“How do you it?”
This is the most common question I am asked in the ICU. From patients, family, friends, students and even colleagues.
“How do you deal with life and death every day?”
Life and death.
Life and death seem dichotomous. So black and white. But, in reality, in the intensive care unit, the distinct line that we think exists between these, starts to blur. Life support measures such as ventilators, vasopressors, cardiac devices, and ECMO all prevent a natural death. Death is at times inevitable, we may delay, it but not prevent it. Other times we will succeed in saving a life and our patients will go on to live another day.
In the ICU , we live in the blur. We try to help patients and families understand the complex and confusing moments in the ICU when they stand in the blur with us, unclear of what will happen in the next few minutes and hours, whether it will be life or death. Should we start life support? Should we continue it? If I choose life support, will I ever wake up again? What do you think life will be life if I survive?
During these discussions, we talk about life and our deepest values surrounding whether quality of life outweighs quantity, the guilt of dying and surviving, how we can honor life and pursue it aggressively and at other times, how to allow death to occur with the greatest of dignity. The question of "How do you do it?" often comes toward the end of the conversations. How do you talk about life and death every day? How do you handle the inevitable deaths and the sadness?
First, the ICU is not a place focused on death, its a place of celebrating life. Celebrating the love, the accomplishments, the joy of a life well-lived - whether or not that life continues, we celebrate. We rejoice in moment as best we can. It is also a place of focusing on the future - many ICU patients share deep-seated dreams they have never chased due to fear or perceived obstacles, but when recovering from critical illness, they realize life is too precious to allow fear to dictate our actions and to live with the regret of not chasing the dream. Often, patients encourage their family and friends to do the same. Look forward and LIVE, love and find joy.
Second, this deep discussion about our individual beliefs, our humanity and our mortality, is truly part of the job I love. It may be messy, confusing and yes, blurry, yet, in it’s simplest forms, I have two jobs. 1) To understand how each patient has defined life and death and practice medicine within those definitions to the best of my ability; and 2) To remind families and friends that my goal is to care for their loved one(the patient), but the ICU can be traumatic for everyone involved, therefore it is also my goal to care for everyone in that room, not just the patient, as best I can. Why? Because I have yet to have a patient recover from critical illness and not express concern over the toll their illness has taken on family and friends.
And in those deep discussions, those moments of witnessing humanity with all of its beautiful fragility, vulnerability and yet profound strength, are the fuel that bring me back to the ICU. This is both the how and the why to answer "How do you do it?"
Because humanity is worth fighting for, preserving and sharing. It just so happens that the best way I can do that is through medicine.