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You’re listening to a frequency podcast network production in association with City News.
Jordan Heath-Rawlings
How well do you know death and what it looks like? I really don’t know it at all. I have lost loved ones, of course, but never in front of me, never up close, close and personal, and certainly not over time. As death approaches and is ultimately accepted, fewer and fewer of us do know death that way now, and one emergency room physician wonders what that is costing us. I say costing here, both literally and figuratively. When we don’t understand death as a natural part of life, it can be more difficult to accept, to make our peace with, and to let a loved one go when it’s time. Literally. It costs us as a healthcare system not to let that loved one go when the situation is dire beyond all hope of normal recovery and the patient waits in the ICU unresponsive, clinging to whatever’s left of life, a doctor will ask the family, what should we do often? And understandably, the family will say, do anything, do everything. So the doctors will, even if the result might already be a foregone conclusion. This is a conversation about what those words do everything mean in practice for the family, for the doctors and nurses in the healthcare system itself, and most importantly, for the suffering person to whom everything is being done.
I’m Jordan Heath-Rawlings. This is the big story. Dr. Blair Bigham is the emergency room physician that I mentioned. He is also the author of Death Interrupted how modern medicine is complicating the way we die. Hello, blair.
Blair Bigham
hello.
Jordan Heath-Rawlings
Maybe you could start with this, and we’ll circle back and get to why I’m beginning with this question, but once you’re brought to a hospital alive in an ambulance, even just barely alive, how hard is it to actually die once you’re there? Well, I guess it depends on a number of things, but the short answer is, it’s pretty hard to die in a hospital these days. We have a lot of technology, a lot of medication, a lot of science around, resuscitation how we bring people back to life or keep them alive when they’re sort of on the cliff’s edge and we employ it. And sometimes we’re extremely successful at that. And so when you come to the hospital in extremes, it is usually pretty hard to die. So give me some examples of some of the newer technology and services that are routinely done now that we can postpone death for weeks or longer, even if somebody might never recover, what kinds of stuff do you do?
Blair Bigham
Sure. So if somebody can’t recover, we are reluctant to do anything. When you can’t recover and you’re dying, I think most people would want a dignified, peaceful, painless death, and so we want to accommodate that. But when it’s unclear if you’re going to make it or not, we tend to have hope. We tend to believe in life over death and want people to survive. And we have a suite of technologies that can help accomplish that. If your heart isn’t beating, we can actually divert blood through tubes out of your body, through a motor, back into your body, sort of like an external heart pump to keep the blood flowing. If your lungs aren’t working, we can put you on a breathing machine that pushes oxygen into your lungs every three to 5 seconds. If your lungs are so broken that they can’t even accept that oxygen, we can have an oxygenator membrane, basically a fake lung that we run your blood through. If your kidneys are broken, we can put you on dialysis. If your gut isn’t working, we can feed you through an IV or through tubes. Most organs I can artificially support with technology. Your liver and your brain are the tricky ones. If they’re not working, I’m running out of options. Your liver, obviously, we can transplant. Transplant technology is a gift for many, many people, and your brain is the one where really, I don’t have a substitute for that.
Jordan Heath-Rawlings
Maybe you could explain just a little, because I found this fascinating in your piece in the Walrus how you kind of juggle those various procedures to, like, using one causes damage to another organ, and then you have to mitigate that damage. How does that juggling act work?
Blair Bigham
Yeah, it’s tricky. A lot of the time, it’s based on priorities or what’s most immediately threatening your life. So if you have a terrible infection that requires antibiotics, you’ll get them. But then sometimes those antibiotics hurt your kidney, and so you might end up on dialysis. Once you’re on dialysis, the rest of your body gets a little annoyed. It can be a bit inflamed from having blood run through a circuit. So then you might need vasopressors, very special medications that keep your blood vessels tight, that can annoy your heart. And so then you end up on other medications to keep your heart happy. It’s all a balancing act. Every organ is so intricately dependent on another that when one fails, I can treat it. But when we get these interactions between organs, it becomes a lot trickier.
Jordan Heath-Rawlings
So you began your career not as an ICU physician, but as a paramedic compared to what you kind of just described. What was your view and experience of death while you were in that role?
Blair Bigham
Being a paramedic was a great job. It involved a lot of adrenaline. And we would get to somebody’s house after they called 911 or maybe to a shopping mall or a city intersection, and there would be someone there who was dying. And it was always very clear to me that they were dying. And sometimes it was very clear to me that there was absolutely nothing that I could do. They were too far gone to help. And it seemed more black and white to me on the streets. As a paramedic, than it does now in the ICU, where people, their body, their physiology, their anatomy falls apart instead of over minutes, it’s falling apart over many days or weeks.
Jordan
When somebody is in the ICU and is in really bad shape, unable to answer questions themselves, and likely kind of as you described, heading for that slow decline, possibly towards death, what kind of discussions would you typically have with a family member about options? And what do they tend to say in that situation?
