When dying is probable

Taureef Mohammed

IT IS ALMOST midnight and I, along with a couple other residents, am tidying up things in the ICU, when the nurse for bed 20 says, “He is not doing so well. I think we should call the family.”

I can’t remember what brought him to the ICU, but whatever it was, he was now on life support. Machines and medications kept him alive – kept his blood oxygenated, his blood pressure up, and his brain perfused.

I called the not-so-old man’s son, and fumbled my way through the conversation, explaining how despite our efforts, his father’s heart, kidneys, lungs were failing, and he was declining.

Then I passed the phone to the charge nurse to arrange a family visit.

“I don’t think you understand what’s happening. Your father is dying,” I overheard her saying. “You need to come in now.” Embarrassed, I sat around until the conversation ended.

“I am sorry I botched that. I didn’t say he was dying.”

“I’ve been around for a while,” charge replied.

How could I not say the word? It felt worse than missing an obvious diagnosis. Outside of the ICU, I could usually recognise when someone was dying, and patients’ families appreciated when you told them so. They wanted to be present for the final hand squeeze, the last glimpse, the final breath. The dying moment was precious.

So missing it bothered me. Was it that I really did not think he was dying? Or was the ICU – where my patient was tethered to machines via lines and tubes, his consciousness dialled up or down by titrating infusions – just strange to me?

Dr Wael Haddara is chair of critical care at London Health Sciences Centre and Western University. I first met him in the hospital sanctuary, where on Fridays he would lead the jummah prayer. Whether he was rounding in the ICU or giving the sermon in the sanctuary, he was always the same: soft-spoken and reflective.

I asked him: Was my patient actually dying?

“Well, 60 per cent of patients with multi-organ failure, which your patient had, will die, but 40 per cent will not. Discerning between the uncertainty is what some have problems with,” he said during an interview at his office. “In medicine, early on you are uncertain and you don’t know if it’s a gap in knowledge, so you always wonder, is this reversible?”

Experience, he said, helped us balance uncertainties and communicate them to families.

But, he added, we all had our inherent biases, and went up to the whiteboard to explain. Drawing a horizontal line, starting at zero, "dead," and ending at 100, "alive," he explained, “Studies have been done where doctors, nurses, and families are given a scenario and asked what is the likelihood of the patient surviving.”

Doctors invariably landed near the middle. “Where do you think nurses fall?”

“Closer to zero,” I said, thinking about charge. I was correct. And families were closer to 100.

Charge was the pessimist; the patient’s son, the optimist; and I was the doctor, an inexperienced, sheepish fence-sitter, supposedly the realist.

Uncertainty is the albatross around everybody’s neck. And when it forms the basis of a midnight conversation about life and death in the ICU – an unplanned destination for people struck by unexpected, life-threatening tragedies – then that conversation is going to be difficult.

“I tell my residents if you are experiencing uncertainty, don’t download that on the family. If you can’t decide, then asking the family to make a decision is terrible.

“You need to give families a pathway to the uncertainty: ‘Your relative is at high risk of dying and these are our recommendations, but we can be wrong.’”

Subtle communication strategies, he pointed out, influenced a family’s decision-making.

“Percentages mean nothing to people. Instead of saying 30 per cent, say: 'Out of ten people, seven will have a good outcome, and three will have a bad outcome.’”

Framing, he added, also mattered: if the family was presented with only the negative outcome, they would be less optimistic, and the opposite was true. So state both outcomes, he said.

In medicine we like algorithms: A, airway, B, breathing, C, circulation. But communication, it seems, is not as simple. If anything, it is the total opposite. “The art is long,” Hippocrates said.

Do I feel more comfortable now navigating a conversation about who is dying and who isn’t?

No. But I do feel less embarrassed about bed 20.

Taureef Mohammed is a graduate of UWI and a geriatric medicine fellow at Western University, Canada