By Dr Lucy Davies, Anaesthesiology Resident, SingHealth Residency
The intensive care unit (ICU) is a place where we push life to the boundaries, where we support, or in some cases, replace every organ. It is a place where patients recuperate and regain life to reunite with loved ones, and also a place where we medical practitioners realise that sometimes, even our best efforts are not enough to save their broken bodies.
In some cases, we watch our patients’ conditions deteriorate, while others who are more fortunate go through the journey to recovery.
The stories are often of someone’s world turned upside down.
One moment, the proud young mother of four sons was riding home on her eldest son's motorcycle; the next moment, she was lying in ICU Bed 5, surrounded by monitors and her weeping family...
In Bed 2, a father had been in ICU for two months and had become a fixture in the ward. On days he felt better, he would sit up and try to communicate despite the tube in his mouth, gesticulating and indicating what he wanted with meaningful looks. On days he did not feel so well, he lay fitfully with his eyes closed.
That day, he had suffered yet another complication in a series of unfortunate complications. His wife hovered in his room pacing - praying, his son smiled weakly as we wheeled him away for yet another operation. The next day as I changed his IA line he struggled to breathe and shook his head sadly at me, indicating weakly "no more”.
“Don’t give up now” I told him, and then wondered if that was the right thing to say.
Another call, another cup of coffee, another week, another consultant, another morning round in ICU, another patient – young, foreign, who had collapsed and hit his head. He was brought in struggling with his breathing, and his oxygen levels could not be determined, so we placed a tube to help him breathe.
His wife watched anxiously as we weaned him off sedation and tried to assess his Glasgow Coma Score: 11. His condition was not severe. Relieved, we removed his breathing tube. He went to general ward the next day. Some stories end more happily than others.
“Please keep him alive” said the family “just a few more days”. We tried. Sadly, there are limits to what is possible.
In Bed 7, a patient lay dying. He had collapsed three times on the way to ICU, with raging sepsis. “Please keep him alive” said the family “just a few more days”. We tried. Sadly, there are limits to what is possible. Despite everything we threw at him, his heart gave out again, and he was gone.
I confronted mortality in the ICU.
That night I sat in church, feeling cold and contemplative, absorbed in watching a candle on the altar as it bravely sought to survive under the full blast of the air conditioning overhead, as it flickered and burned.
The mother with four sons in Bed 5 was now dying. Before the surgery, her left pupil had blown, followed by her right pupil, indicating that her brain wasn’t functioning. In many ways, brain death is harder to accept than cardiac death.
We explained to her family that she was dying and soon HOTA (Human Organ Transplant Act) would step in. We explained to them what that would mean. We offered to withdraw her breathing support.
The family said no, adamantly no, they wanted everything ICU had to offer. They chanted and prayed for a miracle. "She looks so alive" they said to each other, "she looks like she is getting better".
For days and days, while the patient still breathed, we continued to do all we could – monitoring her carefully, giving medications to support her blood pressure, transfusing blood. There were days we questioned what we were doing and why we were still doing it.
But the intracranial pressure monitor continued to read 90, far too high for the brain to function, until finally it was taken out. For days and days, while the patient still breathed, we continued to do all we could – monitoring her carefully, giving medications to support her blood pressure, transfusing blood. There were days we questioned what we were doing and why we were still doing it. We tried to explain, again and again.
Then the day came where she breathed no more.
We tested the cranial nerves, did the brainstem tests. Then we did them again. Then two certifiers came and did them again. And then we turned it over to HOTA to do the rest.
"No" said the family, they could not accept. "No she can't be gone!""No not her organs!""No we won't let you!"
The brain stem tests were done repeatedly.
"You cannot take her organs! Let her go in peace!"
Our consultant spoke to the family, the social workers spoke to them. "It's the law", we explained.
"But it's against our religion!" they said.
Religious leaders spoke to them. Chairman Medical Board spoke to them. It was a journey for all parties, meaningful but long drawn. But finally – they agreed.
As I sat in church and the last strains of "sleep in heavenly peace" drifted from the piano, the candle flickered, floundered and died.
Footnotes:Transplantation is one of the most remarkable successes in the history of medicine. It is often the only hope for people suffering from organ failure. In Singapore, the Human Organ Transplant Act (HOTA) allows for the kidneys, heart, liver and corneas to be removed in the event of death from any cause for the purpose of transplantation.
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