Blair Bigham
Early on, there’s usually uncertainty about if death is assured or not, when there is certainty, when it’s clear that somebody just has too much stacked against them. I do try to be very clear with families, but often the circumstances are somewhat sudden and tragic, and it can be hard for families to hear that their loved one is circling the drain. More often is the case that I’m unclear about the certainty of death. And so it’s worth pursuing the full suite of technologies that we just spoke about in hopes that somebody will recover. And so I communicate my hope to families while also communicating the reality that about 30% of patients who arrive in an ICU will not leave the ICU alive. And so we’re setting up these sort of dual pathways. One very hope focused. For some families, that means being rooted in faith. For others, it means being surrounded by friends and family. But there’s usually hope involved. At the same time, we send these signals that we’re still in very bad straits and anything could happen, including death. And most families are obviously in sort of a bit of crisis. They’re sad. They’re stressed, to say the least, about what’s going on, but they seem to understand that situation. Over time, though, the medical team, as our technologies prove themselves or fail, as the medicines and therapies either work or don’t work, we sort of progress along this continuum where we realize that we’re not getting better. What we had hoped for isn’t coming. And that’s where the communication is really tricky because it’s hard to have that sort of awareness that you’re failing. Right? Your job as a physician is to save someone’s life. And when you can’t, when all of the science and technology and money that our system has is thrown at somebody and isn’t helping, it’s hard to say to a family, this is going in the wrong direction. And it’s at that point that some families just don’t hear the wrong direction bit. They’re on a hopeful path, and it’s hard to switch to that more realistic viewpoint and start to prepare for the idea that this patient of ours might die.
Jordan
And so what will they ask for at that point? Then?
Blair Bigham
They ask for numbers. They want to know the percent, what’s the chance? Is there a 1% chance to live? Is there a 5% chance to live? And I don’t know the percent. Nobody knows the percents. We’re making our best guesstimate based on our experience. But every patient is so unique. We’re looking at thousands of variables, from how their left ventricle is pumping to how their kidneys are filtering toxins. We’re looking at all sorts of numbers and getting sort of a gestalt, a feeling in our gut of where things are going. And when I give a percent, which sometimes I’m sort of bullied into doing, it makes it sound black and white, like, oh, they’re either going to survive or they’re going to die. But even that’s a continuum. Sometimes I can say they’re not going to die per se, but they’re not going to get better. They’re not going to wake up. Sometimes I can say with great certainty that they’ll be severely disabled, unable to interact with the world around them, unable to care for themselves, dependent on machines and people to stay alive. And for many people, that’s a life that would be worse than death. And that’s where families, I think, really struggle, because they view it as asking them to pull the plug or to make a decision to allow someone to die. But really, that’s a decision that I want everyone to be able to make for themselves. I would never want to be tethered to machines. I would never want to live in a nursing home. If I’m unable to interact with the world around me. That’s me. My family knows that. But in a crisis, I worry that my mom wouldn’t be able to enact what I would want and would just say, I’m not able to let my son die. I think that’s what my mom would do, which is why she’s not my power of attorney, right? You have to have these conversations with yourself, right?
Blair Bigham
What would I tolerate? What would I be willing to live like if technology isn’t able to not just prevent my death, but to not give me back my life, right? Not let me run a marathon or go to work in the hospital or all of the things that I love? And so everybody has hobbies. Everyone has a job, a family, and it’s what makes them a person. And if you’re not able to do those, I think a lot of people would say, well, I don’t really want to be, quote unquote, alive if I’m not able to really live the way I live now. And so it’s very tricky in those circumstances to communicate to families that it’s not about a percent or a statistic. It’s really about what I can assure, which is that we’re in pretty deep here, and we’re not going to go back to the way it was. At best, we’re going to be severely disabled. And if you want to roll the dice and continue to use technology, we can do that. But it’s not like they’re going to bounce back to the way they were. At some point, days or weeks into an ICU stay, we can often say that when a loved one says that we want to continue to use technology, and they say, do absolutely everything you can, what does that mean in practice? And how does that apply in the ICU ward to the team that’s trying to save a life, or at this point, I guess, maybe not even save a life, but just prolong it? Yeah, that’s why I wrote the book, right? Because nobody really knows when a family says, do everything on day one, I literally do everything. I do absolutely everything humanly and technologically possible to save off death. When they say that to me, three or four weeks in, it’s a matter of being a good doctor to determine what everything means. I cannot play God. I do not have full autonomy over my patients, but I can certainly decline interventions that have no role to play. And other doctors do this all the time. A surgeon can say, I’m not going to operate on you because I don’t think the operation is going to be helpful. You can’t come back and demand the operation. The surgeon says, I don’t think it’s a good idea. And their expertise reins in the ICU, it’s a little bit different. For some reason, it’s not as straightforward. And so it’s more about understanding what the family’s expectations are, what their hopes are, and trying to pierce through their love for the patient, their commitment to keeping them alive with a balanced view of the patient’s values, so that I can separate your intense love for the patient. And you not wanting them to die. I mean, I don’t want them to die either, but if I’m not able to help them, at some point, medicine can be harmful. And I was taught that medicine should only be helpful. The things that I do to patients should help them. And at some point, putting someone on dialysis or putting someone on a breathing machine can actually be harmful. It’s only prolonging their misery. And so we really try to do our best to communicate with families, to communicate with patients what the realities of the situation are. And they’re rarely black and white, but when we get into the nitty gritty with families, we can certainly figure out that what they’re hoping for isn’t achievable. And if there’s a chance, a very, very small chance that it is, and they want to roll that dice, we often accommodate that. When I trained in the United States, we accommodated that in ways far more invasive than what we tend to do here in Canada.
