Comfort Care

Comfort care is the euphemism we use when we transition a patient from aggressive and invasive treatments to measures that will allow them to pass peacefully. In the ICU, we have several patients each week who become comfort care. It is a paradox of sorts; everyone wants to die peacefully but nobody wants to die. So when there's a 50-50 chance that a patient won't make it, do we push them with dramatic and heroic interventions knowing that they may die despite our best intentions or do we let them go quietly knowing that we had not tried everything? What if it's a 75-25 chance that they won't make it? 90-10? 99-1?

I can tell you the common response. In this situation, even for patients who previously documented that they would not want life-supporting interventions or dependence on machines, it is really easy to say, "let's just keep going one more day." It's also easy to tie the doctor's hands: "he'd want everything except a ventilator." And of course that is perfectly the right of the patient and the family, but is it the right thing to do? After just 4 weeks in the ICU seeing futile attempts to resuscitate patients whose illnesses outstrip the body's resources to cope, I am not sure.

I have written about the end of life a lot, and my conclusions are always the same: the death we want is not the kind of death that occurs in the intensive care unit, or the code blue, or the emergency department, or even the hospital. I believe this firmly. And yet, I feel my emotions clench when I advocate for someone to be comfort care even when I know rationally it is the thing to do.

A 100-year old gentleman comes in with a rip-roaring pneumonia, the kind that in the past was "old man's best friend" because patients passed quietly and swiftly. He wanted to live but did not want intubation. So we treated with antibiotics, tried to give fluid cautiously, and put him on noninvasive positive pressure ventilation. Fluid management was difficult because we felt like our hands were tied. His infection was severe enough to drop his blood pressures, and by textbook, we should be hydrating him aggressively to support his hemodynamics. But fluids will go into the inflamed lung, a risk factor for requiring intubation, and since this was off the table, we could not treat him as we should. He already needed BIPAP or noninvasive positive pressure ventilation. This is a last resort prior to intubation but not a long-term solution.

Day after day, we could not get this patient off of BIPAP. It was clear to us that our options were to intubate or to transition to comfort care, and given the patient's wishes, it was time for us to make him comfortable to pass. I presented this as best I could to the family, a conversation I played out in my head before walking into the room. But even as I spoke, I could feel my heart twinge because I was essentially saying that this patient would die. How do you approach that kind of situation? How do oncologists tell a patient that she will die from cancer? How do generals send soldiers into a battle where the casualty rate is mercilessly high? How does a pregnant woman decide to undergo an abortion?

Death is easy to talk about on paper, on blogs. It is easy for me to sit here and write that the ICU is no place for old men. But I don't mean to discount the process of determining how one will die and undergoing that process. I don't mean to imply that I know some secret about it that no one else does. Because I struggle so hard with it, and weeks after each encounter, I still think about that patient, the family, and how I could have made that transition to comfort care easier, smoother, more acceptable.