Survival, dying well and intensive care

By Thomas Donaldson.

Intensive care (ICU) medicine is amazing. When a disease causes a patient to become critically ill because their lungs, kidneys or cardiovascular system have started to fail, ICU treatments can take over the job of these organ systems to provide extra time for them to recover. Intensive care treatment has prevented the deaths of many patients.

In hospitals, intensive care doctors are the cavalry. When a patient is deteriorating and other treatments are not working, the ICU team swoop in and take them to the ICU. They do things that other doctors cannot do.

As an anaesthetic trainee, I worked as part of ICU teams and got to see how fantastic ICU can be. People at death’s door were prevented from dying and recovered. However, I also saw times when ICU treatment was not enough. When you care for the sickest patients in the hospital, saving everyone is not always possible.

ICU treatment also comes with a cost. It is some of the most burdensome treatment in modern medicine. ICU patients need invasive lines and often need a ventilator to help them breathe. This requires a breathing tube in their windpipe, which usually means they have to be sedated. Sedation can make ICU patients look peaceful, but they are rarely fully unconscious, as this would require a level of sedation that would be dangerous to someone who is so unwell. People who have experienced ICU treatment often report unpleasant memories of their time on ICU, which can include memories distorted into hallucinations and delusions by the combined effects of critical illness delirium and sedative medication.

If these are the experiences of ICU patients that survive, it is reasonable to assume that the patients who do not survive ICU have similar experiences. This means that dying on ICU may involve negative experiences, including frightening hallucinations and delusions in the last days and hours of life.

This creates a dilemma facing critically unwell patients. Their only chance of survival requires burdensome ICU treatments, but these could end up resulting in a negative dying experience if they do not survive.

Deciding about intensive care treatment can be extremely challenging. There is often significant uncertainty about what a patient’s chance of survival actually is. The urgent nature of critical illness means that decisions have to be made in a very short space of time. Also, the patient themselves may be too unwell to take part in the decision-making process and so need to rely on their families and close relations to know what their wishes and values are.

These decisions challenge what medicine is for and what it’s goals should be. Should medicine be aiming to cure diseases, produce healthy humans, prevent suffering, or help people to live as long as possible? Or does medicine have several goals, and if so, what happens when these goals come into conflict, such as in intensive care decision-making, where the goal of prolonging life may prevent the goal of providing a peaceful dying experience?

In virtue ethics, moral decision-making aims to help people flourish. Aristotle argued that to flourish a person needs to both live a complete life and die a good death. Using Aristotle’s concept of human flourishing as the goal of medicine would prevent the importance of providing a good death from being forgotten when making complex decisions about providing intensive care treatment with the aim of prolonging a patient’s life.

This approach suggests that it is important to include palliative care considerations in intensive care decision-making, as well as highlighting the benefit of making advanced decisions. In healthcare systems with a default assumption to prolong life, a focus on providing a good dying experience can easily get lost. When patients would rather not receive burdensome life-sustaining treatments, it is important that their wishes are known, so that they can be actioned if decisions must be made when they are too ill to participate in them.

Palliative care medicine aims to help patients to experience a good death, understanding death to be a natural and inevitable part of every person’s life. Often palliative care is considered separately from the rest of medical practice, only relevant to those patients who have no chance of a cure. However, the virtue ethics goal of human flourishing, as both living a complete life and dying a good death, creates an argument that palliative care considerations are important in medical decision-making when a cure may still be possible.

ICU treatments involve significant burdens to the patients experiencing them. This should not be overlooked in ICU decision-making. If prolonging life becomes the only consideration driving intensive care decision-making, then increasing numbers of patients will die in ICUs, pursuing any chance of survival, no matter how small. Such an approach to end-of-life decision-making for critically unwell patients may hinder their flourishing by exposing them to a negative dying experience.


Paper title: Human flourishing, the goals of medicine and integration of palliative care considerations into intensive care decision-making

Author: Thomas Donaldson

Affiliations: Centre for Social Ethics and Policy, School of Social Sciences, University of Manchester, Oxford Road, M13 9PL

Competing interests: TD has received a School of Law Studentship from the University of Manchester

Social media accounts of post author: @TomDonaldson100

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