Program Director’s Note - Thoughts on a Week in the MICU
Hi everyone,
Most of our patients were dying, imminently if not immediately. Their cancer had become untreatable, or their hearts, lungs, livers, and kidneys were failing. Survivors were outliers.
Prognosis-wise, it was a typical week in the MICU, similar to most academic ICUs that serve as destinations for the desperate. I used to bemoan death in the MICU as predictable, avoidable, and regrettable, but my views have evolved.
These days, our oncologists treat cancers that were once deemed hopeless. Our liver transplant, advanced lung disease, and heart failure programs offer hope where none previously existed. But despite modern treatments, many patients deteriorate, and hope becomes bewilderment as critical illness sets in.
The MICU will always be an epicenter of end-of-life decision-making. I used to approach such decisions quasi-quantitatively, weighing burdens vs. benefits, or pain and suffering vs. the likelihood of survival. Did the discomfort of intubation justify a few more days of life? I thought we could calculate our way to rational decisions, but too often, this approach led to conflict, frustration, and impasse.
Repeatedly rehashing burdens and benefits rarely persuades anxious, overwhelmed patients and families. This is especially true when choices are presented by strangers who swoop into their lives like new characters at the end of an epic novel.
We need to build relationships first: We must introduce ourselves (“I’m Dr. Siegel”), explain our roles (“the senior physician”), set expectations (“I’ll be here every day”), share our goals (“to take care of your loved one”), and make promises (“We’ll do our best”). We ask questions: “What have you heard?” What do we need to know about your mother/father/husband/wife?” What else should we discuss?” We invite families to join rounds, listen to their concerns, and thank them for their contributions. We share their joy if things go well and sit with them when things go badly.
When we build relationships, end-of-life decisions flow more easily. Families recognize our effort. When we say we’ve done all we can, they believe us. When we explain that intubation and chest compressions will just prolong suffering, they can recognize this sad truth. And when we suggest the time has come to focus on comfort, they’re more likely to agree and, often as not, tell us they’ve already reached the same conclusion.
It takes a team to build trust: residents, fellows, consultants, APPs, therapists, pharmacists, chaplains, social workers, PCAs, and nurses. Especially the nurses, who spend the most time listening to patients’ and families’ fears, providing physical and emotional comfort, and nudging the rest of us along.
At our best in the MICU, we are honest and compassionate, hopeful but realistic. We hold patients’ hands figuratively and literally as we guide them through excruciating decisions. We relish the joy of saving lives, but we also welcome the hugs, given and received, from families who know we did our best, we listened, and we cared.
Enjoy your Sunday, everyone. I’m driving to East Rock for a winter hike (see below). Tomorrow morning, I’ll be starting two weeks in the SDU.
Mark
P.S. Don’t miss the deadline to vote for our 2027-28 Chief Residents, tonight at 5 P.M.
P.P.S. What I’m reading
Solito By Javier Zamora
Almost Everything By Anne Lamott
Physicians Are Not Providers: The Ethical Significance of Names in Health Care: A Policy Paper From the American College of Physicians By Lois Snyder Sulmasy and Jan K. Carney
There’s a Reason American Kids Are Such Picky Eaters By Helen Zoe Veit
What’s the Secret to Happiness? These Researchers Have a Theory. By Catherine Pearson
Ash Wednesday and the Burden of Living Your Beliefs By Christopher Beha
What Alcohol Does to the Body By Dana G. Smith, Illustrations by Montse Galbany
“I Failed At Achieving My Irish Dancing Dreams — And It Didn’t Matter” By my daughter Gabrielle Siegel
