Between Life and Death

by Between Life

  My hands trembled as I dutifully fell into the rhythm my instructors had taught me. On the first compression, I tried not to focus on her troubling and vacant stare. On the second, as I sank my weight into her breastbone, the dear lady’s ribs cracked beneath my hands. The crunch of the bones flooded me with nausea. I fought the impulse to recoil, and squeezed my eyes shut to focus on the rhythm, the counting, and the protocol, rather than on the grotesqueness of each compression.

  She regained a pulse after twenty minutes of resuscitation but sustained severe brain injury, as well as bruising and bleeding of her lungs from the CPR. She spent her last days unconscious, fighting a ventilator. When her family realized cure was impossible, they made the heart-wrenching decision to focus on her comfort and let her go.

  Sadly, my introduction to CPR represents a disturbingly common scenario. Overall, only 30 to 50 percent of people who suffer cardiac arrest survive resuscitation, and only 6 to 15 percent live to leave the hospital.9 Of the small number of us who survive, 34 to 50 percent will suffer brain injury from oxygen deprivation, with deficits ranging from mild memory impairment to severe disabilities in language, attention, and thinking (cognition).10 Many of us who undergo CPR in the throes of severe illness will never return to our former selves.

  In addition, skeletal chest injury, ranging from broken ribs to a fractured breastbone, occurs in up to 90 percent of people who undergo CPR.11 As anyone who has sustained a rib fracture can attest, such trauma inflicts stabbing chest pain with each breath. Bones require immobilization to heal, yet ribs move every time we breathe. The recovery process is long and slow, and the simple act of breathing elicits pain.

  When administered judiciously, CPR saves lives. However, when the chances of survival from cardiac arrest are low, CPR looks and feels like defilement rather than care. To make informed decisions about CPR, we must clarify prognosis and likely outcomes, taking into account our unique medical history and with the gospel guiding our way.

  But before we plunge ahead, let us pause to explore the role of defibrillation in cardiac arrest.

  External Defibrillation

  External defibrillation refers to an electrical shock that resets the heart. This jolt of electricity is applied across the chest with paddles or pads, and it reverses abnormally chaotic heart rhythms (ventricular fibrillation) or rhythms that force the heart to contract too quickly (ventricular tachycardia). In each of these variations of cardiac arrest, defibrillation enables normal pacemaking cells of the heart to assume control again.

  While TV scenes of doctors wielding paddles wax cartoonish, they do capture the crucial impact of defibrillation on survival. The odds of surviving cardiac arrest from an abnormal ventricular rhythm are five times higher than for other causes, precisely because of the power of defibrillation to help.12 Approximately 25 to 40 percent of people who arrest from ventricular fibrillation survive to hospital discharge.13 Patients with unstable ventricular tachycardia fare even better, with up to 65 to 70 percent leaving the hospital alive.14 In contrast, only 2 to 11 percent of patients with cardiac arrest from other causes—e.g., complete interruption of electrical activity in the heart, bleeding, trauma, blood clots—live to return home.15 This dramatic discrepancy highlights the potential of defibrillation to save life.

  Defibrillation incurs little suffering. The region of the brain responsible for awareness requires tight regulation of blood flow, so in cardiac arrest, unconsciousness occurs instantly. While in other circumstances a jolt of electricity to the chest would inflict severe pain, in the case of cardiac arrest, we are unaware when paddles contact our skin. As with my young patient who awoke confused after a single shock, people who survive defibrillation rarely recall the event.

  On the other hand, a similar procedure, electrical cardioversion, uses a lower voltage of electricity to treat abnormal heart rhythms less severe than those causing cardiac arrest. People who require cardioversion are usually awake, and those who require it rarely tolerate it without intravenous sedatives.

  Putting It Together

  Most of us will encounter decisions about cardiac arrest either in the calm of our primary care doctor’s office or more urgently when it threatens a loved one in the emergency department or ICU. In all circumstances, candid, thorough discussions with a trusted physician are crucial. Our path requires careful review of the factors influencing survival and reflection upon Scripture to do as God requires: “to do justice, and to love kindness, and to walk humbly with your God” (Mic. 6:8). In short, we need to determine when to press on and when to relax into the embrace of our Lord.

