Between Life and Death

by Between Life

  In addition to inflicting significant discomfort, intubation increases risk for pneumonia. Within as little as a few hours after intubation, a film of bacteria lines the inner wall of the tube, creating a reservoir that can infect the lungs.8 The risk of pneumonia increases with every day spent on the ventilator and is a major source of mortality in the ICU.

  Tracheostomy

  After seven days of intubation, pressure from the endotracheal tube ulcerates the vocal cords and can scar the windpipe.9 To avoid these complications, doctors often recommend tracheostomy (trach, pronounced “trake”) for anyone on a ventilator for more than two weeks. In this procedure, a tube is surgically inserted through the neck and into the windpipe, just below the Adam’s apple. The endotracheal tube is then removed from the mouth, and the trach is connected to the ventilator.

  At first glance, the idea of surgical connection to a breathing machine seems subversive, even ghoulish. However, life with a trach can trouble us less than we might presume. When struggling through critical illness, the ability to communicate your thoughts, concerns, and fears can offer solace. Tracheostomy facilitates this interaction, even while you still require the ventilator. Removal of the endotracheal tube from the mouth eliminates the need for sedation and allows you to mouth words, write, or use letter boards to communicate with clinicians and loved ones. Eventually, a tracheostomy permits you to transition off the ventilator and undergo speaking trials, with a plan to remove the trach altogether when you no longer require breathing support.

  The most important question to consider with tracheostomy is whether, in your unique circumstances, the procedure implies long-term ventilator dependence. If a trach is another step toward recovery, we may embrace the risks. On the other hand, if it signals a prolonged death while ventilator dependent, we should question its worth.

  Noninvasive Positive Pressure Ventilation

  In some reversible cases of breathing failure, a less-invasive option of lung support called noninvasive positive pressure ventilation (NIPPV) can help. Also called CPAP or BiPAP depending on its settings, NIPPV is essentially a ventilator connected to a face mask. I will use the most familiar term, BiPAP, for the rest of this discussion.

  While you’re on BiPAP, clinicians strap a tight-fitting mask to your face, and the machine provides extra air pressure with each breath you take. As you require no tube in your windpipe, you remain awake and communicative, and the mask may be removed and replaced at intervals with little consequence. BiPAP is most effective for quickly reversible problems, e.g., fluid in the lungs or a severe asthma attack. Over the last decade, BiPAP has also entered the homes of people suffering from sleep apnea.

  Although less obtrusive than a ventilator requiring a tube, BiPAP does confer risks. If you have claustrophobia, you may tolerate the tight-fitting mask poorly. BiPAP requires you to initiate your own breaths, which may not be feasible in severe illness. The constant flow of air into the mouth risks stomach distension and vomiting as well as impaction of oral secretions within your lungs. These latter points render BiPAP a bad option if you are drowsy and confused,10 as without the ability to cough you can easily develop pneumonia. More ominously, in cases of acute respiratory distress syndrome (ARDS), a condition in which widespread illness triggers lung damage, BiPAP actually worsens survival.11 Furthermore, if a trial of BiPAP fails, the risk of death is actually higher than if a ventilator with a tube was used from the start.12 Those of us with rapidly reversible causes of respiratory failure stand to benefit most from BiPAP; those of us with more insidious breathing difficulties may suffer further harm from it.

  Transient Support versus Prolonged Ventilator Dependence

  When we cite our wishes against a breathing machine, we are often thinking about long-term ventilator dependence. We may not consider the instances when a brief period of support promises to return us home. For example, everyone who undergoes general anesthesia for a surgical procedure requires a brief period on a ventilator. Even a simple operation for appendicitis or for a diseased gallbladder requires a short time of ventilator support. Few of us object in these circumstances, because we anticipate that after completion of the operation the tube will be removed, and we can go home.

  Remorse still gnaws at my heart when I think of my patient from medical school days who died from fluid in her lungs. Would she really have refused a ventilator if she had known that her breathing difficulties would resolve in two days? When a breathing machine promises to restore us to a full recovery, many of us will accept its temporary discomforts. And as God’s image bearers, we often should.

  On the other hand, for those of us with crippling baseline lung disease or those walking in the twilight of life, the arduous experience of mechanical ventilation may worsen our suffering needlessly. Weaning from the ventilator increases in difficulty as days in the ICU accumulate. The more support a machine provides, the less work our muscles perform to breathe. With disuse, these muscles degenerate, and eventually we lack the strength to breathe independently. The longer we remain on a ventilator, the greater the challenge to free ourselves from it.

  Yet even here, we must be careful not to overgeneralize. We may develop ventilator dependence but suffer little if we still engage with loved ones and partake in activities we find meaningful. For example, people with profound weakness from neurological diseases may require a ventilator long-term but can still enjoy life-giving fellowship. To ascertain for ourselves, and for our loved ones who cannot speak, the best course of action regarding ventilator support, we must pay close attention to the clinical outlook at hand, the duration of ventilation in question, and most importantly our unique attributes that render such treatments as paths either to desolation or to hope.

