Mandela: When is it time to let go?

His going terrifies many South Africans, fearful he is holds the country together

Share

Nelson Mandela will be preparing this morning to endure his eighth day in intensive care. As nurses at the Pretoria hospital bustle about making the 94-year-old former president of South Africa as comfortable as it is possible to be amid the oxygen masks, tubes and beeping machines of a modern intensive care unit, the world anxiously awaits the next bulletin on the frail anti-apartheid hero’s health.

On Thursday, Jacob Zuma, South Africa’s current president, appealed to people to pray for “Madiba”, Mr Mandela’s clan name, following a visit to his bedside. He was improving but remained in a serious condition, Mr Zuma said, after a “difficult few days”.

 While this glimmer of hope may temporarily have allayed the anxieties of a nation – and the world – it cannot disguise the fact that Nelson Mandela’s life is drawing to a close. And that has raised the question of when it is time to let go.

This is Mr Mandela’s fourth unplanned hospital admission since late last year. In December, he spent 18 days in hospital being treated for a recurrent lung infection and gallstones, and it is the lung infection, a legacy of the tuberculosis he suffered while imprisoned in the 1980s, that has led to his latest admission.

The prospect of his going terrifies many South Africans, fearful that he is the glue that holds the country together. At the same time, there are murmurings in the South African press calling on the Mandela family and his doctors to acknowledge the inevitable.

 His old friend and fellow Robben Island prisoner, Andrew Mlangeni, told the South African Sunday Times: “The family must release him so that God may have his own way with him. Once the family releases him the people of South Africa will follow.”

Similar opinions are being expressed around South Africa dinner tables, the BBC reported, though few are prepared to join Mr Mlangeni and air their views in public for fear of a backlash.

Details of Mr Mandela’s condition are being closely guarded by his inner circle, anxious to preserve the dignity of the “father of the nation”, and the media has largely respected their wishes. When, earlier this week, a US TV station claimed to have details of the state of Mr Mandela’s internal organs, other news outlets declined to take up the story.

The dilemma his doctors face – when to stop “striving officiously” as the Hippocratic oath has it, and switch focus from curing to caring – is all too familiar to palliative care specialists. Recognising that the end is approaching and broaching the subject with the patient and their family demands strength and delicacy – and is often avoided.

“Breaking that bad news is very difficult but very important,” said Mayur Lakhani, the chairman of the UK National Council for Palliative Care. “Recognising the signs when someone is dying should not be seen as a failure but as opening up the doors to comfort care.”

In the old days, the choice was either/or, cure or care. “Now we can cure and care. Some things can be fixed – an infection, for example – but the focus is on maintaining the quality of life for as much of it as remains.”

In England, it is estimated that as many as 92,000 people a year die without their approaching death being recognised or acknowledged, so they are denied the palliative care that could keep them comfortable. Instead, said Dr Lakhani, they get the “standard aggressive treatment, which does not work”.“We have frail elderly people getting heroic treatment who end up suffering worse.”

According to the US surgeon and author Atul Gawande, writing in The New Yorker, the healthcare system we have built to save lives is utterly failing to deliver what patients want and need when the end comes. “Spending one’s final days in an intensive care unit because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realising that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or ‘It’s OK’ or ‘I’m sorry’ or ‘I love you’.”

Recognising the inevitable is not, specialists insist, defeatist. It does not mean abandoning active treatment, but changing focus from prolonging life to improving its quality.

The natural response of relatives is to wait until doctors tell them there is nothing more they can do. But modern medicine has advanced to the stage where there is always something more that doctors can do.

It was to halt the unnecessary suffering that can result – and too often does – from the unfettered use of technological interventions that the Liverpool Care Pathway was devised to guide medical teams caring for patients in the final few days and hours of life. As the body’s organs begin to shut down, the programme advises on when to give drugs, when to withdraw food and liquid and how to minimise pain and suffering.

Drawn up in a Liverpool hospital, it has spread across the NHS in recent years as a means of bringing kinder, less aggressive, hospice-style care to patients dying in hospital. But it has become embroiled in controversy over the alleged failure of some doctors and nurses, unable or unwilling to broach the issue of death, to explain fully to patients and their families what was happening and seek their consent. A review chaired by Baroness Neuberger is due for publication next month.