  A host of factors influence the likelihood that CPR will help. Abnormal ventricular rhythms, for example, confer better chances for survival than other causes. On the other hand, you are less likely to recover if you require CPR for longer than five to ten minutes, or if you have multiple episodes of arrest requiring repeated CPR. If you survive initial CPR, factors such as abnormally low blood pressure, persistent coma, need for a ventilator, pneumonia, and kidney failure still all decrease your chances of leaving the hospital. Details from your personal medical background also play a role, with the following conditions decreasing the chances for survival after cardiac arrest, even with prompt provision of CPR:16

  preexisting cancer

  Alzheimer’s disease

  widespread infection (sepsis)

  severe stroke

  two or more chronic medical conditions (e.g., diabetes, hypertension, chronic kidney disease)

  heart disease, especially advanced congestive heart failure

  I do not suggest, in listing these conditions, that everyone affected by them should decline CPR. Rather, I urge you to consider, prayerfully and in collaboration with a doctor, how your individual circumstances will influence the outcome of CPR. Diseases vary in severity. As unique, loved image bearers of God, we all differ in our rigor, strength, and resilience. If your unique medical story promises a high likelihood of recovery from cardiac arrest, then as a steward of God-given life, you should carefully consider accepting CPR. On the other hand, if significant medical illnesses already enfeeble you, dogged pursuit of resuscitation might only delay death and incur suffering.

  To illustrate, let us return to the gentleman at the start of this chapter. He arrived in the emergency department with kidney failure and with a heart rhythm that defibrillation could not fix. He suffered from preexisting dementia and cancer, and required prolonged CPR. After he regained his pulse, he remained unresponsive, suggestive of brain injury and coma, and he also required medication to support a dangerously low blood pressure. With so many severe illnesses and injuries afflicting him, his recurrent cardiac arrest was unsurprising. His previous declaration of “do-not-resuscitate” reflected an accurate assessment of what CPR would mean for him.

  While in retrospect, the futility of CPR in this gentleman’s case appears clear, his daughter’s uncertainty reflects a common conundrum in end-of-life care. In the quiet and calm of a doctor’s office, decisions of aggressive care may seem obvious. When calamity strikes, however, the weight of guilt and grief bears down upon us, adding confusion and misery to an already heartbreaking scenario. In addition to the question of what our loved one would want, and how we will carry on without him or her, as Christians we also agonize over what God permits.

  When aggressive care is futile, a gospel-centered response recognizes that our earthly lives end, that God works for good even in death, and that through Christ’s resurrection, we belong to God. When we recognize that CPR will only inflict further harm, a view of the cross guides us to relinquish our grip on this world and commit our spirit into the hands of the Lord (Ps. 31:5; Luke 23:46).

  Whether we cling to the glimmers of life or resign ourselves to the certain end of mortal life that awaits us, let us seek to glorify the one who knows us, who molded our bodies, and who so loves us that he gave his Son so we might also know resurrection and life everlasting (Psalm 139; John 3:16; 1 Cor. 6:19–20; 15:50–
55). Even while death of the body looms, the Spirit endures. While we wait, we cling to the promise of the life to come: “I am the resurrection and the life. Whoever believes in me, though he die, yet shall he live” (John 11:25).

  Take-Home Points

  Cardiac arrest refers to interruption of blood flow from the heart to the body, either by an abnormal rhythm, by a structural problem with the heart, or from a noncardiac cause such as bleeding or blood clot.

  Because the heart delivers oxygen to all parts of the body, cardiac arrest is lethal.

  CPR and defibrillation are the two key interventions in cardiac arrest. When used wisely, they can be life saving. When used indiscriminately, they prolong the dying process and incur unnecessary suffering at the end of life.

  Determination of whether CPR and defibrillation promise to save your life or incur suffering requires a meticulous review of your medical history with a trusted doctor.

  4

  Introduction to Intensive Care

  After initial CPR, care for a critically ill person transitions to the ICU, where nurses and physicians provide meticulous monitoring and treatment using a wide array of technology. This chapter provides an overview of the purpose, promise, and limitations of ICU care.

