Science in Christian Perspective
Comforting Job in the ICU: Ethical Issues in High
DAVID L. SCHIEDERMAYER,
Assistant Professor of Medicine Medical College of Wisconsin
From: PSCF 41 (March 1989): 20-25.
This paper has been previously published in Christian Medical & Dental Society journal, Vol. XIX, No. 4, reprinted here with permission
Field studies of physician behavior in the ICU reveal a focus on the technological imperative rather than human comfort. This is a new phenomenon. A review of the history of ICU technology reveals that cardiopulmonary resuscitation, artificial ventilation, dialysis, intravenous feeding, and intensive care units have been developed within our lifetimes. Several criticisms of high technology are explored, and the ethical problems of ICU access, rationing, and statistical vs. identifiable victims are examined. The caring imperative in medicine preceded the technological imperative; the goals of medicine include the compassionate care of ICU patients.
job continued his
Terrors overwhelm me;
my dignity is driven away as by the wind;
my safety vanishes
like a cloud.
And now my life ebbs away;
days of suffering grip me.
Night pierces my bones;
my gnawing pains never rest.
My skin grows black and peels;
My body burns with fever.
Hospitals are places of pain and suffering, and intensive care units (ICU's) distill human agony. They are the places where we would find a modern job, a patient with a life-threatening disease, who is febrile and possibly septic. In the modern ICU, patients are frightened and overwhelmed by the severity of their illnesses and the inescapable presence of high technology. Their dignity is "driven away as by the wind" others regulate their bowels and bladders, examine, feed, wash, and turn them.
The ICU is a place where 73 percent of the patients are terminally ill, and where 15 percent of our health care dollar is spent,1 where physicians employ therapies which are often extremely invasive and only potentially or marginally beneficial,2 and where some of the most difficult ethical dilemmas in medicine arise.
Critical illness is often accompanied by loneliness and disorientation. job describes the feeling: "my safety vanishes like a cloud." Unfortunately, studies reveal a dearth of opportunity for human comfort in the ICU. A survey of visiting policies in 78 ICU's in Ohio demonstrated that 25 percent allowed only 2 visits per day, and 42 percent restricted visits to under 20 minutes. Most units rarely or never allowed children under 12 to visit. The authors of the study point out that there is no empiric medical evidence which supports the need for these sorts of policies.3
Field studies of physician behavior in the ICU reveal a focus on laboratory evaluation rather than on patients; a lack of expression of personal feelings; and an excessive dependence on invasive technology.4,5,6 One of these studies records an example of the focus on the status of the machinery instead of on the care of the patient.:
A preadolescent boy, hospitalized with leukemia, became severely immunocompromised by his therapy. He developed pneumocystic carinii pneumonia and his condition rapidly deteriorated. He required ventilatory assistance ... arterial cutdowns and a Swan-Ganz catheter. Numerous complications developed. One morning after a long and complicated presentation of serial blood gas determinations, pulmonary wedge pressures, intake and output, and similar material, a staff anaesthesiologist commented that everything 'seemed alright.' The weary resident who had made the presentation replied uncomfortably, 'Yeah, except the kid.'4
Providing comfort in these kinds of situations is our biblical imperative and our professional obligation. In this paper I examine the nature of intensive care and suggest some solutions for better comforting "Job" in the ICU. These solutions must consider access to the ICU and the limits of the technological imperative, Let's begin be examining the development of ICU technology.
The Development of ICU Technology
Thirty-five years ago a patient with failure of the heart, lungs, kidneys, or gastrointestinal tract died within a few minutes, days, or weeks. G.D. Phillips traces the development of life support systems as shown in Table 1.7 Most technologies, such as CPR and artificial ventilation, were limited to animal experimentation until the 1920's and 1930's, and much of the actual development occurred after 1950.
External cardiac defibrillation began in 1956, and the use of mouth-to-mouth resuscitation became widespread in the late 1950's and early 1960's. However, there may be much older examples of resuscitation. Elisha put his full weight on the body of a dead child and put his mouth on the child's mouth, then repeated the maneuver; the child returned to life (2 Kings 4:32-35). Fourteenth-century patients who suffered cardiac arrest were whipped with nettles, and in the seventeenth century they were draped over a trotting horse, without reported success.8 Choosing among these three techniques would be easy: the gentle touch and the effective prayer of the man of God would be my preference, and I would have wished to forgo resuscitation in the 14th and 17th centuries. Those readers who are sometimes concerned about the violent aspects of modern CPR may find its historical predecessors interesting!
Thus, we may draw the following three conclusions from our review of the development of ICU technology:
1. ICU technology as we know it has developed within our lifetimes.
2. There are mechanical emergency support or resuscitation systems for most of the vital organ systems except the brain and the liver.
3. Since 1958, intensive care has grown into a multidisciplinary and multinational discipline.9
The Critique of High Technology
Despite the benefits of ICU technology-improved survival for patients with trauma and critical illnesses here has been increasing criticism of medical technology.
