When treatment can no longer reach its goal

An intensive care measure is permissible if two conditions are met: it is medically indicated, and it accords with the patient’s wishes. If either ceases to apply, the goal of treatment changes.

This is not the end of treatment. It is a different treatment. The goal is then no longer to prolong life, but to relieve symptoms.

The treating physician establishes the indication; the authorised representative or court-appointed guardian gives consent. You will be asked what he would have wanted. You will not be asked whether he should die.

• I examine what the treatment under way is intended to achieve and whether it can achieve it.
• I establish whether there is an advance directive, a health care power of attorney or a court-appointed guardianship, and whether it applies. If none exists, what he would have wanted must be established. You are involved.
• Where appropriate, I propose a time-limited trial (TLT): a defined goal, period, criteria and date for a new decision. This is a documented procedure, not a delay.
• I tell you that you, too, can request a clinical ethics consultation, not only the treatment team.
• I record what was discussed and give it to you. In eight months, you will want to read it again.
• I speak with the treating team, not against it.

There is a point beyond which a flight brings the patient no benefit and burdens him. There is another at which a flight remains right although he is unlikely to survive it — because the goal is home, not the next hospital.

Those are two different questions. I answer them separately, and I answer them beforehand.

My fee does not depend on whether the flight takes place.

If a flight takes place, I put in writing beforehand what will apply if he dies en route: who will decide then, where the aircraft will land, who will issue the documents. This question is difficult. Clarifying it beforehand is the only way to take it out of your hands.

That is when my medical role ends, but not on the same day.

• I explain what the documents say: medical certificate of death, death certificate, laissez-passer for a corpse. I tell you whether they are complete and internally consistent. In Germany, they are generally not examined again.
• I tell you which decision is governed by a deadline. Depending on the country and religion, the choice between burial at the place of death and repatriation must be made in hours, not days.
• I tell you who handles what follows. The German mission abroad issues and authenticates documents. It organises nothing and pays nothing. The transfer is carried out by a funeral director whom you engage and pay.
• I do not organise repatriation, I do not recommend a funeral director, and I accept money from none of them.

After four to six weeks, I offer you a conversation. Not to comfort you. To go through the course of events again, because by then the questions have changed. You do not have to accept.

This is not bereavement support. I am not trained for it.

This is not palliative care. That is provided by whoever is on site.

This is not an assessment of the doctors who provided the treatment.

And I tell you nothing I cannot substantiate. Not even if it would help you at that moment.