book cover Adapted from Death Interrupted: How Modern Medicine Is Complicating the Way We Die © 2022 Blair Bigham. Published by House of Anansi Press as part of The Walrus Books series.

Ican’t recall a time as a paramedic when I pronounced someone dead without complete confidence.

Back then, it was a relatively easy decision to make. The Ministry of Health in Ontario, where I served on ambulances and helicopters for a decade, had a list of things that qualified someone as being “obviously dead.” It’s the type of list paramedic trainees have to recite for exams, and I knew it colloquially as Policy 4.4.

Policy 4.4 included things that didn’t really need to be spelled out, like decapitation, rigor mortis, gross charring of a burned body, and obvious decay, which is a far more common thing for a paramedic to find than you might think. In some memorable cases, I knew I was about to pronounce a person dead as soon as I stepped off the elevator; the stench coming from their apartment was unmistakable, and the superintendent of the building always knew just as well as I did what we would find on the other side of the occupant’s door.

When death was clear, my work was done. There were no lights and sirens, no hustle, no TV-drama moments. With a look at my watch and a nod to my team, a life was determined to be over. Out came the shrouding white bedsheet (actually, they were halfway between salmon pink and faded orange), and I would head out of the room to shatter the life of a stranger.

“I’m sorry to tell you this . . . ”

But sometimes death was less clear. There would be no obvious criteria—the look of death had yet to set in—and my mind would race to determine what I could do to pull a person back from the cliff’s edge. Those were the times adrenalin junkies like me trained for—it was like being a pilot in a simulator when engines fail. We had a term for patients like this: we’d say they were circling the drain. We’d initiate a choreographed attack on death: two paramedics almost silently executing steps we’ve internalized such that they were as automatic as blinking.

We’d pound hard and fast on the rib cage to eject blood out of the heart. We’d place a breathing tube into the trachea and attach an oxygen-filled bag to it, squeezing air into the lungs like bellows blowing into a fireplace. We would slip a cannula into an arm vein to inject adrenalin directly into the blood so it would reach the heart expeditiously. And, if the stars aligned and we could detect the right electrical rhythm in the myocytes of the heart, we would defibrillate with an electrical jolt of 360 joules. Zap.

Zap. Zap. Zap.

My record is thirteen defibrillations on a single patient, far beyond the usual three shocks. On scene in a kitchen, then in the driveway, then all the way to the hospital. I remember teams of firefighters rotating through the exhausting chest compressions, keeping blood flowing to the patient’s oxygen-dependent brain while another paramedic squeezed a ventilation bag. We used our knees and elbows to brace ourselves, sprawled out like spiders for stability, as the rig swung around corners and bounced down city streets, lurching from side to side.

Zap. Zap. Zap.

We screeched up to the garage door adorned with its electric-red sign that said “Ambulances.” With the sirens off, as we waited for the door to peel open, we looked at one another, anxiety high. The patient was only forty years old and had collapsed in front of his wife, who had immediately begun CPR while his daughter had dialled 911. If anyone could be saved, it was this man. I zapped him again as the back doors of the truck swung open.

After an hour or so, the electrocardiogram was flat. The emergency doctor placed an ultrasound probe on the patient’s chest, angling it upward to show an image of a heart that was still. The only thing left on the list of possible causes was a massive blockage high up in one of the two main coronary arteries that deliver oxygenated blood to the ventricles. Back in 2007, there was no fix for that. The dozen or so professionals in the resuscitation bay looked around at one another, drenched in sweat, and sighed or frowned or closed their eyes or did whatever they did when a person was dead dead. Then I went and got a latte, because I was exhausted and there were still nine hours left in my shift.

As a paramedic, I always felt limited: limited by my training, by my equipment, by the ridiculous rules that seemed to be written to make my shifts in the field feel like a job in a cubicle. I hated the feeling of dropping off a critically sick patient in an emergency room, never to hear of them again. Was my diagnosis right? Did my treatment work?

I was hungry for more than I could offer in my role, and so I made the decision to hang up my paramedic’s uniform and head to medical school.

