What Should Doctors Do When We Experience A Miracle?
IT was just before dawn in the intensive care unit when something unexpected happened. My Covid-19 patient’s condition had been worsening for weeks, and we had finally recommended to his family that we stop all aggressive interventions. It was clear he was dying. But that night, my team watched in amazement as his oxygen levels started to rise, slowly at first and then steadily. Standing outside his room, I found myself, somewhat uncomfortably, thinking of miracles.
As a critical-care doctor, I become nervous at the very idea of miracles. I hear the word and think of tense family meetings and impossible hopes. I imagine loved ones at the bedside waiting for improvement that will never come. Miracles are often what patients’ families beg for, and they’re not something that I can provide.
But then there are patients like this one.
Doctors all have cases that shake us and that we find ourselves revisiting, particularly amid this pandemic. Often these are cases of the patients that we were unable to save, but there are also patients whose very survival proves us wrong. I struggle with what to make of these outcomes and how to navigate the questions that they raise. The longer I practice critical care, the more I wonder: What does it mean for a miracle to happen in the intensive care unit
Though the word “miracle” has a religious overtone, I am not invoking the spiritual or the supernatural. As doctors in training, we attend entire lectures to help us navigate conversations with families who are waiting for divine intervention to bring their loved one back from the brink. What I am interested in is how we deal with the one-in-a-million outcomes, the patients who surprise and humble us.
Consider the patient from that overnight shift. He was a young father with Covid-19 and a cascade of complications, including pneumonia, sepsis and devastating bleeding. By the time I met him, he had been deeply sedated for more than a month and was attached to a ventilator and a lung bypass machine to keep him alive.
As the days and then weeks passed, punctuated by one medical catastrophe after another, it became clear to all of us in the ICU that the damage to his lungs was not survivable. He was dying. His family started to prepare themselves to say goodbye, but they asked us to wait a few more days before we took him off the machines.
Now, a year later, he is still recovering but is at home and with his family, and I marvel over the photographs they send me.
Though his story is remarkable, there’s a part of me that doesn’t want to share it. Not because our predictions as his medical providers were wrong I am comfortable with admitting to prognostic error
but because most people, when faced with illness, secretly believe that they may be the outlier, that improvement is possible even in the face of overwhelming evidence to the contrary. Doctors want that for our patients as well. That is what leads oncologists to offer terminally ill patients fifth lines of chemotherapy and last-hope clinical trials, and it is what brings surgeons back to the operating room one last time.
Sometimes that drive to beat the odds is what pushes doctors to be great. But if taken too far, these instincts lead to false hope and suffering for our patients and their families, protracted critical-care admissions and futile procedures. After all, in most cases in the ICU, our initial prognoses are correct. So there’s a risk to standing at the bedside, thinking about that one patient who made it home despite our predictions. We can give that experience too much weight in inuencing our decisions and recommendations.
Doctors do not want to deprive our patients of the chance to surprise us. But we must also ask ourselves how many deaths we are willing to prolong for the possibility of one great save.
A great save can be complicated. As tempting as it is to focus only on life or death in the ICU, there is a vast world between survival and true recovery. Even patients who do surprise us by making it out of intensive care might never improve enough to return to the activities they love. If a life is remarkably “saved,” only for the person to suffer for months in long-term care hospitals, delirious and dependent on a ventilator, that’s not a total success.
Of course, there are cases in which improvement is truly impossible, a person’s cancer is too far gone, the sepsis too advanced. But in other cases, for better or worse, I find that I am now more willing to push forward than I once was. This might mean I give that extra round of antibiotics or that one last trial of high-dose steroids.
I try not to push for too long and risk causing pain because I am unwilling to acknowledge the realities in front of me. But I might let myself hope for a few more hours or a few more days while working to prepare my patient’s family, and myself, for the likelihood that the person they love will not be OK.
On a recent weekend in the
ICU, one of my patients was a woman in her 60s with cancer that had caused her lungs and liver to fail. The doctor who had been taking care of her for the week told me the plan: If she was no better on Monday, the family would take her off the ventilator, but they wanted to wait through the weekend. Why I asked. Well, my colleague explained, they wanted to give her time for a miracle.
When I visited my patient early Saturday morning, she was still intermittently awake, uttering her eyelids, and I hoped she was not in pain. As day turned to night, her blood pressure teetered. And before my shift ended, I entered the room again to find her adult children gathered at the bedside.
“She’s not getting better, is she ” her daughter asked. As gently as I could, I explained that despite our best efforts, she was not.
Her daughter started to cry as she realized that there would be no Hail Mary save, no reason to wait until Monday. There would be no miracle, but perhaps there would be peace. It was time to say goodbye.