Unrealistic families are so difficult to work with and you feel their desperation, but at the same time, them finding it hard to accept reality is making the end even worse for their loved ones.

I had a gentleman on our ward, terrible alcohol-related liver disease, physiologically much older than he is. Bedbound, legs contracted (when you don't stretch out your arms or legs, the tendons get tight), not been out of bed in a few months, recurrent aspiration pneumonia -- 3 episodes in a month -- from poor swallow (basically, your swallowing muscles are so weak, your saliva often goes down 'the wrong hole' into your lungs and that develops into an infection), did not tolerate an NG tube for feeding and couldn't eat proper food because of said poor swallow, ongoing drinking of alcohol, generally very frail, precarious kidney function.

His wife asked me during his five-month hospital stay if he could get a liver transplant.

He later gets readmitted -- it probably shouldn't have happened. His reserve is so terrible there is little we can do. Antibiotics likely won't work because that depends on a functioning immune system and he's just at further risk of aspiration pneumonias. Very little will upset the precarious balance his body is working with. He will just end up dying in the hospital if he gets admitted, after lots of blood tests, drips, invasive investigations. Whereas he can die at home surrounded by loved ones if he doesn't get readmitted. There is nothing we can fix. We've told her time and time again time is short, he has poor reserve, and if he does pick up he will never reach where he was a month ago, two months ago. He will stabilise at this very precarious spot before dying... assuming he can even stabilise.

His children are realistic. They understand how frail and how ill he is. They know even if he survives this episode, he will die in the near future.

His wife, however, begs me to do "something, anything" to make him live for another day, another two days, "because he wants to live." I was surprised a previous colleague had managed to make her understand that resuscitation would be futile in this patient.

Quality of life isn't something we get to determine but for someone who can't even sit up in bed, who can't eat or drink without choking, who has a long-term catheter, who gets washed and bathed in bed and cleaned when he moves his bowels -- what quality is there?