I can’t really help how much I think about death. I try to focus on the good in every day – even on the worst of days – and remind myself the value of existing in the moment. But, while your job might revolve around metrics or marketing, education or evaluation, mine has every bit to do with dying. I’m a critical care nurse, and I can assure you: I’ve seen more people face death than you’re comfortable knowing. I’ve witnessed more people take their last breaths than you could fathom. And I’ve watched a flat-line scroll across a cardiac monitor more times than I can count – truly, because after my first year in the intensive care unit, I’ve stopped counting. And consider this: I’m just a few days shy of my four-year anniversary in the cardiothoracic surgical ICU: just imagine what those with two or three or ten times my experiences have encountered…
Death, it goes without saying, comes with the territory. Critical care medicine and nursing is intended to manage that cohort of men and women who are toeing the line of existence: at any given moment, something can go wrong. At any given moment, some organ system can shut down. At any given moment, my patient can die. And on any given day, they do…but only if we allow them to… You see, medicine has advanced to levels that allow us to take on incredibly complex and challenging physical conditions and reverse, repair, or eliminate them. We can utilize catheters and wires; microscopic incisions and video cameras; technology and imagery and advanced techniques to treat heart disease, stroke, maternal/fetal emergencies – you name it. Through skilled practice and critical thinking, we are capable of saving the lives of those who, just a few decades prior, would undoubtedly have succumbed to their disease burden.
And then there’s the other part of it all…the cohort of lives that we don’t quite save…but just sort of, well, maintain. Any ICU nurse will tell you that sometimes, stagnation is progress. Other times, it’s sheer purgatory. Any modern-day intensive care unit comes equipped with the technology and resources not only to revive a person from physical death, but also no matter how poor the prognosis, delay the inevitable outcomes. Imagine yourself, for just a moment, as one of the patients charged with my care. I would never wish this position upon anybody – but this is life – bad things happen when we least expect them. On any given shift, I have the means to manage any number of your organ systems outside of your body. Through direct collaboration with a medical team, I can manage a device that serves as an artificial, external heart. I will watch it pull blood out of your one side of your circulatory system and pump it back to the other, with the associated risks being bleeding, stroke, and infection, just to name a few. I can generate a productive cough through a mechanical ventilator by manipulating a probe past your trachea and into your lungs, sucking out what you’re too weak or incapable of eliminating on your own. I can clean and purify your blood through my continuous dialysis machine, filtering out the toxins produced by your body as byproducts of cellular death. You probably won’t have the urge to urinate any longer, since the external kidney is taking the place of your own failed organs, but just in case you do…well, I have another probe I can place through your urethra and into your bladder to catheterize you and prevent (hopefully not introduce) infection. Since nutrition is important to healing – or, since you may never recover, helps to prevent you from wasting away, I am tasked with making sure your belly is full. I pour cans of tube feed into a bag large enough to hold an entire liter of soda, but you will likely only be capable of handling a teaspoon of nutrition down the tube in your stomach at a time. Your life-sustaining medications slow down other parts of your system – one that has already taken some sort of a physical hit – and your stomach will no longer function regularly and effectively. I can manage your sleepy stomach through intravenous medications to help move your feedings forward, and rectal suppositories to make sure you are passing the canned liquid nutrition out of your gastrointestinal tract. If you start to bleed or develop diarrhea, I may need to improvise: after all, you won’t tolerate being turned on your side to be cleaned and cared for very often. I can place a tube inside of your rectum – one that I gently place with lubricated fingertips and two pairs of gloves – and essentially tether a waste container to your backside. That way, once your skin begins to break down, ulcerate, bleed, tear, or necrose, it won’t be further irritated by stool that’s collected on your linens.