  We begin at the bedside.1

  At the Bedside

  When jaundice yellowed my patient’s skin, her mother massaged her face and arms with jasmine lotion. When her eyes, vacant and bloodshot, darted about the room in delirium, photographs soon papered the walls, and favorite toys piled atop her. Daily her mother read Harry Potter aloud to her and recalled memories alive with the seashore and laughter.

  Three months earlier she had entered the ICU doors with her abdomen swollen with infection. After a dozen surgeries, impenetrable scar encased her intestines. Over and over, she would creep forward a few steps toward recovery, and then an infection caused by our efforts to keep her alive would topple her backward. The ventilator gave her pneumonia. The catheters that delivered medications to maintain her blood pressure clotted and caused infection. All the while, the bacteria smoldering in her belly, never completely eradicated, released molecules into her bloodstream that made her blood vessels leak and her limbs balloon to elephantine proportions.

  The day before my patient died, her mother crumpled into a hospital room chair and held her head in her hands. “She’s not going to make it, is she?” she asked, without raising her head.

  I didn’t answer, but the weight of my hand on her shoulder conveyed my opinion. She quaked with grief beneath my palm. We sat in silence for a long while, she drawing deep breaths of lament, I subduing my own breaths, which seemed so intrusive against the tenderness of her anguish. “I keep begging God to take out my heart, to keep it from breaking,” she finally whispered. “But I don’t even know if he’s listening anymore. My family says this happened to her because I stopped going to church. They say God’s punishing me. What if it’s all my fault?”

  The next day, my patient spiked yet another fever, and her blood pressure plummeted. We had used every antibiotic in our arsenal, and a multidrug-resistant infection—a microbe we could not combat—had overtaken her. She required continuous dialysis for kidneys that would not recover. Her liver was failing. Contusions blotched her extremities as clotting factors in her blood unwound and drifted limply. While the ventilator still gave her breath, and medications still squeezed her blood vessels and stimulated her heart, our options to cure her had run out.

  After a heart-wrenching discussion, her mother consented to discontinuing organ support. We would stop all medications, disconnect the ventilator, and focus on her comfort—and on saying goodbye.

  At the end, her mother climbed into the hospital bed with her. She wrapped her arms around her and clutched her to herself, enfolding her in the same warmth she had offered to her as an infant. With tears streaming, she gripped her, prayed, and issued promises into her ear. As we witnessed a heart flayed open, all of us—nurses, doctors, students—cried along with her.

  The Power to Support

  Intensive care medicine has progressed dramatically since Florence Nightingale, the nurse who served during the Crimean War in 1850s Europe, first separated the most severely wounded soldiers from others for specialized care. This groundbreaking prioritization of the sickest patients progressed to “shock units” in World War II, then to iron lung wards for polio patients in the 1940s. With the advent of new techniques from 1988 to 2012, mortality among ICU patients dropped 35 percent.2 Among people with chronic obstructive pulmonary disease, stroke, and heart attack, the survival benefits are even greater, with a 50 percent reduction in mortality.3 Through the grace of God, we now have a vast array of interventions to support nearly every failing organ system. (The chart in appendix 1 outlines ICU measures in our arsenal and the organ systems they support.)

  As a medical student I first witnessed the power of critical care to help. While on a rotation in pediatric surgery, I cared for a young boy whose abusive mother fractured his pancreas with a kick to the abdomen. In a matter of hours, his blood pressure declined, and his kidneys stopped making urine. His wide brown eyes disappeared as his eyelids swelled shut and his extremities ballooned. The pediatric intensivist and her team stood vigil at his bedside and fought to keep him alive until surgeons could take him to the operating room.

  Two months later, I glimpsed him cavorting through the hallways of the main pediatric ward. A nurse ran after him, and he cast her a mischievous smile as he propelled himself forward on his IV pole as if it were a scooter. Aside from that IV pole, he resembled any other young child—frivolous, bursting with energy. The machinery that had entangled him in the ICU helped restore him to himself.

