Are Patients On Life-Support Alive?

As recently as today, I faced this question that has been a source of great uncertainty and pain for relatives of patients admitted to ICU. It has also not been an easy one for healthcare workers who take care of these patients, and often the source of mistrust and friction. For seven of my early years as a doctor, I worked in an ICU.  It is a high pressure area: that strange place where you meet the best medicine mankind has to offer and at the same time the limitations of the profession, and at times helplessness. Yet it is also fulfilling: when the outcomes are good, and from knowing that you are doing a meaningful thing for a patient who 100% needs it.  Let me answer YES to this question then explain why.

I remember two friends from South Sudan, one of whom was admitted to the ICU with a life-threatenting critical illness. We honestly felt his chances of making it were lower than coming out. Still, we deepened his coma as this was his only chance as far as medicine goes. Two weeks in with the weight of a heavy medical bill and armed with the “revelation” that doctors in Kenya would keep patients in ICU though “dead” to make money, the friend came all fired up with the temper of an enraged elephant.  To say that it was a difficult discussion would be serious understatement. About two months later as the friend supported Ding (not his real name) on his shoulder to walk on his way home after bieng discharged, we smiled with him broadly as I reminded him of the the day he wanted us to pull out all the machines or else he would “teach us a lesson.”

I am afraid that direct translation – that dangerous tendency that has started wars in the past –  is often incorrectly applied to the medical phrase “Life support.” Marriam Webster Dictionary defines a life support system as “an ARTIFICIAL or NATURAL system that provides all or some of the items (such as oxygen, food, water, control of temperature and pressure, disposition of carbon dioxide and body wastes) necessary for maintaining life or health.” Did you know that an astronaut requires a life-support system to go into space as does a diver diving deep into the sea? Both of these groups of people are expected to come back and so do most of the ICU patients though the chances for the latter group are lower. However, many mistake Life Support to mean that life has left a patient, who then is hooked onto complex machines to give a semblance of life. This literal translation is wrong in its entirety. Even doctors with the help of advanced machines do not have the ability to achieve this. Only God can.

In medicine, life support systems consist of the following (among others):

1. Ventilator – This is the breathing machine.  By far this what is often referred to as life support while in fact all it does is push air into the lungs and out. The amount of oxygen, the pressure and the rhythm of the breathing can be altered depending on the patient’s condition. Patients in deep comas or with head injury or with severe lung disease, or who for some reason cannot breathe adequately for themselves would require this machine.

2. Feeding tubes – This can be translated literally. Often it is a long tube that goes through the nose all the way into the stomach. Sometimes it is a tube inserted directly into the stomach through the skin.

3.  Monitor – That TV like screen with numbers and lines is simply a monitor.  All it does is read the status of the patient and displays it so that medical personnel can tell that status at a glance. What is frequently monitored is the heart rate, the blood pressure, the blood oxygen saturation, and pressure in the right side of the heart which estimates the volume of fluid (blood) in the blood vessels. For most modern monitors, medical personnel are able to set a normal range for these monitored parameters. If the reading goes outside these ranges, the monitors would sound an alarm. Most wires attached to an ICU patient are monitor wires.  Interpretation of monitor readings as simple as it looks is a very complicated and technical issue. However, almost anyone with a patient in ICU can and should learn to identify the heart rate (not rhythm) on the monitor.

4. Blood pressure support – Inotropes or drugs to increase blood pressure may be given to patients whose blood pressure is too low to meet the body’s requirements.

5. Dialysis – Believe it or not, dialysis is a form of life support. Now you begin to see the difference between the medical definition and the lay (direct translation) definition of the same :).

The above are the common components of life support. In reality,  there is no man-made way to make a person whose life has left to appear alive. Only the Almighty God can do that. However, just before life leaves, one common event is that the heart stops. Immediately after the heart stops (and/or breathing) health care workers do have a small window during which they could save the patient’s life if they could restart the patients’ heart and restore breathing. This “restarting” is what is called CPR (Cardio-Pulmonary Resuscitation. Cardio means heart and here refers to circulation of blood, pulmonary means lungs but here refers to breathing/ventilation). CPR is a dramatic and physically intense process where health workers physically compress the patients’ chest, push air in the lungs, give a lot of medication and sometimes use eletrical therapy. Trsut me, if CPR is going on, you will know. This is the only “life support” in the literally translated meaning of the phrase and it is not always successful.