As I progressed through my training, my title kept advancing: a student becomes a clerk, who becomes an intern, who becomes a junior resident, who becomes a senior resident, who becomes a fellow. Eventually, I reached the coveted title of attending physician, which means you are a fully fledged consultant, an expert in your discipline and someone who, ostensibly, is no longer required to work eighty hours each week.

As I rose through the ranks, so too did my level of responsibility. And now I never came across a patient who met the criteria of Policy 4.4. My paramedic friends never brought a single one of those to the ER—they were left in the field for the coroner’s office or funeral home to collect. My days of seeing death as black and white were over; it was shades of grey, and there was no policy manual to guide me.

After starting to work in the ER and, later, the intensive care unit (ICU), I found I could go further to reverse death than I ever could before. Most of the time, you still go through the motions—the way you do as a paramedic—with your gut instincts validating the algorithms taped on the walls of every resuscitation bay I’ve ever seen: cycles of CPR, attempts at defibrillation, adrenalin every five minutes or so. It’s remarkably routine. Ten minutes in, you tend to know. A flat line, a weak squiggle, a pathetic tracing of a heart that is too sick to beat. As the minutes tick by, the energy in the room starts to fade. Then you pause, look into the creepily open eyes of your patient, and purse your lips. At least, that’s what one of the nurses told me I did. I can remember her telling me that’s how she’d know I was out of ideas, out of hope.

But there are always those cases that remind you why you’re awake at 3 a.m., surrounded by cranky walk-ins with the flu and chronic back pain and marijuana-induced vomiting. Those cases where the routine is tossed aside and you keep going and going and going. Where the energy doesn’t dim, and no one thinks of quitting. Those cases, which might be one in ten patients, are why people work in demoralizing emergency rooms around the world. Those saves—we call them ROSCs (return of spontaneous circulation)—are joyful.

I soon learned that those moments came with a caveat. Resuscitating someone back to life was why I had entered medicine, but as I gained more knowledge and experience, I also began to realize something else: there are many people coming into our hospitals who shouldn’t receive any resuscitation at all.

Doctors are as afraid of death as patients are—afraid because every death can feel like a failure. Death can be a challenge to our professional identity. It can cut us deeply, personally. And so we find it a great relief when families tell us to “do everything” to save our patient because it gives us something to do. But death is also a matter of statistics—surgeons and transplant doctors are judged by their survival metrics. That means the system incentivizes nondeath under the assumption that dying is the only bad outcome one can experience after surgery.

Survival is hardwired into our brains. The amygdala, a prehistoric part of the brain common to monkeys, dogs, and even mice, helps drive us to find sustenance, to fight off attackers or flee from their grasp, and to procreate. It also means that giving in to death is not something that comes naturally. If we start hemorrhaging blood after a table-saw accident, our amygdala kicks in. The rest of the body responds too: hormones increase the heart rate and blood pressure. If our ancestors were being chased by sabre-toothed cats, blood would divert from their intestines to their muscles to help them fight or flee as fast as possible. If your life is in danger, expect your body to react automatically and dramatically.

These days, giving in to our primordial instinct to stay alive often means asking doctors like me to “do everything” to save you. But, in doing this, we sometimes do ourselves a grand disservice. In delaying death, we may only cause more pain, more suffering, more despair.

During the COVID-19 pandemic, I cared for hundreds of people sickened to the extent that they required life support. Around two-thirds of them survived to leave my ICU; the rest died slowly, over weeks, as the virus shredded their lungs. The body’s response to the coronavirus was often unhelpful. Chemicals released by the immune system would cause the sponge-like lungs to stiffen, becoming fluid filled and heavy. Once irreversible damaged occurred, lung transplantation was the only path to recovery, and most patients aren’t candidates. Worse, there were way more potential candidates than donor lungs.

To guide us, we relied on established criteria devised by experts for lung-transplant candidates. It was pretty easy to end up excluded. In Ontario, being obese disqualified patients because they often had much worse outcomes; virus-shredded lungs have trouble expanding against a massive belly, and patients would struggle to heal.

This put us in a tough spot: after three or four weeks, we could tell which patients were on the path to recovery and which ones were not going to make it. Backup plans had been written at the highest levels of government to allow us to unilaterally remove these patients from ventilators if we didn’t have enough machines to go around. Fortunately, this worst-case scenario never occurred where I work.

