Is it time to unplug...

A couple days ago, one of the ICU nurses was telling me that she has seen a lot of patients come into the ICU, often in such bad shape, she was sure they would never leave. Yet, more often than she expected, these patients who had death cloaking their very breaths would leave the ICU alive. At the same time, she has seen patients who were sitting in their beds, eating dinner and then dying within a half hour, their lives lost to a paroxysmal death. She told me that these experiences convinced her it is God who determines the outcome.

I really enjoyed that insight from her, for God is rarely mentioned or considered in the ICU. You are too busy calculating corrected calciums, interpreting ABGs, or figuring out vent settings to remember that a little prayer for the patient could only help in the midst of placing central lines, G tubes or peering into the patient's body with CTs or xrays...

The remembrance of God also seems surprisingly absent when it is time to make decisions about the final disposition of patients in the ICU. Today, the daughter of one of my patient's decided it was time to transition her mother to hospice and withdraw the ventilator.

I feel sad for the patient. She cannot talk, she cannot move herself, her heart beats too fast and in an irregular rhythm, her lungs don't work well enough to allow her to breathe on her own, her kidneys are failing, her body is swollen with fluids, and she has a huge ulcer on her back that goes down almost to the bone. That's only a few of the things wrong with her...

Despite all this, she still opens her eyes and looks around the room. She will still wince when in pain. To me, she is very much alive. Although she does not seem to gaze in a particular pattern, and will not track your movements, her eyes do open and move about. The nurses, and I, feel that sometimes she understands what we're saying or doing, though we have no objective evidence of that at all.

I feel like we should still fight for this patient, that there is still hope for her. Yet all the physicians, nurses, residents, clergy and, now, even the daughter, feel like she has gone beyond hope. That she is in some sort of living death and that it is time to remove the ventilator and see if she will complete the journey or, miraculously, remain.

As we were discussing the case, prior to meeting the daughter, a priest working for the hospital said he felt it was a moral sin to keep such people going when there was no benefit, no real chance for survival, that we were only prolonging their suffering.

I found that comment strange coming from a Catholic priest, as I always thought the Catholic Church thought highly of those who endure suffering, in line with the Christian belief that Jesus (peace be upon him) suffered on the cross so humankind would be forgiven for their sins. So I would have expected some other line of reasoning to support withdrawing care, one not based on notions of suffering, but rather on notions of beneficence, mercy, etc.

Of course, Muslims do not believe Jesus (peace be upon him) suffered on the cross, rather he was miraculously lifted to Heaven and thus never crucified. For us, forgiveness is not dependent on anyone's suffering, but rather on our repentance and God's Grace and His Love of Forgiving...

Yet it seems the entire question of whether or not to continue my patient's treatment hinges on the notion of suffering, or quality of life. The argument is made that withdrawing care will benefit her more because it will relieve her of suffering and because further treatment is futile, that no meaningful recovery is likely.

I don't think any of us really know how much my patient is suffering. The only real objective sign of suffering we get are the winces, and changes in respiration and heart rate, when we insert a central line. Many studies, in fact, have revealed that physicians are remarkably bad at assessing a patient's suffering. Surveys that asked patients with disabling conditions about their quality of life, almost always rate it higher than the physicians or nurses who treat them...if we make that mistake with people who have their cognition intact, than why should we be any better with people who do not?

I think we need to remember God in such situations and ask whether or not He has given us any guidance on this issue. Rather than focusing exclusively on the patient's quality of life, or suffering, we should also consider the inherent sanctity of life, and the tremendous virtue associated with protecting and preserving life placed by all Abrahamic faiths. I am sure we would find the guidance if we devoted more of our efforts to pursuing it...

One other factor one must not ignore is the economic incentive that exists to withdraw care. It is "cheaper" for society to unplug, and it consumes far less resources if you decide it is time to let the patient die a "natural" death. Sometimes patients have to make the horrendous decision of how to pay for expenses for such care, and some may feel forced by economic circumstance to pull the plug. Economics muddy up the waters, and many family members feel great guilt in such situations.

In the end, I still find myself at something of an impasse. Rationally, I can understand the arguments in favor of withdrawing care. Emotionally, I refuse to pull the plug, to cut loose the one tether they have to this world and, along with it, all hope of them ever coming back.

Once my patient is transferred to a hospice, she will be made as comfortable as possible and the ventilator will be withdrawn. The outcome, as it has been all along, is God's decision. I only hope we all made the right one in bringing her up for judgment...