the glory and the horror

Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes.

- Benjamin Franklin, Letter to Jean-Baptiste Leroy, November 13, 1789

These past few weeks have seemed to prove his statement so true. During my last call, I saw 4 patients die in the MICU, 2 of whom hadn’t been in the ICU more than 24 hours. One of them was a tough one, as the guy had just come in at 5 am in the morning, talking and actually appeared kinda put out that he was in the hospital, and by noon, we had already coded (i.e. attempted resuscitation) him twice, and he had died.

The other part of the statement is also true, but not nearly as stressful or emotionally tiring. We’ve also seen (and paid) our property tax bill, which was more than we thought it would be. Suffice it to say that when you don’t pay state income tax, you’re bound to pay somewhere else.

When dealing with the relative certainties of death, it’s one thing when we have attempted everything within our power to resuscitate. It is clear that we have reached the limit of medical science when we have thrown the kitchen sink at the patient and nothing has worked. The question is whether or not we are always obligated to do so.

When a patient has suffered a significant injury to the brain, usually in the form of a prolonged period of decreased/minimal, or even absent blood flow to the brain, permanent damage occurs in the brain, and repair of such anoxic tissue (i.e. tissue that has been deprived of oxygen) is minimal to non-existent. When the entire brain is subjected to such stresses, it does not do well. We may be able to recover some level of minimal function, such as primitive reflexes, or maybe the patient will breathe on her own, but that does not mean that recovery of more complex functions is likely, or even possible.

So what does that mean for the family? Many will cling to the hope of recovery, at least for a time. They will hope and pray that their loved one will regain some degree of meaningful (which is always hard to define) neurologic recovery. They pray that their loved one will remember them, will react to their presence, will interact with them. They hope for what is generally thought of as a miraculous recovery, since the doctors have all told them to expect and plan for the worst.

Sometimes, the patient continues to decline, and eventually dies of something, like an infection, or just continued deterioration caused by underlying illnesses, such as cancer or heart problems. Sometimes, patients will stabilize, but in a very tenuous state, with a thin line dividing stable (for now) and very sick. The difference can be quite the precipice, and there may not be a gradual slope from one side to the other.

What happens when a family is convinced that their loved one will recover completely? Is that simply unrealistic? Is it wishful thinking? Is it hope? Is it faith in a powerful God, who has already triumphed over death? Is it trust in a Power that knows no bounds? Is it a delusion, a fixed false belief? Is it a refusal to face what is the most reasonably expected outcome?