Between Life and Death

by Between Life

  In addition to the physical, emotional, and psychological toll of intensive care, ICU interventions themselves threaten medical complications. Nationwide efforts focus on reducing the incidence of hospital-acquired infections, 20 percent of which occur in ICUs.9 Many ICU treatments require catheters and tubes that create portals of entry for bacteria, doubling mortality rate.10 Breathing tubes, for example, increase the risk of pneumonia. Central lines (chapter 6) required for monitoring and medication administration risk bloodstream infections, and urinary catheters cause—you guessed it—urinary tract infections. Powerful antibiotics used in the ICU can kill bacteria helpful to our gastrointestinal system, paving the way for severe infections with limited treatment options. Paralytic agents, used to relax the chest muscles in severe respiratory failure, place patients at risk for profound weakness that can persist for weeks, prolonging ventilator dependence and ICU stay.11

  When complications arise from our treatments, they drive us into a state of chronic critical illness. Setbacks counteract small gains in recovery. We limp along in the ICU for months, becoming more debilitated and accruing more injuries as time passes. The outcomes of this cascade are disheartening: 50 percent of people with chronic critical illness die within a year.12 As we unabashedly strive for recovery, ICU measures themselves can steal our hope for cure.

  Far from Heaven

  Although God has blessed us with the capability to care for one another in remarkable ways, the man-made trappings of the ICU reside far from heaven. Our interventions are imperfect, as we are imperfect: “There is not a righteous man on earth who does good and never sins” (Eccles. 7:20). When a disease cannot be cured or even improved, aggressive ICU measures embody futility. They inflict suffering without hope of resolution and deprive us of the ability to pray, worship, commune with other believers, and meditate upon Scripture. To chase after futile treatments that deprive us of spiritual nourishment is to strive after the wind and to discount our hope in Christ crucified (Eccles. 1:14; 1 Tim. 4:10; 1 Pet. 1:3).

  To address end-of-life issues under such duress requires that we carefully tease apart the benefits and limitations of each intervention and carefully consider likelihood for recovery—all with God’s Word fueling our inquiry. In all circumstances, keep these questions in mind:

  Is the life-threatening process reversible?

  What is the best conceivable outcome?

  How much suffering does this treatment inflict?

  How will pursuit of this technology influence my walk with the Holy Spirit?

  Most importantly, the edifying clarity of God’s Word may guide us. As we strive to discern God’s will, the apostle Paul again offers wisdom:

  I appeal to you therefore, brothers, by the mercies of God, to present your bodies as a living sacrifice, holy and acceptable to God, which is your spiritual worship. Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect. (Rom. 12:1–2)

  A Shared Pain, but Not Punishment

  Before we move on, one more topic deserves attention. Families report higher rates of depression, anxiety, and complicated grief when they lose loved ones in the ICU, as opposed to in the home or in hospice.13 As was the case with the mother who held her daughter in her arms as she died, so deep is our heartache, so immense the pressures of end-of-life care, that we may doubt God’s love. We reason that if we suffer calamity, we did something to deserve it.

  At a cursory glance, this thinking appears consistent with principles undergirding the fall, Noah and the flood, and the destruction of Sodom and Gomorrah (Gen. 3:14–24; 6:5–7; 19:24–25). In such narratives, punishment for depravity descends swiftly and violently. The book of Proverbs teaches, “The wage of the righteous leads to life, the gain of the wicked to sin” (Prov. 10:16). Yet to use such passages to argue that our suffering is always deserved ignores myriad instances in the Bible when God engages with suffering not to punish but to accomplish tremendous good.

