Life for the Win

As I’ve been restricting my running about to save what’s left of my feet, I’ve no exciting tourist photos to build a story around. But the other night on the BBC I encountered this story, which I hope you’ll enjoy.

In October of last year, Richard Rudd was riding his motorcycle past a filling station near Kidderminster, Worcestershire, when a car exiting the station struck him and threw him 20 feet. Rudd, 42 and the divorced father of two teenage daughters, could initially move his limbs, but a post-operative infection caused his organs to begin shutting down, and he went into a coma. When he emerged, he was completely paralyzed.

He was moved to a special neuro-intensive care unit at Addenbroke Hospital in Cambridge, where doctors determined that the damage to Richard’s lower brainstem was such that he would never recover movement in his body, or the ability to speak, or even to breathe on his own. His father and his children agreed that Richard himself would not want to live in that condition.

They related stories of Richard saying things like “If anything like that happens to me, I don’t want to go on.” Richard’s father said he felt that keeping his son alive would be “like playing God.” There was “no way in a million years” Richard would want to live in these circumstances. It seemed pretty clear that if Richard had thought to draw up a living will, it would have included a provision to withdraw care at this point.

The family’s consent to take Richard off the ventilator having been given, it was now up to the doctors in the unit to come to a decision. There seemed to be a general agreement that there was no point to keeping a man alive who wouldn’t want to be under these conditions. But Professor David Menon, a leading expert in treating brain injuries, and the creator of the neuro-intensive care unit, felt there was still some input missing. Richard’s.

He went to visit Richard, shortly before the time scheduled for shutting down the respirator and removing the tubes that fed oxygen to his brain. He asked Richard if he would move his eyes to the left. Richard did, then to the right on Menon’s second request. A BBC film crew was present, and caught the expression on Menon’s fact that seemed to say “This changes everything.” Richard performed those eye movements over and over at Menon’s request, but was unable to respond to a more complex suggestion that involved holding on to an instruction over time.

Menon determined that Richard was not capable of giving a meaningful answer to the question of whether he wanted to live…yet. His responsiveness hinted at higher brain function still intact. He decided to wait for the final life-or-death decision until Richard himself might have a chance to weigh in.

Menon put a speech therapist on the case, who interviewed the family for Richard’s likes and dislikes, and facts about his life. She came to his bedside every day with a list of 23 questions to which he could answer yes or no by moving his eyes to the left or right—questions that included tests of long- and short-term memory. Every day for three weeks, she asked the same questions and got the same answers. Sometimes after the questions, she'd have a conversation with him. Richard passed all tests easily. At no time did anyone ask him about withdrawing care. It wasn’t yet time for that question. Menon wanted to give Richard time to consider his life as it was now.

What Richard had been experiencing since waking from his coma is what doctors are now calling “Locked-in Syndrome.” The patient’s total paralysis and inability to speak are much the same as in vegetative states, but as demonstrated by the recent case in Belgium of a man who reported having been conscious during a 23-year vegetative state, locked-in patients are awake and aware, although unable to communicate. David Menon had demonstrated that the nerves controlling the muscles that moved his eyes—located higher up on the brainstem than the worst of the injury—were still intact and responsive to Richard’s will. He had given Richard Rudd a way to communicate with the outside world.

Once Professor Menon was convinced that Richard was capable of understanding his condition and prognosis, and of considering the question of his own future, he began to have that talk, and ask those questions. Three times on separate occasions, he asked Richard if, under the circumstances which he now understood, he wanted to live. Three times Richard answered yes.

The photo below was taken in March of this year, five months after Richard Rudd’s motorcycle accident. He had, by this time, learned to move his head an inch in either direction. He had also recovered the use of some of the muscles in his face, allowing him to smile.

Richard’s case has inflamed renewed debate over living wills, which are legally binding documents. A spokesman for a group opposing the use of living wills says: “This case shows the weakness of giving legal force to documents which, by their very nature, can never cover every possibility.” And no matter where you come down on the subject, you might agree that there’s a difference between an imagined future and a tangible present.

David Menon puts it this way.“There may sometimes be differences between what a patient declares when he is fit and healthy, and what he feels when he is the one in the hospital bed.” Richard Rudd is living proof of that.