  As we tackle the issue, the scriptural principles introduced in chapter 2 must guide our hearts and minds. Given our unique story, does a ventilator promise preservation of God-given life or prolonged suffering and death? How does it influence our ability to serve God and to live out the fruit of the Spirit (Gal. 5:22–23)? How can you provide Christian witness as your own breath fails?

  The following additional questions may guide you as you contemplate your situation. Ideally, such deliberations should occur in depth, with a doctor, tailored to your individual narrative, and before life-threatening illness robs you of speech.

  How will the diseases I manage daily influence my ability to wean from a mechanical ventilator?

  In cases of mechanical ventilation among loved ones, how reversible is the condition driving respiratory failure?

  For how long can we anticipate a need for the ventilator?

  What is the likelihood for long-term ventilator dependence?

  Trust in the Lord

  When faced with the tragic challenges of modern medicine, we take refuge in the God who knows us: “O Lord, you have searched me and known me! You know when I sit down and when I rise up; you discern my thoughts from afar” (Ps. 139:1–2). We revel in the gift of his Word, which itself is “breathed out by God” (2 Tim. 3:16). While our days in this world vanish on the wind—“Surely all mankind stands as a mere breath” (Ps. 39:5)—his breath unseats mountains and weaves galaxies (Pss. 18:15; 33:6). Even if we gasp for air, he is with us. We rest in the assurance that he loves us and that he sent his Son to die for us so that we might know him. Whether we breathe with the aid of a machine or relinquish our breath at life’s end, we have the hope of the risen Christ. Remember that when all is finished, we will breathe anew (1 Thess. 4:13–18).

  Take-Home Points

  Mechanical ventilators support breathing in the setting of respiratory failure.

  The ramifications of ventilators vary. In reversible conditions, ventilator support is often transient and minimal. In severe illness, ventilators assume complete control of lung mechanics, require sedation to tolerate, and can progress to long-term ventilator dependence.

  Ventilators incite emotional turmoil from fear, loss of control, and an inability to communicate, as well as di
scomfort from the breathing tube.

  Whether a ventilator offers promise of life or prolongation of death depends upon the likelihood of weaning from it. Baseline health conditions, reversibility of respiratory failure, and degree of ventilator support influence the outlook for recovery.

  6

  Cardiovascular Support

  Vasopressors, Inotropes, and Lines

  Medications that support blood pressure and heart function (called vasopressors and inotropes, respectively) garner little controversy compared with CPR and ventilators, but they can still create a conundrum for the loved ones of the dying. These powerful drips are ubiquitous in the ICU, and in many circumstances they serve as a barometer for the severity of an illness. Families at the bedside quickly learn that a decreased dose of medication written on a nurse’s hourly flowsheet means “better” (as less support is needed), and they cling to this tangible reflection of a loved one’s progress.

  Unfortunately, critical illness is much more complicated than this simplistic correlation implies. While in clinical practice, I regretted the frequency with which loved ones, heartened by an improving vasopressor requirement, struggled to comprehend a family member’s imminent death. From the vantage point of the ICU doorway, it can be difficult to discern that a declining dose does not always signal recovery. In this chapter I hope to illustrate the uses and limitations of these medications so that in critical situations, we can better understand how they function. Throughout, let us draw our peace from the assurance that Christ has overcome death. “For this light momentary affliction is preparing for us an eternal weight of glory beyond all comparison” (2 Cor. 4:17).

  At the Bedside

  For three months, his family took shifts and rearranged schedules so he would never suffer alone. They relinquished wages and graduations so that throughout the long days and nights, while nurses wiped sweat from his brow and drew blood, love would linger with him.

  His life before the hospital had been rich yet fragile. He filled his days with card games, grandkids, and pondside strolls, but he engaged in these from his wheelchair, with his portable oxygen tank his constant companion. As the days in the ICU mounted, those moments of cards and water seemed increasingly remote. The days meandered like an ancient winding staircase. Sometimes they inclined, wound, or crumbled, but overall they proceeded downward.

  He was never weaned from the ventilator. After three months the machine still creaked and sighed through his tracheostomy like a bellows. A continuous dialysis machine hummed in the corner of his room. He spent most of these days clouded in delirium, although he would occasionally scowl. Every so often, in a fleeting burst of lucidity, he would shove his nurse away during an attempt to clean him or to dress his bedsores. Their eyes would lock, and the nurse would try to steel herself beneath his fierce gaze as he mouthed, “No!”

  His family exchanged worried glances whenever he protested ongoing care. Yet when the nurses gently inquired about changing his care goals, dread blanched their faces. Through a sheen of tears, they would scan the room for an escape.

  They found a foothold in the array of bags, pumps, and tubing that dripped medications into his veins.

  “How much blood pressure medicine does he need today?” they would ask.

  “The same as yesterday. The vasopressor dose hasn’t changed,” the nurse would answer.

  “Well, that’s good news!” they would exclaim. “That means he’s stable!” Their enthusiasm mismatched their haggard expressions.

  The morning he died, his bloodwork revealed shutdown of nearly every organ system. He had already lost function of his lungs and kidneys. Under the stress of yet another infection, his liver also failed, and his blood could no longer clot. He sank into irrevocable multiorgan failure.