  After Joseph’s brothers hurl him into a well and sell him into slavery, the Lord raises him up beside Pharoah and saves his people. “You meant evil against me,” Joseph says, “but God meant it for good, to bring it about that many people should be kept alive” (Gen. 50:20). Before restoring a man’s sight, Christ explains that his blindness occurred not in penalty for sin but so “the works of God might be displayed in him” (John 9:1–3). Christ delays traveling to his dying friend Lazarus, whom he loves, so that in raising him from the dead he might glorify God (John 11). Even in the case of Job, the introductory chapters of his story reveal he is “blameless” in God’s sight and that the calamity that befalls him occurs not as punishment, but as part of a divine plan to defeat the adversary (Job 1–2).

  Such passages warn that we must never presuppose to know God’s intent for someone in anguish. God has infinite capacity to effect goodness in the midst of suffering. No theorems hem in his glory. The cross reveals in luminous brushstrokes our Lord’s mercy and grace and his overflowing love for us, made manifest in the death and resurrection of his own Son. In the most magnificent sacrifice the world has known, the Lord allowed suffering, not to punish us but to save us. The misery of ICU treatments need not stamp out our joy. Our hope wells forth not from our circumstances but from the Spirit residing in us through Christ crucified.

  Take-Home Points

  After initial resuscitation from an acute, life-threatening event, care transfers to the ICU for meticulous monitoring and support.

  Measures implemented in the ICU are organ supportive, not curative. They augment or replace the function of failing organs until the process causing critical illness can be reversed.

  If an underlying disease process is reversible, ICU technology can save life. If not, such measures prolong suffering and death.

  Both patients and loved ones report high rates of depression, anxiety, and post-traumatic stress disorder after critical illness.

  5

  Mechanical Ventilation

  When we declare, “I don’t want to live on machines,” we usually have a ventilator in mind. The very idea of breathing machines evokes nightmares from science fiction movies, with contraptions overriding the natural order of things and, in so doing, destroying our humanity. During the rare occasions when we consider ventilator support,1 such macabre imagery misleads us toward overly simplistic conclusions. Either we refuse a breathing machine under any circumstances, or in a burst of bravado we insist upon “doing everything.”

  A Complex Issue

  At the bedside, questions of breathing support are far more nuanced. Some cases involve a limited time on the ventilator, with a full recovery afterward. If we reject a ventilator in such circumstances, we risk carelessly discarding the life God has entrusted to us. In other situations, the ventilator controls every aspect of breathing and continues indefinitely without promise of improvement. If we insist upon treatment in the face of futility, we disregard the promise of new life in Christ.

  How do we discern our path? The question is not as much one of right and wrong as of recognizing God’s grace in either ushering us toward recovery or calling us home to heaven. Our job is to humbly walk the road he forges for us.

  To help us visualize the way, we will review the capabilities and limitations of breathing support—when they harm, when they help.

  At the Bedside

  Each morning I would stumble through medical questions, and she would poke fun at the overstuffed pockets of my medical student coat.2 To humor me, she would share recipes for her favorite dishes. I would pause in listening to her lungs as she retold stories of family reunions on the beach.

  Then, one day, her breathing quickened. She complained of nausea, and her lips paled to the color of nightshade. An alarm sounded as the oxygen level on her monitor dropped. I called for help. Moments later, a crowd of physicians and nurses rushed into the room. I retreated behind them as my supervising resid
ent forced air into her lungs manually with a bag mask.

  Her kidneys had failed, and fluid normally removed through the urine had backed up into her lungs. Dialysis would solve the problem, but in the meantime she needed a short period on a ventilator to support her breathing and keep her alive. She had no advance directive, so my team had an urgent conversation with her family.

  To our surprise and dismay, her family insisted she would never want to be on a ventilator. Period. Despite the urgings of my team, they remained insistent. They gathered around her to say goodbye, and an hour later, the room fell silent.

  The entire ordeal turned my stomach. That morning she had joked with me about my ridiculous pockets. That afternoon she was gone. I remembered our early morning conversations and grappled with the reality that she would never return to the seaside family barbecues she loved so much.

  Afterward my chief resident collapsed into a chair in the residents’ lounge with consternation darkening his face. He wrung his hands and stared at the floor.

