Dealing with an incurable illness or terminal condition is an inevitable reality of the practice of Medicine. Not uncommonly, especially in the Intensive Care Unit, we care for the patient with no chance for recovery and survival. Keeping that patient comfortable and allowing him or her to die with dignity becomes the priority of care.

Occasionally, I hear requests from the family members of the dying patient – “Can you give her a little something to…you know…make her comfortable and let her pass away quickly?”

Keeping the terminal patient comfortable is the purpose of comfort care. Facilitating or hastening death is considered unethical or even illegal. Physician assisted suicide or euthanasia is illegal in most states.

In theory, comfort care is quite different from euthanasia. Keeping the patient comfortable and letting the nature take its course is at the core of palliative care approach. Yet, the line between keeping comfortable and facilitating death is often blurry.

The same medications used to control pain and discomfort, primarily opioid analgesics and sedatives, could be used to “help” the patient to stop breathing. The concept of terminal sedation assumes death as an outcome of the intervention.

There are no standards regarding the amounts of medication that could be given for the purpose of comfort before it could be considered a “lethal dose”. Patients on chronic opioids, like many cancer patients, may develop tolerance to the medication and require very significant doses just to control the pain. In contrast, it might not require a lot to stop the breathing of an 89 year old with bad kidneys.

As one transplant surgeon in California found out, it is possible to get in trouble for trying to keep the patient comfortable before death.

Dr. Hootan Roozrokh was accused of hastening the patient’s death by administering large amounts of Morphine and Ativan. The incident took place in November of 2006. The prosecutors alleged that Dr. Roozrokh was hastening the patient’s death to harvest his organs for donation. Subsequently the doctor was acquitted of all charges. His defense was able to prove to the jury that the medications were administered to keep the patient comfortable.

The patient in the above incident had been on opioid analgesics and likely was tolerant to the effects of those drugs. It was very reasonable to assume that he required seemingly exuberant doses of Morphine just to control his pain and discomfort.

This case indicates that there could be a very thin line between what we consider terminal sedation and euthanasia. The purpose is clearly different – keeping comfortable vs. hastening death. Yet, in clinical practice, it is more of a continuum or spectrum of actions and outcomes. Often, it’s not all that difficult to cross that line.

We are all going to die. It is only a matter of when and how. Barring suicide, we do not have much control over the timing, yet the how of death is something we can change.

I see people die in the Intensive Care Unit all the time. In many cases, death as an outcome is not a surprise. Often, it becomes obvious days or even weeks ahead that the patient is not going to survive. Even then, many patients go through multiple tests, invasive procedures and treatments in the last days of their lives without obtaining any clear benefit on the quality of life or life span.

I see patients die in agony, pain, distress and confusion. I see families unable to decide what to do for their loved ones. Even worse, I see family members squabbling about what grandpa would want when they should be focusing on providing him comfort and peace.
I do not consider this as a good death.

I probably have never seen a good death. Dying at home, surrounded by loved ones and, most importantly, being at peace with death is what I consider a good death.

Not all of us will have the luxury of knowing that death is coming. People die in accidents. People die from heart attacks and unexpected acute illnesses. Yet, based on statistics, most of us will know when it’s coming.

Somebody once told me that often people die just like they lived their lives. I didn’t believe it first. Having spent several years in the Intensive Care Unit, I am becoming a believer.

Death or dying is an inevitable part of the ICU practice. Most deaths we see in the ICU are anticipated or at least somewhat expected. In many cases the patient dies because the treatment has been stopped since there was no hope for meaningful recovery and survival.

I have heard many times people referring to withdrawal of care as “pulling the plug”.
Personally, I do like this phrase. I consider it somewhat inappropriate and even vulgar. When talking about withdrawal of treatment, I prefer phrases like “letting the patient die in peace, changing the goal of therapy towards comfort, letting nature take it’s course, withdrawing aggressive treatment” etc. Once in awhile, though, in a discussion with the family, somebody would use this exact phrase – “pulling the plug”.

It is not just that it cuts my ear; many people might not even have a very good idea of what it means in the first place.

Pulling the plug means letting somebody die by withholding aggressive treatment. Often, families expect their loved one to die almost immediately after stopping that treatment – just like pulling the plug.

First of all, many patients survive for hours or even days after the aggressive treatment has been stopped. The family should always be prepared for this.

Second, there might not be a “plug” to pull in the first place, if the patient is not receiving aggressive life support or treatment.

One thing that is being closely identified as a “plug to pull” is a ventilator or breathing machine. If the patient is on a ventilator and the family insists on withdrawal of care, the breathing tube is pulled and the ventilator is turned off – the “plug” is pulled. Even though the ventilator is considered to be life support, some patients still survive for some time after it has been removed.

Dialysis for kidney failure is another piece of machinery that is often being identified with the “plug”. Stopping dialysis will eventually lead to the patient’s death, but the process of dying might take several days or even longer.

In many cases, the patient is not on a ventilator or dialysis machine. There is no physical switch to turn or plug to pull. If withdrawal of treatment and comfort care is considered by the family and is in the patient’s best interests, in actuality the feeding tube might be the only thing that is keeping the patient alive.

As a physician you have to be sympathetic and understanding. You also have to be respectful to the patient. A lot has been written about doctors’ responsibilities as healthcare providers and about patient’s rights as healthcare consumers.

What about patient’s responsibilities? Do they have any?

