Death in the ICU

6a00e552e3404e88330133f0d2ee1c970b I just finished a rotation in the intensive care unit (ICU). This particular unit was surgical and neurology, mostly. Dispersed amongst the large number of my patients who had brain bleeds was the esophageal variceal bleed, the diabetic ketoacidotic patient, and the handful of motorcycle trauma patients who were often only in their 30s or 40s. Most of the brain bleeds left the patient severely disabled, often requiring mechanical ventilation to breathe and many medications to increase blood pressure and decrease brain swelling.

Admittedly, I find it exciting to help with a code, a.k.a. cardiac arrest, which happens frequently in the ICU. I enjoy the rush that comes with potentially stabilizing and saving a patient’s life in minutes. Considering about 1% of true cardiac arrests are revivable, of course I would never wish it upon a patient. I chose to do this rotation so that I would be involved with a number of codes and help guide very ill patients either to recovery or to a peaceful goodbye. Many of the patients had the latter.

Death and dying can be scary things. For families who are watching their loved ones deteriorate, they struggle to make decisions about what to do next. The hardest part is to have the family decide what the patient would want – to possibly survive only to be paralyzed on one side and in a nursing home at age 40, or to leave memories of his or her time alive as a well, fun, successful, loving, etc., person. Many families seem find it difficult to let go, but often the patient would not have wanted to live so disabled.

As a physician, the role is to help families differentiate between their own desires and the patient’s wishes. It can be difficult not to cry, but explaining things from a medical standpoint is a mature coping mechanism that works nearly every time. I have had to console parents as they cried over their deteriorating son or daughter and told me, “this is not how it’s supposed to be.” They already buried their parents, and they always assumed that their child would bury them, not the other way around.

At the end of the day, the right answer is always, “what would the patient have wanted before he or she was in this state today?” Answering that question accurately is true love, even if that means stopping any further interventions and letting that patient give his or her peaceful goodbye.