But, in many ways, a policy about how much treatment to provide might have been helpful; for many patients whose chances of survival were next to zero, families and medical teams alike struggled to accept the inevitable outcome.

At the peak of the pandemic, I remember treating patients in their thirties who were too far gone to be saved, ineligible for additional machines and transplants. There was no way out. Day after day, they would have life-threatening episodes where the breathing machine couldn’t deliver enough oxygen; we would rush to apply safety gear and begin inflating their lungs manually with an Ambu bag. Sometimes, for over an hour, until our hands would cramp, we would have to bag their lungs before they settled back on the machine. The whole time I would wonder what on earth we were doing.

We would use words on the phone with the patient’s family that were direct but not quite crystal clear: “He’s doing worse today” or “I’m very worried she won’t make it” but never “This is the end” or “He’s about to die.” So, for days longer than we should have, we kept putting these patients through the pains and trials of modern intensive care.

Eventually, their hearts stopped. Despite the fact that chest compressions would not help, we did them anyway, because there were notes that said the family wanted “everything done.”

I’m glad I wasn’t at work when one of those patients lost his vital signs—what we call coding. I’m not sure I could have stood there and watched my colleagues pound on his chest. I know a few doctors who just wouldn’t bother; they’d just stop, and it would be over. But the culture at many hospitals is that more is more, and most people in the ICU receive extreme measures even when everyone knows they won’t work.

This scene has played itself out so many times during the COVID-19 pandemic, though it didn’t begin with it. When the heart stops because the lungs are broken, coding someone does nothing but ensure an undignified, miserable end. Based on common practice in Ontario hospitals, I eventually stopped offering CPR to dying COVID-19 patients when I was working in the United States. That made many of my American peers—nurses, respiratory therapists, other doctors—profoundly unsettled. Some of us wouldn’t offer the full suite of resuscitation procedures—what some might call “futile care.” But others, stuck in the do-everything mentality, ran the code, sometimes for thirty or forty minutes, throwing the kitchen sink at someone in their final moments.

The implications of this behaviour go beyond wasted syringes and defibrillator pads. Families would be ushered away, chaos would fill what should be a peaceful place, and staff would have visceral reactions, using words like “cruel” and “unethical” to describe the final efforts expended on a patient. It was a lose-lose-lose scenario.

But medicine doesn’t have to be that way.

In the ICU, death is not always as certain as it was for those thirty-year-olds with horrible COVID-19 and shredded lungs. Sometimes there’s a chance, and when there is, doctors tend to paint a simplified picture. We say the odds may not be great, but there is a chance. But “a chance at what?” is something we aren’t good at answering.

For some, it may be a chance at full recovery. For others, it’s a chance to be in a nursing facility, attached to feeding tubes and breathing machines. But, when people decide to roll the dice and ask that “everything” medically possible be done in a crisis, they do so without knowing what that might mean.

When there is a choice to be made, it is not mine alone, but doctors like me play an integral role: my honest and clear assessment, and how I communicate it to a patient’s loved ones, can ease the decision to let go of someone in a controlled, peaceful way. If I do this right, and families process the details with an open mind, an assured death can be beautiful, tender, and comfortable. It can bring peace and closure. It can avoid the chaos, the broken ribs, and the existential distress that comes with calling a code for someone who is too far gone to benefit from modern medicine.

But, too often, there is ambiguity, and it usually leads to decisions being deferred, the direct consequence of which is more suffering. Technology can now prevent death from coming too soon, but it can also delay its timely arrival. How to achieve a timely death isn’t really taught in medical schools or spoken about in many hospital hallways, and it has become a critical gap in our culture.

An illustration of a woman in a car.

Before the mid-nineteenth century, when physicians rarely had medical degrees and often had no real training at all, death just kind of happened. Lungs would stop breathing, hearts would stop beating, and there was nothing anyone could do. We weren’t always good at recognizing death when it did arrive. History is riddled with stories—some perhaps accurate, others definitely folklore—of people who were declared dead but then woke up, sometimes at their own funerals. One long-standing story—which the Vatican now denies—is that, for centuries, a pope’s death was confirmed by a candle flame held up to the Holy Father’s face to detect any air flowing in and out of his lungs. That was followed by a hammer whack against the forehead while his name was called out. If he did not awaken, his demise was announced.

