Death in the ICU

Patients like Rita, the plainspoken 50-something woman who understood that her lungs were growing stiff and that the hamburger on her hospital tray would taste better with a touch of mayonnaise. Rita was one of the patients I admitted while on overnight call in the ICU. I liked her immediately.

Over the course of her days with us, Rita’s breaths grew more labored and her lungs less forgiving. We escalated her breathing aids, stopping short - at her request - of placing a breathing tube down her throat because this would be a point of no return. But Rita had watched her mother die of a seemingly similar lung disease, and when extensive tests revealed that her illness was untreatable, she decided that she’d had enough.

Ninety percent of patients who die in ICUs do so after a deliberate decision to limit medical interventions, by one estimate. Though cultures vary widely in their attitudes toward withdrawal of care, the trend toward it is international in scope.

Normally, the ICU is an arena for medical heroics. We tend to betray this bias in the way we speak to our patients and their families: praising them for being troopers, for fighting against the evil that is their pathology. But they can be just as brave in letting go. As doctors and nurses, we can serve our patients by bringing the same technology to bear on helping them go gently - with medicines that dull pain and air hunger. I saw it done over and over again during my month in the ICU, and I was struck every time by sadness and a strange sense of relief.

I came to work one morning to find Rita lying in her hospital bed, deeply sedated, with a breathing tube in place. She had written out her wishes with a black Sharpie on a sheet of copy paper sitting on her bedside table: She wanted her boss to know that she wasn’t playing hooky when she called in sick. And she wanted family members to hold her hand as she passed. Soon after, her nurse and respiratory therapist turned off her machines and she was gone.