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?
SPONSORED FEATURES
iJobs Job Widget
iJobs General

Recruitment Genius: Senior Environmental Adviser - Maternity Cover

£37040 - £43600 per annum: Recruitment Genius: The UK's export credit agency a...

Recruitment Genius: CBM & Lubrication Technician

£25000 - £27500 per annum: Recruitment Genius: This company provides a compreh...

Recruitment Genius: Care Worker - Residential Emergency Service

£16800 - £19500 per annum: Recruitment Genius: Would you like to join an organ...

Recruitment Genius: Senior Landscaper

£25000 - £28000 per annum: Recruitment Genius: In the last five years this com...

Day In a Page

Read Next
Labour's Jeremy Corbyn arrives to take part in a Labour party leadership final debate, at the Sage in Gateshead, England, Thursday, Sept. 3  

Jeremy Corbyn is here to stay and the Labour Party is never going to look the same again

Andrew Grice
Serena Williams  

As Stella Creasy and Serena Williams know, a woman's achievements are still judged on appearance

Holly Baxter
Refugee crisis: David Cameron lowered the flag for the dead king of Saudi Arabia - will he do the same honour for little Aylan Kurdi?

Cameron lowered the flag for the dead king of Saudi Arabia...

But will he do the same honour for little Aylan Kurdi, asks Robert Fisk
Our leaders lack courage in this refugee crisis. We are shamed by our European neighbours

Our leaders lack courage in this refugee crisis. We are shamed by our European neighbours

Humanity must be at the heart of politics, says Jeremy Corbyn
Joe Biden's 'tease tour': Could the US Vice-President be testing the water for a presidential run?

Joe Biden's 'tease tour'

Could the US Vice-President be testing the water for a presidential run?
Britain's 24-hour culture: With the 'leisured society' a distant dream we're working longer and less regular hours than ever

Britain's 24-hour culture

With the 'leisured society' a distant dream we're working longer and less regular hours than ever
Diplomacy board game: Treachery is the way to win - which makes it just like the real thing

The addictive nature of Diplomacy

Bullying, betrayal, aggression – it may be just a board game, but the family that plays Diplomacy may never look at each other in the same way again
Lady Chatterley's Lover: Racy underwear for fans of DH Lawrence's equally racy tome

Fashion: Ooh, Lady Chatterley!

Take inspiration from DH Lawrence's racy tome with equally racy underwear
8 best children's clocks

Tick-tock: 8 best children's clocks

Whether you’re teaching them to tell the time or putting the finishing touches to a nursery, there’s a ticker for that
Charlie Austin: Queens Park Rangers striker says ‘If the move is not right, I’m not going’

Charlie Austin: ‘If the move is not right, I’m not going’

After hitting 18 goals in the Premier League last season, the QPR striker was the great non-deal of transfer deadline day. But he says he'd preferred another shot at promotion
Isis profits from destruction of antiquities by selling relics to dealers - and then blowing up the buildings they come from to conceal the evidence of looting

How Isis profits from destruction of antiquities

Robert Fisk on the terrorist group's manipulation of the market to increase the price of artefacts
Labour leadership: Andy Burnham urges Jeremy Corbyn voters to think again in last-minute plea

'If we lose touch we’ll end up with two decades of the Tories'

In an exclusive interview, Andy Burnham urges Jeremy Corbyn voters to think again in last-minute plea
Tunisia fears its Arab Spring could be reversed as the new regime becomes as intolerant of dissent as its predecessor

The Arab Spring reversed

Tunisian protesters fear that a new law will whitewash corrupt businessmen and officials, but they are finding that the new regime is becoming as intolerant of dissent as its predecessor
King Arthur: Legendary figure was real and lived most of his life in Strathclyde, academic claims

Academic claims King Arthur was real - and reveals where he lived

Dr Andrew Breeze says the legendary figure did exist – but was a general, not a king
Who is Oliver Bonas and how has he captured middle-class hearts?

Who is Oliver Bonas?

It's the first high-street store to pay its staff the living wage, and it saw out the recession in style
Earth has 'lost more than half its trees' since humans first started cutting them down

Axe-wielding Man fells half the world’s trees – leaving us just 422 each

However, the number of trees may be eight times higher than previously thought
60 years of Scalextric: Model cars are now stuffed with as much tech as real ones

60 years of Scalextric

Model cars are now stuffed with as much tech as real ones