It was standing room only at a lunch time discussion last week entitled ?Let?s Talk about Dying? attended by medical professionals.

All the seats in the first floor conference room at King Edward VII Memorial Hospital were taken and latecomers had to stand at the back of the room to hear the hour-long discussion with a panel of speakers addressing what was termed ?the last taboo subject?.

For those who work as doctors, nurses, physicians and carers the subject of death and ethics presents a host of dilemmas ranging from how and when is it right to inform a patient that they are dying and nothing more can be done for them, to deciding what medical procedures to give or withhold if a patient is likely to die regardless.

And is it always right to seek the guidance of a family relative over the future of a patient who can no longer make their wishes known regarding whether to allow further medical intervention to keep them alive?

Those were amongst the questions posed during the session, which is part of the Bermuda Hospital Board?s Ethics Committee awareness week.

Dr. Alistair McCrirrick, physician leader of anaesthesia at the hospital, gave the audience a number of scenarios to consider, such as should a moribund patient have surgery. He said: ?The question is normally ?will the patient die if we do not operate?? but the question should actually be ?do they have a chance of survival if we do operate??

?Medical treatment is only ethical if it offers a reasonable chance of success. There has to be a balance between what there is to lose as to what there is to gain if you go ahead.?

He said it was important to make a distinction between a irreversible natural dying process and an acute but preventable event affecting a patient. He gave one example from his own experience where he judged an unconscious patient to be beyond medical help but was overruled and the patient underwent a number of medical procedures.

The patient lived a further three months but never regained consciousness. Those who had overruled Dr. McCrirrick said the patient may not have been revived but was showing ?pain responses? shortly before they finally died.

Dr. McCrirrick said that was, in his opinion, an example of where it was ethically wrong to use medical resources in a futile situation.

Medical practitioners also have to consider the question of ?consent and assent? when faced with deciding whether to carry out invasive and hazardous treatments on patients unable to give their permission. There is, in Bermuda, no legal provision to cover one adult giving consent for medical procedure to be carried out on another adult, even if they are family members.

Dr. McCrirrick said other factors can come into play including, in extreme cases, a family member wanting a patient to die so that they can gain is some manner such as through a legacy. He said: ?What you really want is assent, where you explain what you want to do. Relatives are important, but only in indicating what a patient wants.?

Another on the panel was Dr. Christy Simpson, assistant professor in the Bioethics Department at Dalhousie University in Halifax.

She said the aim was to have ?shared decision making? between medics and the patient or the patient?s immediate family.

There needs to be ?value judgements? made on what level of treatment is appropriate with regard to keeping a patient alive and what quality of life they will have as a result.

Dr. Simpson said it was also vital medical professionals meet up on their own, away from their wards and specialist areas, to discuss with colleagues the ethics of patient treatment when death is a strong possibility.

Dr. Elaine Campbell, co-chair of the Ethics Committee, highlighted another sticky point created when medical professionals try to couch their words in ?coded? form resulting in patients and their families not being fully aware they are trying to inform them that the patient is dying and it is time to consider whether further aggressive medical procedures are desirable.