By Natalie Uy, MS2
Delicate, difficult, and compassionate. That’s how I would sum up my month of Pulmonary, Critical Care, and ICU.
I saw an incredible variety of cases – from hepatic encephalopathy, hepatorenal failure stage II, Charcot Marie Tooth, chronic idiopathic eosinophilic pneumonitis, pediatric sarcoid, hyperosmolar hyperglycemic non-ketosis state, and all sorts of shock (cardiogenic, hypovolemic, septic), cancer and more.
Now the nature of Critical Care/ICU is that these people are sick. While it’s incredible to see someone in a coma intubated with drips wake up and walk out the hospital, there are also tough moments.
Sitting in family conferences discussing end of life and palliative care, I couldn’t help but feel oddly intrusive. Sometimes choices are clear cut. As my attending told me, one can be stable and fight for life in the ICU only for so long before the body gives out.
After two weeks, one woman, Mrs. L, suddenly declined. Her 90-year-old husband had the legal power to make decisions on her behalf, but he had to rely heavily on his nephew. Mr. L looked so sad during the conference but nodded almost imperceptibly, agreeing to take off all aggressive measures. There’s so much legality and documentation about codes and family decisions, which I had no idea before.
Sometimes it’s not so clear. One devoted elderly wife fretted about her husband Mr. W, who had been in the ICU for weeks, neither improving nor worsening to give us a clue – “Do I let him go? Do I give him a chance? I don’t know… help me doctor, please tell me what to do.” Unfortunately, the doctors have no crystal ball, and even they were debating amongst themselves on the best next options.
Initially, Mrs. W chose to let nature take its course, then later chose the more aggressive procedure after another doctor changed her mind. Mr. W thus got better, and when I saw him open his eyes for the first time and wave feebly at me from the ICU bed, I could not believe how close he had been to meeting death. A second chance seemed clearly the right choice.
Then a few days later he deteriorated, and the wife doubted herself, “What can I do? He’s depressed about life and giving up, but I can’t just let him go at this point – his body is falling apart but his mind is now alert. Did I miss my chance to let him go peacefully?”
It’s as grey as can be. All I could do was hug her and give her tissues.
Clinical judgment is managing vitals and medications, and beyond that, managing expectations and emotions. And delivering compassion with honesty in the face of death is really the hardest task of all.
Editor’s Note: All names have been changed and all patient identifiers have been removed from this story.