Patients go the ICU to die. And the deaths they die are truly horrific. We as doctors and we as society must rethink goals of medicine and goals of life in the modern era. When we can keep patients “alive” indefinitely on machines, should we?
Patient 1. Her name was Charlotte. She was an award-winning landscaper and lifelong gardener from Georgia. Well into her eighties, she had a gentle southern drawl, piercing blue eyes, ramrod straight posture, and a sincere smile. She loved to read biographies. Her favorite flower was the British lady orchid. Prior to developing colon cancer, she had only ever had hypothyroidism; no other medical problems. When she had originally been diagnosed with cancer 6 months ago, she resisted any treatments, arguing that she had lived a solid life and wished to spend her remaining time outside, in the gardens, where she had lived her entire life. Her grown children, unable to cope with the prospect of losing their mother, convinced her to undergo chemo, then radiation, and finally surgery. She was in and out of the hospital environment for months, and I cared for her during her final month–which she spent exclusively in the ICU. Her surgery went poorly, and she developed respiratory failure, requiring her to be intubated. No matter what we tried, we could not wean her from the ventilator; her lungs had simply become too weak to function on their own. This woman, who had spent eight decades breathing deeply the lush fragrances of her parks and gardens, spent her last moments with sterilized oxygen being forced into her lungs by a machine. On the day before she died, she wrote something on a piece of paper and handed it to me. It read, “I want to go outside.” I looked back into her brilliant blue eyes, and nodded. It took bribery, threats, pleas with her family, and calls to the hospital chief medical officer, but we managed to get her transferred to a chair and wheeled to a private courtyard in the back of the hospital. She still had the breathing tube in place, and her oxygen levels were continuing to drop, but she could smell the fresh rain-soaked earth and pine needles. I’ll never forget her face. Ineffable. Tears rolled down her cheeks as she squeezed my hand. She stayed outside until nightfall, until her oxygen levels had fallen so far that she was barely conscious. We brought her back to the ICU, and she died within an hour. As I watched her breaths come to an end, I felt such anger at her medical course. All she had wanted was to be in her gardens at home. Instead, she got six months of hospitals and one, final evening in a dingy hospital courtyard.
Patient 2. Her name was Margaret. A 65-year-old smoker and obese diabetic, she predictably suffered a massive heart attack, and during the attempts to repair the arteries of her heart, she sustained a stroke–her fourth in the past year. Her brain was devastated. For a week, she lay intubated and sedated in the ICU; and even after she recovered enough neural activity for the breathing tube to be removed, she remained delirious and unable to form complete sentences. She had wires going into her wrist arteries for continual blood pressure monitoring; she had lines going into the veins in her neck and under her collarbones to measure the pressures in her heart and lungs; she had urinary and fecal catheters placed; she had a feeding tube going into her nose; and she required a face mask for continual oxygen delivery. Her skin was sallow and sunken, a patchwork of bruises and breakdown from repeated needle sticks for blood labs. Her adult children watched for days as their mother tossed and turned in her bed and periodically cried out unintelligible monosyllables. Physically and emotionally exhausted, the family left one afternoon for a quick respite, and in that hour of their absence, their mother died. Alone, with tubing and IVs sticking in and out of every orifice of her body. Her last words were a garbled childish plea for “more ginger ale.” I stood at the foot of the bed and observed as her heart rate on the overhead monitor slowed from 50 to 30 to 10 to 5 to 0–a flat line. Her head fell slightly to the side, and her breathing, which for days had been labored and coarse, finally ceased. I placed my stethoscope on her chest. Silence.
These two women died within 24 hours of each other. Driving home that evening after my shift, I compared them to the woman described in a BBC article who had been diagnosed with terminal cancer and who had chosen to spend the last year of her life not receiving chemotherapy but instead traveling widely throughout the US. During her travels, she fulfilled many of her personal dreams and wishes, and her final days were filled with memories and friendships and kindness, not with medications and laboratory testing and invasive procedures. She died well.
I failed my patients. The US healthcare system, with its blinkered focus on life saving rather than life enrichening, failed them. Surely they and their families would have preferred a few peaceful and meaningful days, or even hours, at home over their protracted weeks of ICU hell. Reflecting on these two cases has caused me to reconsider my own end-of-life wishes and those of my patients. Above all else, I do not want to die in a hospital. I’d rather live my death fully than die and be artificially sustained in some travesty of “life.”