Stephen Berry is the author of The Historian as Death Investigator, published in 2011, and a professor in the history department at the University of Georgia. After I described my conundrum around whether we are now overtreating patients approaching death, he said, with the excitement of a teacher commanding a lecture auditorium, “We only have to go back 200 years!”

Back then, Berry explained, when nearly everyone died in their living room or their bed, they fulfilled “the most important role of their lives: they showed other people how to die.” When death was a common thing to witness, it was somewhat familiar. It wouldn’t be unusual for a mother to bear six or eight children but see only two or three survive to adult age. Disease, accidents, and violence killed many in their twenties and thirties. A simple skin puncture could get infected, and people would die of sepsis in the absence of antibiotics.

Doctors had a paucity of pharmaceuticals and medical interventions at their disposal. Things that I can’t imagine someone dying of today, like postpartum bleeding or a dental abscess, could be fatal. This meant that, throughout your life, siblings, uncles, aunts, friends, and others around you would die, and when they did, there was a good chance you’d be there to see it happen. There was a fear of death but no denial that it would come.

Death pervaded so much of life, Berry told me, that the Shaker sect oriented many of its views around it. Ann Lee, the daughter of a blacksmith in Manchester, England, and one of the community’s earliest members in the 1700s, had lost all four of her children to early death from various causes. Berry said that this cumulative loss led the founders of the Shakers to believe that you shouldn’t have children at all. The group practised celibacy and was against procreation.

High infant and child mortality rates meant that global life expectancy in the nineteenth century is estimated to have been around thirty years. But, by 2000, it had jumped to nearly seventy; today, the residents of some countries, like Switzerland and Japan, can expect eighty and beyond. Berry credited this to advances in public health and medicine. “It happened relatively overnight,” he said.

Berry was sympathetic to the dilemma I was experiencing. While advances in science and medicine were welcomed, they brought with them a challenge too: the medicalization of the dying process. Before the mid-twentieth century, the pronouncement of death wasn’t so much a formal process as it was a natural conclusion. “Pa would just die in his bed,” Berry said. The grey zone I was caught up in simply didn’t exist for most of human history. Death could not be deferred; it came when it came, and that was that.

As doctors became more sophisticated, so too did the methods used to determine death. The term “somatic death” was created to signify the cessation of heartbeats, either by palpation of the carotid artery in the neck or listening with a stethoscope for the valves opening and closing in the heart. We still use a version of this definition today, though we’ve twinned it with “neurological death,” or brain death, which occurs when there is irreversible loss of consciousness and brain stem function, including the ability to breathe.

Yet technologies and medicines have continued to grow in sophistication, sometimes blurring the line between alive and dead. Mechanical ventilators can keep air moving in and out of lungs indefinitely; dialysis machines can filter waste out of the blood without the kidneys; drugs can mimic the hormones and chemicals produced by the brain and other glands; and the heart’s cruise-control feature, called automaticity, means that it can beat outside the body for a number of hours so long as it receives a decent supply of oxygen.

One striking example of how technology has disrupted time-tested means of pronouncing death is the growing implementation of extracorporeal membrane oxygenation, or ECMO. It involves placing large tubes (think garden hoses but smaller) into veins and arteries to divert blood from the heart and lungs. The blood runs, instead, into a centrifugal pump, then through a membrane system that removes carbon dioxide and diffuses oxygen, then back into the body.

Patients on ECMO don’t have regular pulses—the centrifugal pump generates a continuous rather than a pulsatile flow—and aren’t necessarily breathing, because the oxygenator, which is about the size of an Amazon Alexa speaker, can do all the gas-exchange work. Yet these patients are very much alive, sometimes sitting in bed, reading the newspaper. (I’ve heard of many a jerk doctor or nurse who has sent a medical student into a room to check for vital signs, only to watch the panicked junior, moments later, run for help.)