The Historical Development of ICU Technology
Cardiopulmonary Resuscitation (CPR)
1847-Internal heart massage in cats
1901-Successful internal cardiac massage in a woman who collapsed during chloroform anaestbesia
1947-Internal cardiac defibrillation
1956-External cardiac defibrillation
1776-Bellows for resuscitating the drowned
1932-Artificial ventilation in anaesthesia
1953-Use of ventilator in polio patient
1923-First peritoneal dialysis in man
1937-Intravenous amino acids
1968-Complete intravenous feeding
Intensive Care Units
1958-Baltimore City Hospital ICU
-Toronto General Hospital ICU
1988-Over 5000 ICU's worldwide
Several studies have shown that patients with acute myocardial infarction or acute pulmonary edema may survive just as well outside of the ICU as in it.10,11 Data collected in the neonatal ICU confirm that gains have been made in the survival of infants with increasingly low birth weights-in the 1960's the limit for giving ventilatory support was 1500 grams, in 1970 it was 1000 grams, in 1975 it was 750 grams, and in the 1980's the limit is around 500 grams. The success, however, is not unqualified. Ventilatory management has been difficult, and multiple medical complications may occur. The tiny infant may have patent ductus arteriosus, immature brain and germinal matrix, and incomplete vascularization of the retina.12 Increased attention and funding of neonatal intensive care technology may be diverting attention and funding from basic prenatal care and primary care pediatrics.13
Some outspoken critics of modern medicine, like Ivan Illich, question whether any significant gains have really been made in the recent technological revolution.14cal sentiment. Like most clinicians, I am generally favorable to technological advances, because I see many of them help my patients on a day-to-day basis. Technology is a double-edged sword, but it often allows us to reverse physiological processes which threaten our patients' lives. We know adequate food and housing, proper sanitation, and childhood immunizations are more potent life-savers than are arterial lines. But arterial lines work very well if the patient is hypotensive and hypoxic. Why then the bitter critique of high technology?
The Problem of the Technologic Imperative
Perhaps we can find the answer in one of the most eloquent of the anti-technology voices, Christian philosopher Jacques Ellul. In his work, The Technological Society, Ellul makes the following points:
1 .Ours is a progressively technical civilization.
2. The ever-expanding and irreversible rule of technology is extended to all domains of life.
3. Our civilization is committed to the quest for continually improved means to carelessly examined ends.
4. What was once prized in its own right now becomes worthwhile only if it helps achieve something else.
5. Technique turns means into ends.
6. "Know-how" takes on ultimate value.15
The problem, according to Ellul, is that technology does this without plan; it just happens, as a sort of technological imperative. ICU technology is used because it is the ultimate medical "know-how." Continual improvement in machinery is sought while the medical ends of the technology are only hastily examined. Ellul's critique must be acknowledged as at least partly valid. Better technological assessment is needed. The ends of medicine-prolongation of life, reduction of suffering, improvement of function-should be served by each technological advance.
The caring imperative in medicine preceded the technological imperative, and for all its science, medicine remains an art. Part of the art of modern medicine is the ability to use technology without being enamored with it to the detriment of the patient. "Know-how" is important, but should not take on ultimate value in medical care. We prize the patient in his or her own right as a person for whom Christ died. The patient is not the means for us to achieve our own ends (i.e., the testing and perfection of medical technology).
ICU Access & Rationing Systems
Thus, while we acknowledge the validity of some of the anti-technology arguments, it is more helpful to ask how we can justly and humanely use the technology we have developed. There is voluminous literature on this topic. Physicians, for instance, can ration ICU care in response to resource shortages. In one case, a shortage of nurses decreased the ICU bed capacity from 18 beds down to 8 beds, and physicians responded by restricting
patients who suffered cardiac arrest
were whipped with nettles, and in the seventeenth century
they were draped over a trotting horse, without reported success.
ICU admissions to more acutely ill patients and reducing the amount of routine monitoring. As the bed shortage worsened, the percentage of patients with chest pain who actually had myocardial infections increased. The physicians admitted fewer "rule-outs." There was no increased mortality and no apparent withdrawal of care from dying patients.16 In another study of 1151 ICU patients, during times of crowding patients discharged from the unit were sicker and younger. Older patients were less likely to be discharged than younger patients and, again, no adverse outcomes were reported. Surveying only ICU patients in these studies, however, may create a selection bias; the studies should focus on every patient in the hospital or the ER who could be an ICU candidate.17
Many fascinating arguments can be made about who should have the "last bed" in the ICU: should there be a waiting line, or a lottery system, or should medical need take precedence? These arguments are not purely theoretical, as anyone who has tried to admit a critically ill patient from the ER to a full ICU can verify. There has been a court case involving Susan Von Stetina, a 27 year-old trauma victim who remains unconscious several years after being accidentally disconnected from a respirator at a time of an ICU night nurse shortage. The
of the art of modern medicine
is the ability to use technology without
being enamored with it to the detriment of the patient.
suit claimed the hospital failed to establish a priority system. One patient already in the ICU met the criteria for brain death, and 2 others were electively discharged in the morning. The jury ruled in favor of the plaintiff and awarded a verdict in the sum of $12,470,000. The Supreme Court of Florida has returned the case for a retrial because of the $4 million awarded for pain and suffering.18,19
Should Job Be Admitted to the ICU?