  We met with his family to guide them through the end. After we laid out all the harrowing details, they held one another and wiped tears from their eyes. Yet they remained unconvinced.

  “I don’t understand,” one of his sons said. “You’re telling me everything is worse, but his vasopressors are the same dose as yesterday. They haven’t gotten worse. It doesn’t seem like he’s dying, based on that. I think we should keep going.”

  “The vasopressor dose is just one piece of the puzzle,” I tried to explain. “His lab results show us that his organs are failing. Soon, his blood pressure will follow.”

  “Well, I think we should wait until that point. I say we keep going until God makes it abundantly clear to us.”

  “He’s in a lot of pain,” his nurse interjected with concern. “He’s dying. We shouldn’t prolong it.”

  “I don’t agree that he’s dying,” his son shot back. “I mean, you’re always writing these numbers down, every hour. Now you’re telling me they don’t matter?”

  We agreed to continue treatment but not to escalate any doses of his medications. In a few hours, the patient’s blood pressure drifted downward. As the numbers slunk into ominous territory, his family agreed to transition to comfort-focused care. They crowded around him, as they had for so many months. They alternated between holding his hands and stroking his forehead as they said goodbye.

  The Basics of Blood Pressure

  Most of us in the US worry when our blood pressure is too high. We cut salt from our diet, exercise, and take medication so that when we sit upon the examination table and the blood pressure cuff squeezes our arm, our doctor smiles and repeats a “good number”: 120/80, 110/70, or maybe even 100/60. Such lifestyle changes to lower blood pressure protect against heart disease, kidney failure, and stroke.

  In the ICU, severe illness creates the opposite problem. When blood pressure falls too low, our blood can no longer deliver oxygen throughout the body. Cells soon die, followed by the organs they constitute, and fatal multiorgan failure ensues.

  Blood pressure plummets when at least one of the following mechanisms fails:

  1. the pump action of the heart

  2. the volume of blood in our blood vessels

  3. the ability of blood vessels to constrict and dilate

  In bleeding and dehydration, for example, blood pressure drops as the volume of blood in our vessels decreases. In heart failure, the heart cannot contract with sufficient strength to produce adequate blood pressure. In severe allergic reaction (anaphylaxis) or widespread infection (sepsis), blood vessels inappropriately dilate and cannot maintain the resistance necessary for normal blood pressure. The umbrella term for all these conditions is shock, i.e., inadequate blood supply to the organs. In all cases of shock, restoration of blood pressure to the organs is essential to survival.

  Vasopressors and Inotropes

  Infusions of blood or fluid into our veins can treat shock from bleeding or dehydration but at other times inotropes and vasopressors are necessary to maintain blood flow to organs. Infusions of these medications run continuously, and nurses carefully adjust the doses to meet specific targets.

  Inotropes enhance the ability of the heart to pump and are useful in cases of heart failure. Vasopressors (or pressors), on the other hand, constrict blood vessels that have inappropriately dilated. Every blood vessel in the body contains a layer of muscle, and under normal circumstances, this muscle tightens and relaxes—much like your bicep—to regulate blood pressure. When blood vessels dilate inappropriately, the blood pressure falls to dangerous levels. Conditions that trigger this phenomenon include infection and allergic reaction, spinal cord injury, brain injury, and medications that sedate or treat pain. In such instances, pressors constrict blood vessels to restore normal pressure. Examples of popular vasopressors and inotropes are listed in the glossary.

  Most pressors and inotropes are so powerful that they require the use of specialized catheters for safe administration and monitoring. We will next review these catheters, so common to ICU care.

  Central and Arterial Lines

  Inotropes and pressors are given through specialized catheters that allow medical staff to infuse these powerful drugs safely a
nd to monitor their effects moment to moment. The two most commonly used catheters in the ICU are arterial lines and central lines. Most of us admitted to the ICU with severe illness will require one, if not both, of these lines, and during long ICU stays we may need them replaced several times.

  Arterial catheters, often called “A-lines,” measure blood pressure continuously. They are usually placed in the wrist, but sometimes they will be inserted into an artery in the elbow crease, underarm, or groin. They instantly detect changes in blood pressure and are more reliable than the traditional blood pressure cuff used in doctors’ offices. They also permit frequent blood draws without repeated needle sticks, and when connected to specialized devices they provide information about the function of the patient’s heart.

  Central venous catheters, commonly called “central lines,” are threaded into a large vein close to the heart. They administer powerful medications more safely and effectively than an IV in your hand. Central lines are usually inserted into the neck, below the clavicle, or in the groin.

  Complications and Drawbacks

  Vasopressors, inotropes, central lines, and A-lines are the mainstay of support for patients in shock. However, as with all ICU interventions, their usefulness has limits, and they confer risks.

  While rare, blood vessel injury during A-line placement can require surgery.1 Clot within or surrounding the catheter can threaten blood flow to the hand or foot, also requiring urgent intervention.2

  Central lines require local anesthetic to place, and the sterile drapes necessary to place the catheter cleanly may induce claustrophobia. More concerning, up to one-third of cases of central lines induce complications, including bloodstream infection, bleeding, vessel injury, and lung collapse.3