All this technology makes it quite hard to actually die, but none of it gives any assurance a person will recover. Every organ depends on the others; one by one, the list of parts in trouble can grow until we know the game is up. What’s worse, the treatment for one failed organ often makes another worse. The medications needed to help the heart can turn the toes blue and cause them to require amputation. Some diuretics used to stimulate the kidney can cause hearing loss. The tube in your trachea that allows a machine to push air into your lungs is a superhighway for bacteria: it takes six, maybe seven, days, and then you could have pneumonia. We add antibiotics, which are toxic to your kidney. If you are unable to pee, fluid can build up in your body, overwhelming the heart. Starved of oxygen-rich blood, the brain starts to suffer. It’s a vicious cycle, a game of medical roulette as we race to save each organ from our treatments for the others.

What’s worse, in many hospitals, each area is “owned” by a different specialist: a nephrologist runs your dialysis, a registered dietitian focuses on your intravenous feeds, a respiratory therapist monitors your ventilator, and a cardiologist tweaks your ECMO settings. That leaves me, the poor intensivist overseeing all those critically ill people in the ICU, to gather all the data and make sense of it, making trade-offs between different specialists to ensure each organ has a fighting chance. It sometimes feels like I’m the only one trying to consider the whole patient.

I must admit, using economic arguments to justify making end-of-life decisions is awkward for any physician. But it’s hard to avoid the question when dollars are being spent indiscriminately to keep someone alive and when the harms of technologically supported institutionalization may outweigh the benefits. So, what is the cost of our growing tendency to fight off death no matter what?

The short answer is: it depends. In the US, the daily cost is up to $5,000 (US) per patient, though it can vary wildly. And, in Canada, many ICUs are always full, meaning other patients can’t always get in when they need critical care.

In this country, and in many places with universal health care, the death dilemma is a matter of cost—the money spent on those with no chance of survival could be better spent elsewhere—say, on pediatric dentistry or prenatal assessments or public housing or a universal basic income or just about anything else that could help people live better lives.

You’d think there would be a strong financial argument against continuing care when recovery is impossible; several ICU doctors have mused to me about the costs associated with prolonging life support in brain-dead patients. But not every health system faces cost constraints. In the US, where health care is privatized, chronic, lingering patients may be welcomed by medical centres, though not always for altruistic reasons. These people can be viewed as a means to an end. Indeed, some US ICU stays can lead to bills of more than a million dollars.

There are likely over 100,000 technology-dependent patients, pushed out of hospitals, lying in long-term-care facilities in the United States. Chronic critical illness costs the American health care system over $20 billion (US) a year. Instead of a nurse-to-patient ratio of one-to-one, it might be one-to-six. Around half of these patients die within a year. Some of my American peers describe these institutions, called LTACHs (long-term acute-care hospitals), as institutions to which few would ever want to be consigned. Once there, a person is, in many ways, out of sight, out of mind.

An emerging area of medical study is called “ICU survivorship,” which shows that critical-care outcomes are not binary; it’s not about success or failure, alive or dead. For those who don’t die, life may not resemble anything close to what it was before.

Declining ICU mortality seems like a matter to be celebrated. But the assumption there is that survivors return to their former lives, working high-power jobs, raising their children, vacationing on the beach, running marathons. A 2020 study by the National Center for Biotechnology Information, however, found that while most elderly patients had good functional outcomes after leaving the ICU, many still did not.

In a 2010 study in the Journal of the American Medical Association, only 60 percent of ICU survivors lived longer than three years, compared to 85 percent in the general population. That number dropped to just over 40 percent if you received mechanical ventilation. In fact, if you were mechanically ventilated, you had about a one-in-three chance of dying in the six months after you left the ICU, compared to approximately one in ten for all hospitalized patients. What’s more, about one-third of ICU survivors ended up back in hospital within six months.

Other studies have found that ICU survivors suffer from extreme weakness, nightmares, posttraumatic stress disorder, depression, and other psychological ailments. Surviving an ICU admission might not be as great as it seems.