Assuming that he met the medical criteria for admission, and that visiting policies were amended so that his friends could visit, should job be admitted to the ICU? If we choose not to provide state-of-the-art care for job-assuming we have some effective treatment for him-we are abandoning an identifiable human being. Part of our difficulty in rationing ICU care is that we distinguish between job's life, which is identifiable, and a statistical life, which is only on paper. We may not be willing to put in a stoplight or install airbags to save statistical lives, but identifiable lives are traditionally regarded as worth saving at virtually any cost. Enormous sums are spent to rescue lost mountain climbers, trapped miners, and other visible victims.20
is a double-edged sword,
but it often allows us to reverse
physiological processes which
threaten our patients' lives.
Even if we decide to admit job to the ICU, however, we may face difficult decisions ahead. Once in the ICU, the relationships between a patient's prognosis, resource expenditure, and clinical outcome become more complex than we often realize. Among non-survivors in the ICU, the highest charges are due to caring for patients who were perceived on admission as having the greatest chance for recovery. Among survivors, the highest charges were incurred by those thought to have the lowest chance of recovery. Patients with unexpected outcomes incur the greatest costs. Even making a patient a " no-code" does not necessarily decrease the costs, because such patients are usually the most critically ill.21
What would job want? He would probably want to try the ICU. There is evidence that 70 percent of patients and families who had previously experienced ICU care would be willing to undergo ICU care again to achieve even one month of survival; 8 percent were unwilling to undergo ICU care to achieve any prolongation of life. These data suggest that besides our perception of the enormous value of an identifiable life, patient preferences may also conflict with any policy that limits access to the ICU based on age, function, or medical diagnosis.22 Thus, both sanctity of life considerations and patient preferences would most likely result in ICU admission for a patient like job.
there be a waiting line, or a lottery system,
or should medical need take precedence?
Compassionate ICU Care
The ICU is a frightening place, and too often we comfort" the jobs in our ICU's with the use of high technology alone. Technological comfort is expensive, and it does not address the frightening loss of control dignity, and purpose experienced by the seriously ill patient: "Terrors overwhelm me." The ICU can become a place where doctors strive to outdo each other, where hospitals compete against each other, where money is made, and where patients suffer, often alone. Is there a better way? Let's go back to what we can learn from those who sought to comfort job.
1. job needed human understanding and sensitive spiritual counsel. This would seem to be important in the modern ICU. Often nurses provide excellent comfort care; physicians need to learn from them how to be more compassionate to ICU patients.
sanctity of life considerations and patient preferences
would Most likely result in ICU admission for a patient like job.
Patients fear abandonment. Patients need a sense of control, a sense that we are respecting and honoring them. We need to pay more attention to the patient rather than concentrating solely on the data. We need to be sensitive to patients' spiritual needs, and if we are not comfortable addressing them, we need to enlist the help of the clergy or the hospital chaplain.
2. While we should attempt to use appropriate technology, we need to recognize when technology is futile and when it may no longer serve us but rather threatens to become our master. Professional ego, fear of litigation, competition, and remuneration are entwined with the use of high technology in many circumstances. The critics of technology rightly argue against these reasons for its use.
3. Despite the legitimate criticism of high technology medicine, the ICU care of job and patients like him reflects a sanctity of life view of human beings as identifiable persons whose lives are worth saving despite the odds and the cost. Furthermore, ICU care upholds a traditional medical value which is being increasingly attacked, that of "merely" prolonging life.
need to recognize when technology is futile and
when it may no longer serve us
but rather threatens to become our master.
If I were job's doctor, I would admit him to the ICU and let his friends and family visit him, although I might ask the hospital chaplain to see him also (just in case his friends gave him bad advice!). I would use appropriate technology to treat his infection, skin disease, and fever, and I would prescribe pain medication to control his "gnawing pains." I would encourage the nurses to sit with him, and I would try to do the same. If, in my clinical judgment, job was dying despite ICU care, I would speak with him and his family and work out a treatment plan which would emphasize support and comfort, and I would assure him that I would not abandon him.
But, on occasion, I might hope for the best:
After this, job lived a
hundred and forty years;
he saw his children and their children
to the fourth generation.
And so he died, old and full of years.
David L. Schiedermayer, MD, practices general internal medicine at the County Hospital in Milwaukee and teaches clinical ethics to junior medical students on the wards. He has written and coauthored a number of papers on ethics, focusing primarily on the withdrawal of tube feeding, physician attitudes toward comatose patients, and the standard of care for ethics consultants. He also writes occasionally on medicine for The Christian Medical and Dental Society journal and The Milwaukee journal. He has an interest in Third World medicine and part of his medical training occurred in Liberia, West Africa, at a small mission hospital.
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18Von Stetina vs. Florida Medical Center, 2 Fla Supp 2d 55 (Fla 17th Cir 1982), 436 So Rptr 2d 1022 (1983), 10 Florida Law Weekly 286 (Fla May 24, 1985).
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20M.J. Mehlman, "Rationing Expensive Lifesaving Medical Treatment," 1985 Wisconsin Law Review, pp. 239-302.
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