  Yet despite its promise, ICU care has limits. As we discussed in the previous chapter, cues from popular media tempt us to envision life-sustaining treatment in shades of melodrama. While rescues happen, a depressing number of ICU occupants follow the trajectory of the tragic girl in the opening scenario of this chapter. The longer we require life-sustaining measures, the more complications tally up. Eventually, our bodies wither and break down, until we can no longer combat the diseases eroding them.

  Organ Support versus Cure

  The inspiring story of the boy who recovered from his pancreatic injury illuminates an important point about ICU care. The ventilator and medications that ICU doctors determinedly implemented during his darkest hours did not actually cure him. They kept him alive, but his recovery hinged upon surgery for his torn pancreas. Without that operation, the inflammation ransacking his body would have killed him, regardless of the ventilator pushing air into his lungs. Similarly, despite weeks of the most intensive therapies ICU care offered, the young woman in the opening scenario died because we could not clear the infection from her abdomen. Her ultimate recovery depended not upon the ventilator but on our ability to manage the infection that brought her into the ICU in the first place.

  This distinction between cure and support is critical. A ventilator cannot cure pneumonia. Cardiovascular medications cannot salvage dying heart muscle. Dialysis cannot kick-start the kidneys to function again. ICU measures like ventilators, vasopressor medications, and dialysis are supportive, not curative. They support failing organs until we can achieve a cure through other means—with antibiotics for pneumonia, a stent for a heart attack, or kidney transplantation for end-stage renal disease. Our ability to return a patient home depends upon our power to achieve cure; ICU measures only support organ function in the meantime. If we cannot treat the inciting illness, ICU measures will only prolong death. They may prod our hearts to beat a while longer, but they will never return us home.

  As the following chapters will illustrate, the efficacy of ICU interventions depends upon the reversibility of the underlying illness. If recovery is possible, then pursuit of aggressive measures may fulfill our God-given call to honor life (Gen. 2:7; Ex. 20:13; 1 Cor. 10:31). When no prospect for improvement exists, however, such interventions prolo
ng death and suffering, and obscure from our vision the glorious truth of Christ’s resurrection.

  A Hotbed of Suffering

  Some have difficulty envisioning how an ICU stay inflicts suffering. To help illustrate the experience, let us imagine a common scenario.

  You are rushed to the ICU for difficulty breathing. Doctors and nurses surround you, some of them shouting. They plaster you with monitors, cover your face with a plastic mask, and puncture your arms with needles. All the while, you feel like you’re suffocating. The doctors ask to place a tube into your windpipe and put you on a ventilator, but you don’t understand their words, and you are too panicked to respond. Suddenly your arm stings—they are injecting an anesthetic, but you don’t comprehend this—and you black out.

  Later, you awaken to find yourself in an unfamiliar room, with a tube lodged down your throat. The tube makes you cough and gag, and your eyes tear from the irritation. Instinctively you reach for the tube, only to find that your arms are tied to the bed. You scan the room in panic and discover a catheter protruding from your private parts. Frantic, you fight against the restraints. Your nurse gives you a sedative, and then the world goes dark again.

  A few hours later, when the sedation lightens, you awaken again, and the horror recurs.

  For those of us requiring the most aggressive treatment, these disorienting and frightening ICU experiences can feel nightmarish. Studies suggest that 60 to 80 percent of people who require a ventilator in the ICU suffer from episodic confusion, hallucinations, and delusions (delirium).4 In addition, physical pain and discomfort occur commonly. Prolonged bedrest weakens muscles to the point of wasting, and it freezes joints. Pressure upon wasted limbs opens sores in the skin that over time penetrate to bone. Tests involving needles and ultrasound probes occur daily. People with advanced cancer who die in an ICU suffer significantly worse physical and emotional distress compared with those in home hospice.5 Up to one-third of people who leave the ICU suffer from depression, commonly in reaction to pervasive physical disability.6 One in five people who survive an ICU stay endure the the unsettling flashbacks and nightmares of post-traumatic stress disorder (PTSD)—the same psychiatric illness that torments soldiers after combat.7 PTSD afflicts ICU survivors with similar frequency as it did American veterans from the Iraq war.8