Last week, our medical team found itself between a rock and a hard place. A patient, who had come in with serious pneumonia had gone into respiratory failure. The patient was pushing a century, yet despite her compromised health status and her advanced age, her offspring – the primary health proxies – wanted everything done.
She was intubated.
Days went by with subsequent failed breathing trials, her children by her bedside, telling her to get through this. The possibility of a full recovery decreased on a daily basis.
She was not getting through this. This frail, elderly woman would eventually need a tracheotomy to create a permanent artificial airway to hep her breathe. She also had severe dementia. She was unable to eat in order to maintain an adequate nutritional status. She would need a tube surgically inserted into her abdomen to provide her with nutritional support.
Ironically, despite all this, her heart was strong, so medically she was objectively cleared to undergo surgery. Because her level of dementia categorized her as someone with no capacity to be able to make her own decisions, and she had no advanced directives, her children were in charge.
After multiple conversations with several members of the medical ICU and palliative teams and her nurses, the children, ridden with guilt, refused to consider the eventual, inevitable option of saying goodbye without undertaking extreme measures.
“I need to feel like I have done everything I could,” her son stated tearfully in one of these meetings, as he held his mother’s swollen hand, blue and bruised from the restraints needed to hold her down in order to not pull out the tube that was keeping her alive.
These kind of scenarios happen on a daily basis in ICUs across the country. Today at least 25% of health care spending in the U.S. goes to the 6% of people who die every year and ICUs account for 20% of all health care costs. Although human life at every age and in every condition is priceless, it is, inevitably, temporary; so when is it time to stop fighting nature? There is no magic number that we doctors can objectively rely on; we have no right to give families the green light to completely give up hope. Although we come close to playing God, we are after all not God. So we resort to empathizing … “If this was my mother, if this was my dad…”
An ICU stay is typically a blur of tubes, needles, IVs, and pumps. For the very elderly it is an invasive experience, with noisy pumps and heart monitors going off at all hours throughout the night, and a constant parade of medical staff shuffling through. With every patient and family I have seen through the pain of these decisions, these situations beg me to ask: If patients and family members saw what went on behind the scenes, would they be more willing to let go? If they knew how common their decisions were universally, if they understood this was just nature taking its course, would they feel less guilty? If the conversation had been ongoing for years, would they consider parents, grandparents, and loved ones to breathe their last breaths sooner, without the pressors, the needles, the tubes, the pokes and tube after tube of bodily fluids?