Making the choice between life and death
- 13 July 2010
- From the section Health
Richard Rudd's mother, father and two daughters all agreed it was time to let him go.
On October 23 2009, Richard was riding a motorcycle when he hit a car at speed.
He was found six metres away from his bike.
Diagnosed as paraplegic at the scene, after spending a month undergoing various tests and scans it was confirmed that the paralysis of both arms and legs was to be permanent.
Richard's father - also called Richard - said at the time: "To keep somebody alive whilst they're suffering and they're not going to get better, it's playing God, if you like, because it's going against nature.
"If nature had been left to take its course, Richard would have been gone a few weeks back."
The family was clear that Richard would not want his treatment to be continued. They remembered when discussing a friend who had become paraplegic following a car accident, he said: "If ever this happens to me, I don't wanna go on. I don't wanna be like him."
Initially it was believed that Richard had fallen into a coma from which he was unlikely ever to emerge.
His ventilator was the only thing keeping him alive.
Richard was unable to respond to his family - or even to doctors treating him - but then a startling discovery was made.
The attending consultant, Professor David Menon, discovered that Richard was able to move his eyes in response to simple commands and questions.
This meant that, in theory at least, Richard could make the decision to live or die himself.
Professor Menon is a world-leading expert in the treatment of brain injuries and 13 years ago he established the Neuro Critical Care Unit (NCCU) in Addenbrooke's Hospital in Cambridge.
It is now the largest unit of its kind in Europe with provision for 21 patients at any one time.
In this unit, the rules governing death are directly challenged.
"It's really important to think about death not as an event but as a process," said Professor Menon.
"That process can be strung out quite considerably and slowed down. It can also be interrupted."
In the UK today the legal definition of death is brain death, not whether the heart is beating as many believe.
And Professor Menon thinks that it is not just survival that is important but the quality of that survival.
"Between survival and death there is a slightly grey area," he said.
"The successes of modern medicine are often rightly publicised, but we rarely discuss what happens when medicine fails.
"For example, death is commonly viewed as an event which involves cessation of the heartbeat.
"In actual fact, it is irreversible damage to the brain that decides whether a person survives or not, and the heart needs to have stopped for several minutes before such damage results.
"Indeed, it is common, as with head injury, for the brain to be irreversibly damaged, while the function of the heart and lungs is maintained by intensive care."
Around 40% of patients admitted to the unit make a meaningful recovery.
Two months after Richard's accident, a speech therapist was asking him the same 20 simple questions - about his interests and family - each day.
He answered by moving his eyes left or right to signal yes or no responses.
If Richard consistently answered correctly it would demonstrate that he had the capacity to finally be asked the question about what he wants: to continue treatment or stop it - effectively ending his life.
Richard had been in the NCCU for six months before Dr Menon asked him the question he had wanted to ask him ever since he saw his eyes move for the first time.
"He remembered he had had an accident," said Professor Menon.
"He was aware that he was being treated on an artificial ventilator and being fed through a tube going into his stomach and this was likely to be going on for some time. I didn't specify how long.
"Finally I then asked him if we were happy for us to go on treating him and he said 'yes'. I asked him again and on three occasions he made it clear, just with yes/no answers, that this was a consistent response."
Richard is now able to make facial expressions and his long-term memory is intact.
He has been moved to a different unit nearer his home in Worcester and, after seeing slow but steady improvements, Richard Rudd Snr has changed his view.
"We all sit round and talk in the pub or at work and say 'if this happened to me, turn the machine off'," he said.
"It's all hypothetical and you don't know until it happens to yourself. As a family and friends, if that person can't decide for themselves, sometimes you feel that you can decide for them.
"Because, in theory, you think you can never live in that situation, you sometimes put that judgement onto somebody else.
"At the end of the day, you probably have no right to do that.
"But now Richard's in the situation where that's actually happened. It's real life - it's not pretend. He is in that situation.
"The will to live takes over."