Perhaps the most egregious aspect of the for-profit evils of the US health care system was exposed by a 2019 Pro-Publica report that confirmed what some ICU workers feel at top-notch American medical institutions: sometimes, palliative care is purposely not offered to avoid damaging statistics. In an example of how quality metrics can exacerbate perverse behaviour, transplant patients—particularly those who receive the hearts of brain-dead patients—are deemed by federal regulators to have had successful operations if they survive for one year—or, more precisely, 365 days. This has led to a phenomenon where, for an entire year, patients whose bodies have been ravaged by immune-system rejection, unrecoverable infections, or layers of medical complications are encouraged to push on until they slide across the 365-day mark. On day 366, palliative care is offered, and technology is often withdrawn.

This is not a problem at just one institution. I’ve spoken with ICU doctors in the US who have shared stories of transplant physicians selling families a bill of goods that is at best seen through rose-coloured lenses and at worst is plainly deceptive—a false optimism that seems so plainly unethical and yet is allowed to continue. In my own experience, I’ve been told I am not allowed to discuss prognosis or palliation with ICU patients who have received transplants, a circumstance that has at times led me to cry in the offices of senior doctors. So we push on. Until day 366.

At this point, you might wonder why anyone would want to be an ICU doctor at all. With all this death and conflict, why bother?

Of course, the death dilemma is about what happens when ICU care fails to fulfill our hopes for a speedy and complete recovery. But many patients do improve, some fully, and that’s where the death dilemma lies—we aren’t always good at knowing which way the cards will fall, and no one wants to give up on a patient who could recover.

There are a few subgroups of cardiac-arrest patients who die nearly 100 percent of the time, but one of them is especially dismaying: the people whose hearts are resistant to defibrillator shocks. Many people who are in ventricular fibrillation—a chaotic jumbling of electrical signals that prevents the heart muscle from effectively pumping blood—can be defibrillated into a normal heart rhythm. But some people’s hearts just won’t respond. People in shock-resistant ventricular fibrillation usually have had massive heart attacks; blood vessels feeding the sensitive muscles in the ventricles get clogged, and oxygen can’t reach the tissues. As a paramedic, I would shock these people over and over and over again, rushing them to an ER, where even more shocks would be given. Eventually, the amplitude of the fibrillation, the oscillating lines on the electrocardiogram, would dampen, becoming smaller and smaller until only a flat line remained. I’ve pronounced about a dozen people with shock-resistant VF dead despite heroic hour-long efforts to save their lives.

In recent years, we’ve gotten so desperate to defibrillate these people that some doctors apply two defibrillators, double zapping the patient with occasional success. Some doctors will inject the medical version of Drano, a strong “thrombolytic” that breaks up blood clots, but this trick, too, is rarely effective. In some places, doctors hook the patient up to a CPR robot that pounds a piston onto their sternum 100 times a minute while a cardiologist injects dye into the heart to find the obstructed vessel, then deploys balloons and stents to open it back up. Remarkably, once blood flow is restored, the heart begins beating, albeit very weakly, but more often than not, the brain is pooched—dead from lack of oxygen.

In Minneapolis–St. Paul, though, things are different. There, the odds of pulling through and fully recovering are 43 percent—much higher than in Ontario, much higher than just about anywhere in the world. That’s because medical leaders there didn’t want to give up on shock-resistant hearts. Over a decade, Minneapolis’s hospitals have built expertise and perfected their system so that paramedics equipped with CPR robots now race patients not to a typical emergency-department room but to specialized sites where they are crashed onto an ECMO pump that takes over from the heart and their arteries are unclogged.

Nowhere else in America does it quite like Minneapolis. There are survivors walking around now who would have been dead had their cardiac arrest occurred in Milwaukee or Iowa City or Spokane. By pushing the envelope, the pioneers in Minneapolis upended the resuscitation community.

Medicine is an industry based on pioneering efforts. Whether with the first heart transplant or the invention of the ventilator, it has been through attempting the unthinkable and refining it that we have gotten to where we are today. The medical community wants to keep trying to advance technology to do good, accepting the bad that inevitably comes from slogging toward progress.

While it’s easy for me to criticize my own profession’s inability to just let go and allow people a comfortable death, to deny us the chance to push the envelope is to condemn medical care to the status quo. Reflecting on this makes me incredibly uncomfortable; to get good at something, as they are doing in Minneapolis, there must be sacrificial lambs. Whether by special design, such as in clinical trials, or by the natural means doctors conduct their work, risk will always be a part of medicine. We must aspire to be better, to save more lives in the future. And this means walking a fine line between helping and hurting.

