The View From the ICU
The alternative to doing everything for a dying patient.
Located deep in the bowels of every big hospital, often behind locked doors that open only to the swipe of a key card, is the medical intensive care unit. Known as the MICU, this is where the hospital's sickest patients are brought for the most aggressive possible care. By the time patients need to be in the MICU, several organ systems are usually failing, and there is little chance of a good outcome. Some MICU patients have fixable problems, such as bleeding from the stomach or a sudden blood clot in the lungs. But many have relentless diseases that make decline irreversible and a decent quality of life irretrievable.
Doctors typically ask the person least able to make a clearheaded decision—the closest relative—about the most important choices regarding a desperately ill patient's care. Here is what happens when that relative tells us to "do everything" to save the life of an ailing loved one.
We open the airway with a shoehornlike metal device and slide a breathing tube down the patient's throat so the respirator can breathe for him or her. A second tube goes up the nose and then bends into the stomach to suck out secretions and give nutrition or medicine. (Eventually, a replacement for this tube is cut into the stomach or intestine through the abdominal wall for longer-term "feeding.") We snake a large-bore line into the jugular vein in the neck to give intravenous medicines or take blood samples, thread a smaller line into the main wrist artery to measure blood pressures and oxygen levels, push a third tube up the urethra to drain and measure urine, and often insert yet one more tube up the rectum to drain stool. Heavy narcotics and anti-anxiety medications sedate the patient so he or she will not fight against the ventilator and pull out all the tubes and lines. If a patient needs a ventilator for an extended time, the breathing tube through the mouth must be replaced by an opening cut directly through the front of the throat. Every effort is made to keep the bedridden patient's bones from wearing holes through his or her skin, but frequently this happens anyway, resulting in infection-vulnerable sores. The medicines that maintain a high-enough blood pressure to deliver blood to the important organs can decrease blood flow to the fingers and toes to a degree that causes gangrene. Should the heart stop or begin to quiver, we keep the patient alive by pounding on the chest wall to circulate blood until a blast of electric current can be applied to restart the heart. The ribs usually fracture with the first few thrusts.
When a patient has a chance of meaningful recovery we rush to do all this and more. Sometimes it is doctors and sometimes it is families who push too hard when the prognosis is grim. Despite all the technological advances, medicine is still largely helpless in the face of overwhelming disease. Of the many billions of dollars spent on health care every year, a wildly disproportionate amount is spent during the final few tenths of a percent of a life, prolonging the inevitable, agonizing end for both patients and their families. It goes without saying that the billions of dollars spent on aggressive but futile end-of-life care would be more wisely directed toward education, food programs, medical outreach, and housing—all of which we know lead to longer, healthier, happier lives.
So in a different spirit entirely, I propose an alternative—the "life incentive." I urge the government to spend money on helping us to live well. Offer everyone a one-time payment to spend in our prime years, asking in return that we waive our right to end-of-life aggressive medical treatment in favor of humane hospice care. Use the money to take your children to the World Series, start a small business, ride a horse through the Sierras, learn to play the piano, set your watch to Old Faithful. And along the way, resolve whatever uncertainties or disputes that might prevent your family from saying goodbye when the time comes.