ICU

Waiting for a Miracle

“You understand that if your father’s heart stops we’re going to be pounding on his chest and shocking him to try to get it started,” I say to the family of Mr. Green, “There will many people in the room who you have never met inserting lines in his veins and arteries, drawing blood, giving him fluids, and it will be controlled chaos. If we get him back he will just be even more critically ill than he is now and the next time his heart stops we will repeat the same routine.”

Mr. Green is eaten up by cancer which has metastasized everywhere including his brain. It seems difficult for the family to understand the connection with this and the large fungiating, bloody melanoma on his right big toe. (“Can’t you just amputate his toe?”) He is on the ventilator and is also on a pressor drip (levophed, or epinephrine) to maintain his blood pressure. To say he is not doing well would be an understatement.

“We understand that, Doctor, but we’re praying for a miracle.”

This is by far the worst part of this ICU rotation. Everybody likes to deliver good news but in the ICU it is often necessary to concede defeat. Resident or not, whatever your level of experience you become the point-man of the whole medical profession and it is your job to explain that whatever propaganda the family may have heard, there is no cure for death and when it’s time to go, it’s time to go.

“I’m a religious man myself,” I begin, carefully choosing my words, “And I believe that God watches over all of us and will not abandon us in our time of need. But I also know that any further treatment for your father is only going to put off the inevitable. I can’t tell you how long he has. It may be twenty minutes, it may be a week. I don’t know. But I can say with certainty that we have come to the limits of our ability to do anything but briefly prolong his and your suffering.”

Distressed look from the family.

“So I believe that the best thing to do is to keep him comfortable,” I continue, again choosing my words very carefully, “Trying our best to preserve his peace and dignity.”

“Do we have to decide right away?” asks Mr. Green’s oldest daughter, “We would like to get more of the family involved.”

“Please, take all the time you need. Have the nurse page me when you come to a decision.”

The decision is to change his code status from “full code,” meaning that every effort will be taken to restart his heart and support his breathing, to “Do Not Intubate/Do Not Resuscitate (DNI/DNR).” A simple decision from the point of view of the physician and nurses but incredibly painful for the family who have a lifetime of history with Mr. Green.

A critical care physician once related to me the story of a patient of his who at the age of 82 and after a lifetime of diabetes had developed renal failure requiring dialysis three times a week. He was completely blind, a triple amputee, unable to speak as a result of throat cancer, and had right-sided heart failure from COPD. He had recently undergone a partial colectomy for ischemic bowel and had a colostomy. He was fed via a PEG tube (Percutaneous Endoscopic Gastrostomy) and breathed through a tracheostomy on supplemental oxygen. As one last insult he had recently suffered an MI which burned out a significant portion of his left ventricle dropping his ejection fraction, already low from the right sided heart failure (which drops cardiac output by decreasing amount of blood to the left side of the heart) to something barely compatible with life. But he clung to life and communicated that he wanted every measure taken to keep him alive.

“You know,” The physician said to me, “In Europe they would have let this guy go five years ago. There’s no way they would expend the kind of resources we have to keep him alive.”

“What do you think about it?” I asked.

“I think it’s a tremendous testament of the will of the human spirit to live and I’ll do everything I can for the guy.”

So there’s the problem. When do you keep a patient alive even when treatment appears to be futile? In the case of a patient who can make his own decisions the answer is clear. You do what he asks. When the family acts as a surrogate the decision is a lot more complex. In the case of Mr. Green, the oldest daughter took me aside and confided to me that her brother and her father had had a falling out several years before and had never patched things up. The brother was the strongest advocate for taking all possible measures to keep his father alive.

It would not be too much of a stretch to believe that guilt played some role in the son’s attitude towards his father whose death would leave a lot of important things unsaid, perhaps an apology and a reconciliation.

But that’s how it goes in the ICU. Some patients get better. Some get worse and die despite your best efforts. And some come in and make you wonder why they were admitted because nothing can be done beyond comfort measure.. The ICU shouldn’t be a place for hospice or palliative care but it is sometimes used for this purpose.

ICU