Despite being programmed to always resuscitate, doctors and nurses have an innate sense of when someone is too far gone. In those circumstances, moral distress boils up, eating away at us. Many of us view ourselves as complicit in the evils of a drawn-out death—the pain, suffering, and angst some patients experience as they die slowly on machines that can’t save them.

A code blue is usually associated with acts of medical heroism. But when it is applied to a dying patient in the ICU, it is perhaps the most gut-wrenching betrayal of the Hippocratic oath to do no harm. The pain of chest compressions, the chaos of orders being yelled out, the frenzy of needles and tubes being shoved in your body as you are fading away—doctors know how distressing this must be, and it can be just too much for many of us to handle. ICU teams have come to find workarounds to ethically fraught situations where doing “everything” to a patient who fears death would do absolutely no good and would most certainly deliver harm.

One of these workarounds is the “slow code.” The slow code refers to a situation where a patient is losing their vital signs and requires, through their own expressed wishes or the demands of their family, that “everything” be done. Depending on where you work (or, in some cases, who you work with), this could mean different things. When I was a paramedic, there was no such thing as a slow code; every code got an enthusiastic response, even though it was at the cost of your ribs cracking as we pounded on your chest to beat your heart back into action. This was because we didn’t have any time to assess the viability of such actions; we would arrive, jump out of our truck, and get to work.

But, in the hospital, where the code could be predicted, anticipated, and fretted over, it means the nurse might not call for help right away. The code-blue team might not run quite so fast. The chest compressions might not be quite deep enough to eject blood out of the ventricles.

In recent years, the rules have changed. In some places, doctors are allowed to decide not to do chest compressions, even if the family demands it, so long as there is a reasonable professional judgment that CPR will offer no benefit. When I arrived in the US to do a fellowship at Stanford, I found it puzzling that different attendings told me different things about whether or not CPR was mandatory for full-code patients: some thought it was, and others thought it wasn’t. Rules aside, withholding CPR is contentious, and to avoid the grief that can come with having to justify not performing it, many physicians just run a slow code. They perform half-assed CPR so that it can be documented that “everything” was done. This isn’t necessarily less traumatic for the patient; perhaps it’s just how we medical folk protect ourselves from moral injury.

But old habits die hard. I recently attempted to resuscitate a stillborn child, automatically cutting the cord and moving the flat baby to a warmer so my team could execute a “neonatal resuscitation”—drilling a needle into the infant’s tibia, placing a plastic tube down into the trachea, compressing the tiny chest—in a choreographed display of teamwork. The baby, of course, didn’t survive; she was never going to. But the emergency department is designed to act against all odds. And I didn’t sleep for two days, guilty of the chaos I inflicted onto “baby, Girl 99.”

I asked Art Slutsky, an influential innovator of mechanical ventilation, whether technology had done more harm than good. The devices, he said, were not the problem; they save lives. But they must be used judiciously and wisely. Yes, patients’ wishes must be taken into account, but ventilators cannot be deployed indiscriminately for everyone who, in the case of respiratory failure, will die without one; they must be applied to people in respiratory failure for whom the technology can not only stave off death but lead to a better quality of life.

The end will come for us all, and the timing of that is uncertain. But let’s not kid ourselves: the timing isn’t always entirely outside of our control. Finding the balance between resuscitation and palliation is at the heart of being an intensivist, but it’s also a balance we all must consider for ourselves and our loved ones. To do otherwise is to risk an untimely death tethered to technology.

For many doctors, our careers have become focused on preventing death, but that’s not the same thing as saving lives. I don’t want anyone to die too early. But dying too late might be just as tragic.

Blair Bigham
Blair Bigham is a physician trained at McMaster and Stanford
universities. His book, Death Interrupted, was released in
September 2022.
Nicole Rifkin
Nicole Rifkin is an award-winning Canadian American illustrator whose work has appeared in The New Yorker, The Atlantic, and The New Republic, among other publications.

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