“Pulling the Plug” does not mean “killing” someone
Physicians place patients on life support for a variety of reasons. A planned surgery (with general anesthesia) is the most common reason to place a breathing tube through the mouth into the wind pipe. A respiratory failure or a heart (cardiac) arrest are other reasons to do so. Life support is required for any illness that injures the brain or organs such that the patient is not capable of sustaining their lung or heart function.
The goal is to provide such support till the healing occurs. In a case of pneumonia, the need for such breathing support (ventilator) may be for a few days. In certain cases of coma, observation is required for months. In the second case, a long-term airway support with tracheostomy tube is provided. In a case where the healing is not happening or deemed unlikely, it is important to consider discontinuing such support as it only adds to pain and suffering of the one on such support. In some cases, the degree of healing and recovery may be unacceptable to the patient.
Patients may have expressed their wishes, or instructed family on what to do if they were placed on prolonged life support. At other times, the family may be required to make “withdrawal of care” decisions. Removal from the life support is labeled by some as “pulling the plug”: meaning stopping the ventilator, fluids, and in some cases nutrition. The family may not give permission to the doctors to stop therapies, even in a case where there is no hope. There are many reasons. The most common reason may be that the family still holds on to the hope of recovery. The doctors may present a very poor outlook, yet families feel that their loved one will have better odds. Other reasons may be religious belief or difficulty in “letting go.”
I wanted to address yet another reason that concerns the family. “Am I killing my loved one by pulling the plug?” They are concerned that the loved one will struggle with their breath after removal of the breathing tube and this will be hard to bear. I will relate two cases in our ICU to explain this.
Case A: Tim was eighty-one years old. He had colon (large bowel) cancer and had a surgery that entailed removal of a portion of the bowel. He had been given chemotherapy, however, he had developed multiple problems related to non-healing and leakage of bowel through the incision, called a fistula. He had developed pockets of pus (abscesses) around the bowel. These had been drained in the past with drains. He had grown progressively resistant bacteria over a period of six months and gone through multiple rounds of antibiotics through a catheter in his vein. He was extremely weak and barely made out of bed over few weeks prior to presentation. All the bones in his body were visible. He was admitted to the ICU with infection and “shock” (meaning that his blood pressure was too low to circulate blood through organs). His breathing was very poor, so he needed to be placed on life support (a breathing machine/ventilator) and medications to support his blood pressures. After five days in the ICU, Tim had gone into multiple organ failure. He was growing resistant bacteria in his blood stream that was difficult to treat, his kidneys had failed and dialysis was started. Blood pressure was often so low that his heart had gone into an irregular beat and he was in an unresponsive state. Nothing that the doctors had done, or that they could do was changing the fact that Tim was dying. Now the doctors were artificially prolonging what was an inevitable death. Wife and the daughters accepted the prognosis and understood that death was inevitable, but did not want to stop anything because that would mean they were actively causing his demise. Pulling the plug meant they were “killing him.” They did agree for minimizing blood tests and focusing on comfort. Five days after such discussions, the patient died while still on the machines. During this time, he needed frequent pain medications. The family maintained a constant bedside vigil.
Case B: John had heart disease. He had been short-winded for years. One day he suffered heart arrest and was admitted to the ICU after a long CPR. He was in a coma and he was in shock. Five days later he was not opening his eyes, did not seem to have any movements, and barely had any breathing activity. He was not brain dead but the injury was so advanced that the doctors told the wife that he had a very poor chance of recovery. John’s wife said he would never have any ‘artificial’ device keeping him alive and wanted to remove the support and let ‘nature’ take its course. Doctors removed the breathing machine and John passed the next day. The nurses saw to his comfort, they gave him morphine and valium whenever it was felt he was in any discomfort.
These are two opposing views about the removal of life support. In both cases the result was death. The argument for allowing “natural course” is that death is inevitable. No one can stop it when the time comes. At that stage, trying to delay it by artificial means (that was never the intent or purpose of intensive care) only causes prolonged discomfort which in nature could be a quick process. If nature intended this process to be short and less painful, then it makes sense to just provide comfort with pain medications at that stage.
If an antibiotic is not working, it is stopped. Similarly, aggressive care fails at the end of life. The idea that somehow stopping this failed artificial intervention equates to “killing” does not make sense to an intensive care doctor. The patient was dying, nobody killed anybody. Focus on comfort is the best option the provider can offer. In Tim’s case, five days of unnecessary prolongation was hard on the patient, the family, the caregivers, and the economics of the health system. The human brain shuts down at the time of death. If the family is concerned about breathing efforts, they should take comfort in the fact that the patient themselves are in a coma and unaware.