Ethical dilemmas in intensive care units

I’ve seen more people die in the past six weeks than in six years of practice before COVID-19. At the same time, Dr Robert Redfield, the director of the Centers for Disease Control and Prevention, has already warned about a second wave coming in the fall. Many of us on the front line have been enduring long stints in hazmat suits and forgoing water and bathroom breaks to conserve personal protective equipment. We’ve also been more conscious about our medication choices to reserve sedatives for ventilated patients.

Nevertheless, these small adjustments may not be enough. A few days after my patient went up to ICU, I logged in to a virtual meeting with my colleagues to discuss end-of-life care. We acknowledged that we’d reached a critical point in our healthcare system. We could no longer afford to “do everything” and “save everyone.” But what was the alternative?

We were not trained ethicists or legislators. We were doctors — doctors who follow the rules, doctors who were taught to value all life equally. How were we supposed to decide who gets a shot at being revived and who doesn’t? Yet we reached a consensus rather quickly that patients who were found without a pulse, given the oxygen deprivation to their brains, did not have a chance at meaningful survival. We agreed we should focus our attention and resources on cardiac-arrest patients who received CPR right away because they were more likely to have preserved brain function. It seemed, at least for the moment, that we could navigate these complicated matters after all. That was until one of my colleagues asked, “What about pediatric patients?” I put my microphone on mute and cried.

Since that meeting, I’ve tried to be more proactive about end-of-life discussions. But it’s difficult to open a dialogue when one side comes to it blindsided by his or her condition. Patients are often surprised by how sick they are, and their families are horrified of having their loved ones die alone. Often, I see fear in the eyes of those gasping for air and hear pain in the voices of adult children, asking me how long their mother or father has to live. I know what they seek from me is reassurance, so it feels wrong to bring up code status or to cite grim statistics about how over 80 percent of ventilated COVID-19 patients end up dying. And after having these conversations multiple times a shift over the whirring of my respirator helmet, a part of me just wants to give up and tell them what they want to hear. But then, I remember the lovely man I had sent up to the ICU.

Inpatient records show that as his condition worsened, he grew increasingly agitated on the ventilator. So it fell on his family, who could neither visit him at his bedside nor gather in another room, to make decisions about withdrawing life support. Those wrenching conversations now take place over the phone or, if they are lucky, by video call. His wife and son came to a consensus about withdrawing support only after multiple phone calls with palliative service. He died a week into his hospitalisation. If I could go back in time, I wish I could give that patient a hug, hold his hand and listen more attentively to the stories he was sharing with me. And during the time I spent putting in his central line, I wish I had told him the truth: You are going to die, but I’m here with you.