Arriving at an acceptance of our mortality and of the limits of medicine is a process. Death cannot be avoided – but it can be eased. A large part of negotiating the right treatment at the end of life is to help the family – and in Mandela’s case, the nation and the world – to cope with the overwhelming anxiety that death inevitably brings.

React Now

Latest stories from i100
Have you tried new the Independent Digital Edition apps?
iJobs Job Widget
iJobs General

Ashdown Group: Marketing & Sales Manager

£40000 per annum: Ashdown Group: A reputable organisation within the leisure i...

Tradewind Recruitment: Science Teacher

£90 - £140 per day: Tradewind Recruitment: I am currently working in partnersh...

Recruitment Genius: Doctors - Dubai - High "Tax Free" Earnings

£96000 - £200000 per annum: Recruitment Genius: Looking for a better earning p...

Recruitment Genius: PHP Developer

£32000 - £36000 per annum: Recruitment Genius: A rapidly expanding company in ...

Day In a Page

Read Next
British Prime Minister Tony Blair (L) pictured shaking hands with Libyan leader Colonel Moamer Kadhafi on 25 March 2004.  

There's nothing wrong with Labour’s modernisers except how outdated they look

Mark Steel
 

Any chance the other parties will run their election campaigns without any deceit or nastiness?

Nigel Farage
Isis hostage crisis: The prisoner swap has only one purpose for the militants - recognition its Islamic State exists and that foreign nations acknowledge its power

Isis hostage crisis

The prisoner swap has only one purpose for the militants - recognition its Islamic State exists and that foreign nations acknowledge its power, says Robert Fisk
Missing salvage expert who found $50m of sunken treasure before disappearing, tracked down at last

The runaway buccaneers and the ship full of gold

Salvage expert Tommy Thompson found sunken treasure worth millions. Then he vanished... until now
Homeless Veterans appeal: ‘If you’re hard on the world you are hard on yourself’

Homeless Veterans appeal: ‘If you’re hard on the world you are hard on yourself’

Maverick artist Grayson Perry backs our campaign
Assisted Dying Bill: I want to be able to decide about my own death - I want to have control of my life

Assisted Dying Bill: 'I want control of my life'

This week the Assisted Dying Bill is debated in the Lords. Virginia Ironside, who has already made plans for her own self-deliverance, argues that it's time we allowed people a humane, compassionate death
Move over, kale - cabbage is the new rising star

Cabbage is king again

Sophie Morris banishes thoughts of soggy school dinners and turns over a new leaf
11 best winter skin treats

Give your moisturiser a helping hand: 11 best winter skin treats

Get an extra boost of nourishment from one of these hard-working products
Paul Scholes column: The more Jose Mourinho attempts to influence match officials, the more they are likely to ignore him

Paul Scholes column

The more Jose Mourinho attempts to influence match officials, the more they are likely to ignore him
Frank Warren column: No cigar, but pots of money: here come the Cubans

Frank Warren's Ringside

No cigar, but pots of money: here come the Cubans
Isis hostage crisis: Militant group stands strong as its numerous enemies fail to find a common plan to defeat it

Isis stands strong as its numerous enemies fail to find a common plan to defeat it

The jihadis are being squeezed militarily and economically, but there is no sign of an implosion, says Patrick Cockburn
Virtual reality thrusts viewers into the frontline of global events - and puts film-goers at the heart of the action

Virtual reality: Seeing is believing

Virtual reality thrusts viewers into the frontline of global events - and puts film-goers at the heart of the action
Homeless Veterans appeal: MP says Coalition ‘not doing enough’

Homeless Veterans appeal

MP says Coalition ‘not doing enough’ to help
Larry David, Steve Coogan and other comedians share stories of depression in new documentary

Comedians share stories of depression

The director of the new documentary, Kevin Pollak, tells Jessica Barrett how he got them to talk
Has The Archers lost the plot with it's spicy storylines?

Has The Archers lost the plot?

A growing number of listeners are voicing their discontent over the rural soap's spicy storylines; so loudly that even the BBC's director-general seems worried, says Simon Kelner
English Heritage adds 14 post-war office buildings to its protected lists

14 office buildings added to protected lists

Christopher Beanland explores the underrated appeal of these palaces of pen-pushing
Human skull discovery in Israel proves humans lived side-by-side with Neanderthals

Human skull discovery in Israel proves humans lived side-by-side with Neanderthals

Scientists unearthed the cranial fragments from Manot Cave in West Galilee