Sadly despite all the treatments available some patients are too ill to survive. Death of a loved one is always a terrible event even if it has been expected. The doctors on the intensive care unit will often be able to warn families that there is a deterioration and that they expect their loved one will die despite treatment. Death can still happen very suddenly, and the doctors and nurses cannot always give a family enough warning to return to the hospital to be present. Many elderly patients have frail spouses and it is important that the family support them during what is often an exhausting time. If the patient has been deteriorating for several days it is not possible to be at the bedside continuously.

Relatives should ask any questions they want during the illness and should feel able to ask the doctors about the chances for recovery. The doctors will be as honest and accurate as possible but it is frequently very difficult to predict the outcome for a particular patient. If the doctors feel that there is no chance of recovery then they will not continue to put the patient through the difficulties and discomforts of intensive care but will explain that there is no more that can be done.

 
 
Treatment withdrawal

With the advances in intensive care it is often the case that the treatments will continue to keep a patient alive for a long time after it becomes clear that there is no chance of survival and recovery. In this situation the doctors will discuss withdrawing treatment with the family to keep them fully informed and to understand what the patient's own wishes would have been if they were able to tell us. Ultimately the decision to continue treatment or not rests with the intensive care consultants, and they will frequently discuss these difficult decisions with other ICU consultants as well as the specialist teams. A doctor cannot continue a treatment that is of no benefit to the patient as this breaks the ethical principles under which they practice.

How treatment is withdrawn

There is absolutely no question of giving treatments that will speed up or cause a patient to die. This is sometimes called "mercy killing" or euthanasia and is illegal in the United Kingdom. Treatment withdrawal is the removal or treatments or reducing a level of support that is artificially keeping a patient alive. Intensive care units have a system for doing this in a way that ensures the patient will not suffer. Sedative and pain relieving treatments are continued to make sure that the patient is unaware and not experiencing breathlessness or pain but treatments maintaining blood pressure and high levels of ventilation are reduced or removed. Usually the family are able to be with the patient if that is what the patient and the family wanted. The time it takes for a patient to die is very variable and difficult to predict, from a few minutes to several hours. There are some conditions such as brain injury where it can take many days and under these circumstances the patient will often be transferred to a side room of a normal ward.

 
 
Brain stem death

Sometimes patients have a head injury or a medical condition that leads to irreversible brain damage. If they are on a life support machine it can be very difficult to tell that this has happened and they can look absolutely normal to their families. There are a special set of tests that doctors can do to work out whether the brain is functioning. These are called brain stem tests. The brain stem is the part of the brain that controls the very basics of being alive, such as breathing and control of the heart rate.

Under specific circumstances the doctors can perform these tests to determine whether there is any brain stem function. The tests must be done twice by two different doctors, one of whom must be a consultant and the other one must have been registered for at least five years. The legal time of death is the time the first set of tests were done, although the patient is not declared dead until after the second set of tests, this time difference sometimes leads to distress if the family don't understand the process. Depending on the specific situation the doctors sometimes need to leave a period of time between the test. If a patient is brain stem dead their heart will stop very quickly if the ventilator is stopped.

 
 
Organ Donation

Under circumstances such as brain stem death the family may be approached and asked if they believe the patient would have wanted to donate parts of their body to help other people live. The most important consideration is what the patient would have wanted although organ donation requires the explicit consent of the family as legally when the patient has died (if they are brain stem dead, then they will still be on the ventilator) their body belongs to the next of kin.

Relatives will be able to spend time with their loved one before and after the organ donation procedure.

Non heart beating donation

Only some hospitals are able to offer non heart beating donation. This is a different process, as the potential for donation is identified before a patient has died but when it is recognised by the doctors that there is no chance of their survival. It is discussed with the family very clearly, that the decision to withdrawal treatment is completely independent of the possibility of becoming a donor. The treatment withdrawal process (see above) then takes place as outlined above and the family have a short period of time with the patient before their body is quickly taken to the operating theatre for the donation procedure. Afterwards the family can have more time with their relative.

For more detail on the process of organ donation please visit http://www.uktransplant.org.uk