  “There’s nothing you could have done,” a colleague offered.

  He shook his head. “This was not okay. She just needed dialysis. We’re only talking a day or two on the vent. That’s it.”

  “Her family said she wouldn’t have wanted the vent, under any circumstances.”

  “Not for two days? Really? How well did we explain things to them? Did we really explain that she could be better in two days?”

  As the medical student on the team, I listened to their conversation and silently wrangled with my own remorse. I remembered the distress that had washed over her like a tide, the panic widening her once jovial eyes.

  I feared we had failed her miserably.

  The Basics of Breathing

  Breathing (respiratory) difficulties threaten life because they disrupt the crucial exchange of oxygen and carbon dioxide to and from the bloodstream. As discussed previously, every cell in the body requires oxygen to produce energy. Each time we inhale, air fills our lungs, and oxygen enters the bloodstream. When we exhale, carbon dioxide, a by-product of cell metabolism, passes from the blood vessels back out into the air through our lungs. As our cells need oxygen, and as carbon dioxide is dangerous at high concentrations, this gas exchange is essential to life.

  Numerous processes hinder breathing, but, in general, we need a breathing machine for three main classes of problems: airway obstruction, excess carbon dioxide, and low oxygen.

  1. Airway Obstruction

  Your airway is the conduit that carries air to and from the lungs. It consists of your mouth, throat (pharynx), windpipe (trachea), and tubes that branch from your windpipe into your lungs (bronchial tree). Blockage of the airway is life threatening because oxygen can no longer reach your lungs. Conditions that create this emergency include:

  choking

  swelling of the airway from severe allergic reaction

  blockage of the airway from tumors, blood, or pus

  unconsciousness, for two reasons: (1) soft tissues in the back of the throat block the airway, and (2) inability to cough up saliva, vomit, or mucus

  When airway obstruction is imminent, clinicians place a silicone tube (endotracheal tube) into the windpipe to keep it open and connect the tube to a ventilator.

  2. Excess Carbon Dioxide

  Carbon dioxide makes the blood acidic, which in turn disables proteins that are vital for life. To thwart this process, our body triggers us to breathe faster and more deeply when carbon dioxide levels climb. If disease impairs removal of carbon dioxide through the lungs (a process called ventilation), carbon dioxide can rise to lethal levels. Examples of conditions that inhibit carbon dioxide clearance include:

  chronic obstructive pulmonary disease (COPD, also known as emphysema)

  sedative or pain medication overdose (e.g., from narcotics)

  thyroid disorders

  stroke

  brain injury

  widespread infection (sepsis)

  spinal cord injury

  disorders leading to muscle weakness, e.g., myasthenia gravis

  abdominal swelling that hinders movement of the diaphragm

  Supplying extra oxygen is not enough to treat problems with carbon dioxide. Such emergencies call for the support of breathing mechanics—the physical maneuvers of inhalation and exhalation—with a ventilator or BiPAP machine (see below).

  3. Low Oxygen

  A low oxygen level (hypoxia) is the most common indication for a ventilator. Causes of low oxygen levels are numerous and include:

  fluid within the lung tissue (pulmonary edema)

  fluid within the chest cavity (pleural effusion)

  infection of the lungs (pneumonia)

  obstruction of the small airways with mucus

  lung scarring (fibrosis)

  bleeding of the lungs

  clot within the blood vessels of the lungs

  Supplemental oxygen from a tank can treat mild hypoxia, but severe cases require the extra air pressure attainable only with a ventilator or BiPAP machine.

  This long list of conditions hints at the innumerable possible outcomes with ventilator support. In airway obstruction, the lungs often work normally, and you may be weaned from the ventilator as soon as the airway issue resolves. If you have excess fluid in your lungs, you may need only a few days of BiPAP support and no tube in your windpipe. On the opposite end of the spectrum, if you have severe emphysema and chronic weakness of your breathing muscles and develop a drug-resistant pneumonia, a ventilator may quickly transform from a temporary measure into a permanent fixture. When considering measures for breathing support, thorough discussions with a doctor who knows you well are crucial. Vague assumptions and sweeping generalizations will only lead you astray.