I understand that this all sounds extremely uncomfortable – in fact, it may sound like torture – so I will do my very best to take you out of the picture if and when possible. I will run liquid sedatives and pain medication through your tiny, twisted veins and try to find a balance between keeping you awake enough to stimulate and asleep enough to be comfortable. Sometimes this balance cannot be obtained. Sometimes your blood pressure will drop so low that I may need to scale back on your amnesia-inducing medication and reorient you to the state of your reality. You may be terrified: confused, agitated, and in pain. I will be forced to tie your wrists to the side of the bed so as to maintain your safety, keeping in mind that all the while, you feel the opposite of comforted. Other times, I will be incapable of caring for you even in a dream-like state, and I will need to paralyze every muscle in your body in order to best care for your condition. I will place a probe on your temple that allows me to confirm that you’re completely and utterly out of the picture, and I will keep you this way until your circumstances improve…or, rather, change. Since you will require numerous medicated infusions – caustic ones; dangerous ones; ones that could kill you with even an extra few milliliters in your system – I will need to ensure that you’ve got intravenous access appropriate for the intensive care unit occasion. You may have lines and catheters of every size in either side of your neck or flanking your groin. I will make certain to cleanse and dress these points of access, and while using them to transfuse blood or administer medications, pray that they do not yield a life threatening, systemic infection.
I will collect specimens from your body and submit them for laboratory specimens: no bodily fluid is without potential collection, inspection, and investigation. I will likely escort you on road trips that include exposure to radiation, countless invasive procedures, or trips to the operating room. Often times, I will be the nurse at the head of your bed making sure that you’re adequately sedated and pain medicated for whatever intervention is required today…and the next day…and the next. The intensive care unit comes with no shortage of interventions. And, from what I gather, there is no such thing as “without risk.”
When and whether you finally decide to depart from this life – the term “life” being termed loosely – whether that decision is honored depends on the position and perception of your loved ones. You see, you don’t really have a say in whether you get to live or die: ultimately, they do. And since they are scared and confused and hoping for a miracle – one that, perhaps with enough time and faith, may come – but that’s a big maybe…they decide to push full speed ahead. They wish to save you. They wish to keep you alive, and while they have been informed that you will never be the “you” you once were again, they cannot make the decision to withdraw care. Perhaps it’s too personal. Perhaps it’s ethical. Maybe it’s creed or culture or religion. More times than not, it’s certainly desperation clothed in denial. And so we proceed: we stay the course. We continue to treat, seeking alternative paths toward an expected end. And so by proxy, it is my duty; my responsibility; my professional and ethical obligation, to continue to treat you as ordered and discussed until you declare yourself beyond the point of repair. But I assure you: if I want you alive, I can sure as hell keep you that way. I can jump on your chest. I can crack your ribs. I can inject you with sheer adrenaline in liquid form. I can stun your heart out of its disorganized rhythm and quiet it all with the press of a button. I can pour blood into your bleeding body. I can pump oxygen into your failing lungs. And I can make you a set of vital signs for longer…even if just another hour, another day…because that’s what science, technology, and medicine have become. While it may not be what was intended, it’s certainly what has been created.
I don’t enjoy doing any of this to you: I get no satisfaction from it. But it comes as the flipside of my role as an ICU nurse. On one hand, I can help to save a human life. I can help overcome disease work to evade death and watch as a man or woman get a second chance to live a rich and meaningful life again. Yet on the other…on the flipside of critical care…I am faced with the sobering reality that, in many ways, I prolong suffering. I block only the way out. I provide care that feels conflicted. I am an advocate and I will fight for what is best for the patient charged with my care…but sometimes, it’s not up to me. Sometimes, it’s not up to them. Sometimes it takes days and weeks and hours of stagnation; sometimes it takes forward progress without purpose; sometimes it takes an act of some God that is more powerful than our protocols, to lay that weary soul to rest.
Every hour of every shift, I see Death in his every poetic form: some days cheated; others prolonged; and other still, stiff, cold, and pronounced. But it doesn’t have to be that way. That doesn’t need to be the end. We are educated. We are trained. We are certified. Yet, we’re human. Some days we need the gentle reminder that medicine without humanity is simply science. Science teaches us how to move forward. Humanity, though: humanity calls for a gentle diversion when forward motion no longer means progress. Humanity understands that just because we can, doesn’t always mean we should. Saving a patient doesn’t always mean medications and machines and harrowing heroics: sometimes, it calls for simple humanity. Ultimately, that decision is up to you. Ultimately, you need to show us when.