The correct answer to the question above therefore is YES, patients on life support are alive. There is however no guarantee that they will survive or even wake up. Indeed, the very fact that someone needs life support means that at least one critical organ system has failed and if it doesn’t recover, the risk of death is high. This high risk of death is sometimes the ethical dilemma that care givers face. If an illness bears a 60% chance of death, or even just a 20% chance of survival, would you give this patient this chance through very expensive life support systems that will cost the family millions? If your loved one required life support with only a 20% chance of survival, would you take that chance or let them pass away? I don’ t think there is a right or wrong answer to this question but I lean towards giving the chance IF there is a medical cure to the underlying illness.

The other common misconception is that most ICU patients don’t make it.  Believe it or not, the world average mortality for ICU is 21%. This is still pretty high but considering that mortality would exceed 90% for this subset of patients without the ICU care, its a pretty good save.  The combined mortality for my ICU and HDU was way lower than the world average. This is why I am a big advocate  for accessible PROPER ICUs in each County in Kenya. Proper here is the key word and what it means is a technical discussion I will write on later.

BRAIN DEATH

The discussion on life support is not complete without talking about brain death or brain stem death.

The principal purpose of ICU and its life support systems is to provide temporary replacements for the body’s natural processes while a patient recovers to take over the function carry on on their own, or wake up. However, brain cells once dead do not regenerate (this is not entirely true but the exception is a complicated discussion that would not vary this argument materially) It means that if the part of the brain that controls the state of being awake dies off, there is no practical chance that the patient would wake up. The same applies to the area that controls breathing, the heart beat and some important reflexes.  Collectively, this situation in which parts of the brain that control vital functions such as breathing, wakfeulness, heart rate and other vital reflexes are dead is called brain death. It therefore provides no benefit to the patient or the family to continue treatment.  Some countries allow for removal of machines once brain death is declared and the family informed. In Kenya however, legislation is grey but it is generally found unacceptable to fast-track a patient’s actual death by removing machines. What is done in this case a reduction of medical support and interventions to a minimum and as close to nature as possible. For example, oxygen is set at 21% the same as the atmosphere, the rate of the ventilation machine is reduced and the volume as well, blood pressure boosters, if any, stopped as well as medication, dialysis and CPR are avoided, no investigations are carried out and so on.

Obviously, to make such a pronouncement on a patient is a very serious matter. Imagine the implication of brain death as a misdiagnosis! The medical world has therefore set checks and criteria that must be met for one to be declared brain dead, and this process must be followed even when a doctor strongly suspects that the diagnosis is correct. One of these requirements is that brain function tests must be done under very specific circumstances by at least two different specialistst at least 24 hours apart.

Despite the clarity above, it is wrong for a doctor to refer to a brain dead person as dead.  As you can see, brain stem death is very different from actual death. The two are not interchangeable. In theory, it may be possible to cure brain death through a brain transplant. There is no cure for death. A brain dead patient may also serve as an organ donor. A brain dead patient would be on machine, albeit on minimum support until actual death while a dead patient must be removed from the machine promptly.

In my 7 years experience in ICU, no patient put on minimum support ever recovered. Unfortunately, depending on the severity of the underlying illness, for most patients, the heart would stop in  a period ranging from 15 minutes to 2 days.

What about miraculous healing? I am a firm believer in the power and the authority of the Almighty God. I am a believer in miracles and I have experienced a few in my life. However, I also got to learn that God does not require man, even a brilliant doctor, to buy him time to perform a miracle. If the almighty God decides to heal a patient, he will do so no matter what the doctors do or fail to do, and vice versa. It is therefore proper and advisable to proceed with what is recommended from medical evidence, even as we pray for better outcomes through divine intervention.

Finally, we must build our public health system.  I believe no private entity can out-invest the government. No private entity can “out-benefit” the government in economies of scale or utility of healthcare commodities. As such then, the reasons why the public sector is so far behind the private sector are artificial and rectifiable.The key requirement for public healthacare is leadership with Ability, Integrity, Vision and Passion.

I hope that this long post gives some clarity on this sensitive issue and to those with patients in ICU’s. Post any questions you may have on the comments section below or raise them on twitter: my twitter handle is @ovngani.

May the Almighty God bless our country.