  An Overview of Mechanical Ventilation

  Mechanical ventilators, while a gift, remind us how technology falters in comparison with God’s perfect design. When we draw a breath, our diaphragm lowers, our rib cage expands, and the resultant negative pressure gradient siphons air into our lungs. The motion is smooth, unlabored, and elegant. In contrast, a ventilator helps you breathe by pushing air into your lungs. A breath on the ventilator is a maneuver of force. We can finely adjust targets in pressure and volume for each breath; however, the mechanism, and often the subjective experience, is unnatural.

  In the most benign of circumstances, a ventilator supports your own efforts to breathe. You trigger each breath yourself, according to your own natural rhythm, and the machine gives you an extra push. After delivering a set volume or pressure of air, the ventilator clicks off, and you exhale naturally. On such settings, the ventilator inflicts less discomfort. People who are struggling for air often report significant relief after going on the ventilator.

  On the other hand, mechanical ventilation for severe respiratory failure tightly controls lung mechanics with a precision so unnatural that you require sedation and paralysis to endure it. You may need to be positioned face-down in the hospital bed, which leads to significant facial swelling and skin sores. The recovery from such an ordeal lasts months, with prolonged ventilator dependence a distinct possibility.

  I first witnessed the distressing effects of mechanical ventilation not as a doctor but as a teenage daughter, when my father underwent an emergency operation. When he awoke from the surgery that saved his life, my mother and I sighed with relief. We had no idea that he, in contrast, was terrified. Still confused from his anesthesia, he gagged on the tube lodged in his windpipe, sensed the ventilator overriding his attempts to breathe, and panicked. While my mother held his hand and softly reassured him, he tugged against the restraints and signaled in desperation that something was terribly wrong. “I felt like I was suffocating,” he later explained. “I thought I was having a heart attack.”

  Decades later, I have watched my own patients endure the same unsettling experience. Some, especially the most severely ill, recall little from their time on the ventilator, remembering only the discomfort of endotracheal
tube removal. However, up to two-thirds of ICU patients recall details of intubation and ventilation.3 Afterward they describe pain, fear, loneliness, lack of control, anxiety, and lack of sleep.4 Inability to speak especially challenges people, with 50 percent of ventilated patients describing moderate to severe stress as they fight to communicate.5 These communication difficulties during ventilation are linked with anxiety and depression long after recovery.6 Furthermore, as with so many of our interventions in critical care, the ventilator itself can inflict injury. Delivery of excessively high volumes of oxygen and pressure can damage lung tissue, and in some cases this injury can collapse the lung. Additionally, up to 5 to 15 percent of ventilated patients develop pneumonia, which confers a mortality rate of 10 percent.7 Given these risks for suffering, those with severe baseline impairment or terminal illness should carefully deliberate with a trusted doctor about whether a ventilator will help or offer only anguish.

  Endotracheal Intubation

  Ventilators and endotracheal intubation go together; one always accompanies the other. With intubation, a clinician guides a silicone tube directly into your airway to ensure a stable connection between the ventilator and your lungs. As you can imagine if you have ever experienced water going “down the wrong pipe,” an endotracheal tube is highly irritating. The natural response to anything lodged in the throat is to cough and gag. Given this impulse to cough the tube out, most require sedating medications to prevent tube dislodgement. Furthermore, when you awaken from sedation, your first instinct is to reach for the tube, so wrist restraints are standard safety precautions in the ICU. This combination of disturbances—the sensation of a foreign body in your airway, followed by the realization that your arms are tied down—frequently incites panic. People on the ventilator often plead for tube removal, and those who have experienced intubation in the past loathe the idea of undergoing it again.