What do you do when the patient is being openly disrespectful and unreasonable?
You are supposed to take the “high road”, yet how much abuse should you take?

My patient was admitted with severe respiratory failure and ended up on mechanical ventilation. Subsequently, the patient developed pneumothorax (air in the chest) and extensive SQ emphysema (air under the skin). Later, the respiratory status improved and mechanical ventilation was discontinued. The chest tube remained in place due to a persistent air-leak (air escaping through the chest tube).

The patient was upset about the fact that the chest tube was still in and there was a facial "change".

SQ emphysema may temporarily change facial features due to swelling and air under the skin. Once the air is resorbed (days to a couple of weeks) the facial features return to normal.

Now, what do you do if you are being yelled at for providing treatment that is appropriate in the situation, even though, it does not fit with the patient’s plans (going home in this case)?

I explained, once again, why the chest tube cannot come out now and, when the patient went on a yelling rampage again, so I left the room. Right or not, sometimes, you have to have some respect for yourself.

There is nothing worse for the family of critically ill patients to receive contradictory information from different physicians. It causes an obvious distress among family members and very often leads to a “whom to believe” situation.

Situations like that are not uncommon when the patient after a complicated surgical procedure becomes critically ill and is being admitted to ICU. Sometimes, when recovery is unlikely and the patient or the family is requesting withdrawal of care, the surgeon declines to proceed to comfort measures only approach and insists on aggressive treatment.
Intensivists and Hospitalists taking care of these patients in ICU are often caught in the “crossfire” between family members and the surgeon.

A very interesting study conducted in Wisconsin and published in the Critical Care Medicine Journal examines the process of a surgical “buy-in”, or the nature of the contractual obligations between surgeons and their patients.

The authors describe the potential “obstacles” towards accepting the withdrawal of care by the surgeon. The feelings of guilt and failure by the surgeon in a case of an unexpected poor outcome were likely contributing to the failure to accept it. A poor outcome after an elective procedure had an even heavier emotional toll. This was in contrast to the medical doctor who often views a failure of treatment as failure of the patient or disease to respond to therapy.

Surgeons often assume, according to this study, that obtaining consent for the surgery could be viewed as a surrogate for bi-directional contract, with the patient agreeing to adhere to the postoperative care even if complications occur.

In my practice I have had to deal with situations when the patient is dying, yet the surgeon is refusing to accept the inevitable. Ultimately, it is the patient who is suffering, having to go through unnecessary and often futile treatment.

On the flip side of this problem, I cannot claim that I am always right and the surgeon is just refusing to see the obvious. I have been wrong about the outcome before and having somebody on the team with an opposite view on the outcome might, actually, be a good thing. After all, medicine is not an exact science.

Previously, we examined the fact that trauma patients with no insurance may have worse outcomes than the patients with insurance. What about race? Is quality of care being affected by race?

A study published in the Critical Care Medicine Journal determines the correlation between the quality of care for patients with pneumonia and race.

Several previous studies indicated that black patients with severe infections like pneumonia or sepsis receive lower quality of care. These findings, if true, are very disturbing.

The study published in Critical Care looks at the quality of care for patients with pneumonia from a different perspective. Is it the quality of care within the same hospital that is different or the variation is explained by the difference of care between hospitals?

The quality of care, in this study, was defined by the timeliness of intravenous antibiotic administration and by the adherence to the national guidelines for the treatment of pneumonia. The intensity of care including admission to the Intensive Care Unit and mechanical ventilation was also considered.

In crude comparisons, black patients did receive lower quality of care compared to white patients. Looking further into this difference the authors came to the following conclusions:

The differences were primarily attributed to the variability of care between different hospitals. Black patients were more likely to receive care at the hospitals that provided lower quality of care, regardless of race.

In general, hospitals that served a higher number of black patients provided higher intensity of care, including more frequent use of mechanical ventilation.

There was no statistically significant difference in care provided for the patients with pneumonia within the same hospital. Different clustering of white and black individuals among hospitals could explain some of the differences in quality of care found in previous studies.

The findings of this study, even though somewhat encouraging, are still disturbing on another level. A significant variation in the quality of care that is dependent upon the hospital’s geographical location and the predominant race served is unacceptable and should be eliminated.

Taking care of critically ill patients involves caring for their families as well. Family conferences could be time consuming or even frustrating, yet they are an essential part of our practice. It becomes even more challenging when you are caring for the patient who is unable to come off mechanical ventilation. Those patients often end up with tracheotomy tube (click on image above) to facilitate weaning from a ventilator. Sometimes, patients spent weeks or even months on a Vent and this is what we call prolonged mechanical ventilation (PMV).
Recent paper by Cox et al in Critical Care Medicine “Expectations and outcomes of prolonged mechanical ventilation” indicates that only 9% of patients were alive and could function independently one year after their treatment in ICU involving PMV. This is shocking. What even more shocking was the extent of miscommunication between families and physicians reported in this study. I agree that families often have unrealistic expectations regarding outcomes of critical illness. I also agree that we as physicians often fail to effectively communicate this information to the families. There are multiple reasons for that. Sometimes, you have a “difficult” family and you simply cannot “get through to them”. It happens, but that is only part of the problem. Physicians are often focused on short term prognosis and outcome. Getting somebody off the Vent and out of the Unit is an improvement, right? May be yes, maybe not, and we should help families to decide this.
Based on this article, we should a better job of talking to the families of critically ill patients.