“Let me tell you now, I’m not taking an old guy with renal failure into my intensive care. You can keep him!”
In my first ever call as an intern to an intensive care physician, I was stunned by his derision. Needless to say, both his manner and threshold for age would change dramatically over two decades. Today, he is forced to entertain far more contentious referrals of 90-year-old dying patients to the same intensive care that once rejected a man 20 years younger.
The modern ICU is a medical marvel. Here, people and machines combine to keep people alive against remarkable odds. For a ward doctor struggling to salvage a patient, an ICU referral is the ultimate escape route. For a family member struggling to accept a loved one’s decline, the ICU is the mecca of hope.
Now, the ICU is in our sights again due to warnings that there may not be enough beds to fulfil the demand for coronavirus patients requiring respiratory support. Italian doctors dramatically stoked fears by suggesting that the shortage of beds could lead to rationing: spare a thought not only for the elderly, who immediately spring to mind, but also for the otherwise vulnerable, the disabled, non-native speakers – in fact anyone who doesn’t have “status” in society, because the unpalatable truth is that even supposedly objective decisions in medicine are necessarily tinged with subjectivity.
At these times, it’s tempting to rail against the system and expect the creation of more ICU beds. Hospitals are at it, but that doesn’t stop us from feeling helpless. A productive approach may be to consider why ICU beds are always saturated and what role each one of us can play in promoting the judicious use of a precious resource.
First to doctors. Why do doctors admit patients to ICU? The obvious cases are those who are recovering from surgery, trauma or an acute illness that is deemed reversible with antibiotics, fluids, sedation, cardiac or ventilatory support or temporary dialysis. With meticulous care, they can expect good outcomes, though the journey is still arduous – most people completely underestimate the physiological and psychological toll of an intensive care admission, even on a fit individual.
But what if a person, physically frail or cognitively impaired, with multiple chronic diseases, is admitted to intensive care? 60% of Australians over age 65 have at least two chronic diseases. Patients with multiple chronic diseases admitted to intensive care are much more likely to die or suffer dismal functional outcomes. 80% of 80-year-old patients die within a year of intensive care admission and they live that last year with impaired quality of life. What does impairment mean? It means not being able to walk properly or think clearly; loss of independent living; needing help with personal hygiene, and all the accompanying frustration and angst.
Intensive care physicians argue that while mortality is certain, suffering doesn’t have to be. Yet, about one third of elderly patients receive aggressive, painful and ultimately futile treatments in the last six months of life.
Here, I recall the cachectic, confused elderly man whose surgeon had barred physicians from broaching end-of-life care because he believed he had performed a “beautiful” operation. And the elderly woman with dementia whose howls during dialysis reverberated down the corridors until her nurses pressed their hands to their ears. And, I concede, any number of cancer patients receiving aggressive chemotherapy in the last few weeks of life who come to intensive care to live because apparently no one has addressed the prospect of dying. These situations aren’t unique to one hospital and are a leading cause of moral distress among providers, especially those who feel obliged to follow doctors’ instructions. Physical suffering aside, futile treatment exacts a financial cost, with each day in intensive care estimated to cost $5,000.
Finally, bereaved relatives of patients who die in intensive care experience high rates of complicated grief and post-traumatic stress disorder.
For intensive care to serve its true purpose, doctors must be honest with themselves and their patients about what to realistically expect. Intensifying treatment should not be the default position for every gravely ill patient; rather, we need early conversations about an individual’s values and what really matters. To broach intensive care and palliative care in the same conversation is not as outlandish as it seems when one considers the manner of dying in each instance. But given the challenge of making consequential decisions on the basis of a single encounter, we will need GPs with longitudinal knowledge and perspective. In turn, this requires a fundamental rethink of the role of primary care in an era of fragmented medicine.
But of course, the decision for an admission to ICU involves two parties, doctors and patients. Many doctors have the knowledge and skills to counsel that a patient will suffer mostly harm and meagre benefit from aggressive escalation of care. Unfortunately, they are some of the same doctors left in tears by aggressive (and upset) family members who flatly dismiss any notion about their loved one’s mortality. It’s quite common to find the patient’s best interest subsumed by the competing ideas of relatives. “Family pressures” are by far the greatest contributor to doctors offering non-beneficial interventions, with inadequate communication, medico-legal concerns and disagreement between clinicians being other factors.
What does “family pressures” really mean? It could be a heartrending plea to show mercy and preserve hope, or a torrent of abuse followed by a promise of legal action. Emotionally, these encounters are depleting. Pragmatically, they whittle the resolve to do the right thing. How many ICU beds are occupied as a result of unresolved arguments? How many genuinely needy patients are therefore kept waiting?
To limit the ramifications and the panic associated with the coronavirus will require the intellect of researchers, the commitment of clinicians and sound government. But it will require something else: the cooperation of society.
No healthcare system has unlimited intensive care beds; indeed, some countries have none. The evolving pandemic is an opportunity for introspection and building a template for the future. The virus will pass but chronic diseases are here to stay. Australians should reject frank discrimination but welcome an informed discussion about whether intensive care is right for them. This shouldn’t be mistaken for rationing: indeed, if one is sick enough for ICU to be a consideration, denial is the worst medicine.
Most coronavirus cases so far have been mild. But if the prediction for more intensive care beds comes to fruition, it would be important to know that rather than being helpless bystanders, we had played an active role in protecting our own interests and, along the way, helping our fellow citizens.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death