Life and Death

The razor’s edge

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Death was reduced to a line on a page. It was my last night in the ICU and I found myself staring at my “list,” my list that was vital to mine and my patients’ survival. The list detailed each patient on the service, contained scribbled notes from turnover, and rapidly accumulated more pertinent scribbles throughout the night. It was a “task” list with essential, amplifying information –  a list recently shortened by one patient…again. The patient’s row now contained a sinusoidal ink wave indicating his demise. There were no more interventions to perform. No more labs to follow. He was now a scribble on a page. The irony hit me. Just hours previous he was alive. Not well, but at least alive. And now he was gone. Erased by a serpentine line. Life is sacred here, but death so common that the gravity of each passing faded – until that moment of tranquility when clarity prevailed.

Critical care is fascinating, the herculean feats that we as humans perform to rescue each other is staggering. We jam tubes down throats and artificially breathe for patients whose lungs are failing. We insert large plastic lines into necks and chests and groins to infuse lifesaving medications that ensure perfusion to vital organs. We add one, two, three, and sometimes four pressors for low blood pressures that refuse to respond, and then inotropes to augment the cardiac output of weak hearts. We filter toxins from the blood with intricate complicated machines that substitute for failing kidneys.  Electrolytes are replaced aggressively; antibiotics for infections, fluids for hypovolemia, feeding tubes for nutrition and improved healing. Numerous labs and studies and procedures are performed repeatedly. We consult experts from the various specialties for their recommendations. We acutely resuscitate and then stabilize, and after wrestling patients from the grips of death we commence the “de-resuscitation,” or normalization process.

But knowing when to stop is just as important as knowing when to go. As one attending stated this month, “There are three types of patients in the ICU. Those who need us to acutely intervene to save them, those who need us to leave them alone so they can heal, and those who need us to help them die comfortably. And knowing the difference is the art.” Initially, everyone gets the “kitchen sink,” our “full court press.” We do everything we can to save them. But sometimes, after hours or days, we realize the futility of our efforts. No matter what we do the patient will die, and we are only momentarily prolonging death.

Then after family discussions, we change the patient’s “code status” to “DNR/DNI,” or Do Not Resuscitate Do Not Intubate. If the patient stops breathing and loses a pulse, we will not perform CPR or insert a breathing tube since the probability of recovery is so abysmal. Occasionally, the prognosis is so poor we resort to “Comfort Care.” In those moments, we consciously terminate our resuscitation, we withhold our herculean efforts, and allow death to occur naturally as it has for millennia. We quietly exit the room, allow the family to gather around their loved ones to say their goodbyes, and then we make them comfortable as they silently pass into the night.

My thoughts wandered as my eyes traced that curvilinear line. The boundary between life and death is so fragile, our patients waver on that razor’s edge every moment. We save those we can and allow the others to pass comfortably and with dignity. “MEDICAL RESPONSE TEAM, CODE BLUE…” The overhead announcement shattered the silence. I snatched my list and jogged down the hallway again toward that razor’s edge.

-Brad

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