A Few Thoughts on the ICU

I'm finishing my rotation in the ICU. It is an immensely interesting place to work, but frustrating as well. To my surprise, I do not find the degree of suffering and high mortality depressing. I am sort of happy - relieved - when patients expire (the medical term for die) because most of what we do in the ICU is prolong death, and by extension, pain and suffering.

The moral conundrum encountered daily in the ICU is that we have advanced technology to keep people alive even when a disease process is inevitably leading to death and is medically irremediable. Family members, staff, physicians, and even patients themselves who are still lucid, often conflate the benefits of life support therapy with medical progress. The fact that a ventilator and blood pressure medicines keep dad from dying is interpreted as possibility that things may turn around. In these stressful times people listen to what they want to hear. They cling desperately and hopefully, to small, but medically trivial, "positive" changes in body function - such as blood pressure - from one day to the next.

Family members often want to know "the numbers" - the results from lab tests, vitals signs, and so on. I am learning, however, it is often counterproductive to discuss this data in much detail. A 1-point increase in hematocrit (red blood cell concentration) will be taken as a sign that dad's still hanging on, when in the context of all the other data, it may very well be meaningless. Sure, you tell the family that, "well, the overall trend is such and such, and that number does not necessarily mean so and so" but like I said, people hear what they want.

In other areas of medicine I am very much a proponent of transparent communication. Tell the patient the data, give him a sense of what they mean (to my best medical opinion), elicit questions and then let him decide what to do.

So why is that a problem in the ICU? Most lay people with a loved one dying in the ICU grossly underestimate the severity of the disease process at hand, while at the same time they overestimate the ability of modern medicine to reverse that process. Also, many people dying in the ICU have several organ systems failing, and putting the whole picture together can be very complicated, even for someone who's medically trained. Most people can easily understand the prognosis of a back sprain or even a heart attack, but that of a critically ill patient is altogether different.

For me the most frustrating thing about the ICU is that we are often too focused on preserving life at all costs and loose sight of what the patient might want, what is the likely outcome for the patient even if they do survive, and their pain as we keep them alive. There is a lot of guilt that drives decision making in the ICU, both among family members and doctors. We forget that it is the disease that kills a patient, not the withdrawing of life support. Even people who feel it is a Christian duty to preserve the sanctity of life at all costs seem to forget that it was God who inflicted the disease on this patient in the first place, and that all our life preserving interventions just obstruct the natural process he has willed into existence.

The ICU, as many people may guess, is incredibly expensive. Nowhere in medicine have I seen such exorbitant, egregious use of health care resources. It sounds heartless to insinuate that every patient comes in with a price on their life. But honestly, who ends up paying for a 2-week stay in the ICU with several very expensive medications, CT scans, MRI scans, and so on? Some of the debt is carried by the family, others by the insurance company or hospital, which is to say, the rest of us in the form of higher premiums. One patient I admitted for fulminant alcoholic liver failure recently died after 3 weeks in the ICU. At $3500/day that's over $70,000 just for the room. I think this is a fair price to pay for someone who has a reasonable chance to survive the disease (this guy's pre-hospital mortality was 60% within 3 months) and a reasonable chance of returning to be a functional member of society.

I know that's not a warm-and-furry approach to life; but then again I didn't invent alcoholic liver disease; that's just reality of life and death. Of course most situations are gray and drawing the line between a good and poor prognosis is notoriously difficult and inaccurate. However, there is no doubt that a more open cultural attitude about death and socialized medical system in which health care budgets were fixed, would allow us to more clearly mark that line without guilt. And that I think would be better for all of us, including dad.