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An elderly man was admitted to the ICU and evaluated by six blind physicians.
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The blind cardiologist noted that the patient had a malignant pericardial effusion with tamponade. She recommended an immediate pericardial drain followed by intra-pericardial chemotherapy.
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The blind oncologist noted that the patient had stage IV lung cancer. He recommended palliative chemotherapy and whole-brain radiation.
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The blind neurologist noted that the patient had depressed mental status due to brain metastases with elevated intracranial pressure and impending herniation. She recommended initiation of dexamethasone and hypertonic saline, with hourly neurologic examinations.
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The blind hematologist noted that the patient had a deep vein thrombosis, likely due to malignancy. He recommended initiation of a heparin infusion that could be stopped if there were hemorrhage into the pericardium or brain.
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The blind nephrologist noted that the patient had renal failure with a blood pressure insufficient to tolerate hemodialysis. He recommended placement of a dialysis catheter with initiation of continuous renal replacement therapy.
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The blind intensivist noted that the patient was in shock and not protecting his airway. She prepared for immediate intubation and vasopressor support.
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A nurse with the power of sight walked by and was surprised to see a dying man being harassed by six physicians. She walked into the room and gently said, “It seems to me that there is an elephant in this room. This man is dying and nothing can stop that.” The physicians were taken aback, but recognized the truth of her words.
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Comment
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Critical care medicine is typically reductionist, analytical, and data-driven. Each patient is dissected into organ systems and problems. Enormous amounts of data are involved – vital signs, labs, EKGs, CT scans, medication lists, microbiology, and pathology. For each problem there is a solution, for each abnormality there is a correction, for each symptom there is a differential diagnosis.
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This approach works well when providing curative therapy. The problems are tackled, the details are attended to, and the patient gets better. For a young patient with septic shock, it doesn't really matter what their hopes and dreams are. What matters is immediate, definitive, technically proficient care that saves lives. I've provided curative care to many such patients without understanding who they were as people. That's OK. Not ideal, but OK.
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However, occasionally this approach is applied to patients with unsolvable problems who are in need of palliation. In this situation, things spiral out of control. Problems multiply, rather than being resolved. The goal of caring for the patient is rapidly buried beneath piles of data and technical details. Treatments lead to complications, as we become increasingly lost. The harder we try to make the patient better, the sicker the patient becomes.
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Determining which patients benefit from a curative approach, a palliative approach, or an intermediate approach is one of the most confounding aspects of critical care. There are few easy answers, but rather we are often left blindly groping for insight in the darkness. Engaging those around us can help – patients, families, friends, social workers, nurses, ethicists. Alone we may be blind, but together insight is possible.
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Don't worry, next week we will return to a coldly reductionist, analytical approach with a two-week series about dominating hyponatremia.
Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Very nicely written & enjoyed reading it. But metastatic disease patients are not admitted to ICU. Its one of the icu admission criteria. We let them have peace with palliative care medicine & do not torture them by prolonging their painful life. At least its not practiced in my country.
An Anaesthetist/intensivist from Ireland.
Bravo! I was diagnosed with rare Arterial Fibromuscular Dysplasia and pulmonary artery sarcoma. It amazed me how all of the specialists I had seen diagnosed me with 20 different diagnoses while all looking at the same things. None of the specialists looked at the whole picture, just their piece of the puzzle hence I was misdiagnosed and mistreated for years before one doctor finally put the whole puzzle together. Frankly, it is scary and unsettling to say the least. I am glad I did not stick with the first diagnosis I received, I would probably not have survived.