standard: clear and convincing evidence about what the patient would want if she were able to tell us. The neurologist begins: history, diagnosis, a hemorrhagic stroke with diffuse cortical dysfunction, and the prognosis. He is asked one last time if there is any possibility of recovery, best outcomes, and if she were to survive, what care will she need and where can it be rendered? It is now the family’s turn. They have not been with us when the doctor gave his detailed report and answered questions from the physicians on the committee. They take comfort in knowing that the doctors on the committee, who have not been involved in their mother’s care, are in agreement with the prognosis. They are asked about what they know of their mother’s end-of-life wishes and how they came to know it. There are tears. There is a lifetime of knowing. This is not easy for them. It would be easier is to keep their mother on life support but that is not what she wants. They know it and now we know it. The standard has been met. The doctor can remove the ventilator, and discontinue hydration and nutrition. She will be made comfortable and when it is her time, she will leave us. ‘‘When?’’ the daughter asks. ‘‘We don’t know.’’ ‘‘When will the machines be removed?’’ That is between them and the doctor. ‘‘Now. It has been so hard for us to get to where we are. We would like the pastor to pray for her and then have it done. We want to be with her when you do it. She should not be alone. She needs us there.’’ The Committee’s work is done. The family goes to their mother’s room for last good-byes if death should come sooner rather then later. A member of the Ethics Committee goes to the nursing unit to inform the staff of the decision and to ready the process of removal of life support. A patient’s children at her bedside, praying for her peaceful journey and for the strength to let her begin it. The medical team, a few rooms away, in moral conflict about ending a patient’s life when they have seen life coming back into her in these last 24 hours. They ask for the neurologist and he comes. They gather around patient’s bed. The family is asked to leave one last time. Bringing us to this moment has been torturous for them. They do not need to hear the uncertainties of the medical team with the decisions that have been made.