Jordan
Like what?
Blair Bigham
We would run codes, for example. We would do CPR on people. We would use technology at the very, very end of their life in ways that in Canada, we would never dare do. It was an odd cultural phenomenon for me as a Canadian, to go down there and be resuscitating people who were very far gone, and I was just like, what are we doing? But that was a culture down there. They took pride in their own minds, giving people every chance possible. But there’s a point where I think it’s clear to everyone that there is no chance possible and it’s a matter of culture and societal values. If you went to the UK, I think you would find that they would do even less than we would do in Canada. In the States, they do more. I think there’s a bit of a continuum around the globe. I mean, we could talk about comparative critical care in other countries all day long if you wanted to, but it’s just very interesting that different societies have taken different points of view on this and they all have their own thresholds.
Jordan
This is the part where we talk about ethical concerns and I guess the death dilemma at its core. And it’s also the part that might rankle people a little bit, understandably, because I’m going to ask you straight up, is trying to save everyone whose family wants them saved the best way to go, the best use of your time and your team’s time as a doctor?
Blair Bigham
I mean, the answer is no. And I’m happy to be blunt about that. I had a car for twelve years, all the way through university, all the way through med school. Like, that car lasted me a long time and I didn’t want it to go. And I told my mechanic, and I hope this isn’t I’m not trying to be disrespectful or pithy here, but I told my mechanic that I want to keep driving my car. And my mechanic said, you can’t. Your car is dead. Your car doesn’t have any more life in it. Go buy a new one and we can’t go and buy new family members. But there’s something mechanical about the job of a physician. Just like your car mechanic. There’s only so much I can do to keep oxygen crossing the membranes from the air into your blood. That there’s only so much I can do to make the muscular heart contract and beat. And at some point people are unable to recover. They are too sick, their heart won’t beat anymore. And so when people say do everything, what they’re saying is I’m not ready to lose them. They don’t actually want me to do everything. It’s their expression of saying I’m not ready for my loved one to die. And I have to interpret that carefully. If I interpret it literally, then I’ll end up like my American friends who are doing far more than they should. At the end of life in the ICU, we have an opportunity, when people are at the end of their life, to have some sense of the timing of their death. We can in some ways, schedule the withdrawal of technology and allow nature to take over. Which means that your family can be with you. We can play music. Your uncle can bring in his guitar. Your friend can bring in a keyboard. We can make your death a ceremony of celebration of the way you lived your life. And we lose that opportunity to have what I’ll call a beautiful death. A meaningful death, a touching death surrounded by the people you care about. When we just keep throwing technology at you. Because at some point when the technology fails and your body completely shuts down. It could happen at three in the morning, and then people are running into the room and they’re doing chest compressions, and it’s not a way that anybody would want to die.
Jordan
Here’s, the other question to follow that, and I think it’s particularly relevant now, sadly, is as we see new data from around Canada about ERs and ICU’s starting to overflow again and a health system in crisis. There is also a resource application aspect to this, and what can it cost us to try to and I’m just using the do everything you can phrase as a catch all. What can it cost us to do that to somebody, given the current state of our health system?
Blair Bigham
Yeah. Well, in the United States, we spend tens of billions of dollars a year on long term critical care and most of those patients die within twelve months. And very few of them recover to what I would consider what I think many of my colleagues would consider a meaningful existence in Canada that matters a little bit more. Because as a society we’ve decided that we’re going to pool our collective wealth to take care of everybody with Medicare. And so that means that we need to spend money on children’s dental care, on prenatal care, on diabetes care. I could go on and on and on, but there’s a finite amount of dollars that we can do that with, and a massive amount of money is spent on the last month of life. A massive amount of a hospital’s budget is dedicated to its critical care department, and I support that. That’s what we should use our healthcare resources for, are caring for the sickest people who need the most care, the most technology to turn them around. But at some point, when it’s clear that we cannot have recovery despite technology, if we failed to acknowledge that, my goodness, it would be untenable. It’s not even about the money. It’s just where would you put all of these people who require technology? Who would care for them? It would be I can’t even fathom what that would look like. When we talk about the pandemic, when we talk about acute resources, we certainly heard stories about the need to potentially triage critical care resources. There were rules drafted for who would get a ventilator and who wouldn’t. And to some degree, there was a soft implementation of that where our resources were stretched so thin that conversations were certainly perhaps guided away from a full technological suite of therapy in patients who had maybe not a nonexistent chance of survival, but less than 50 50. The odds are not in their favor. But maybe before the pandemic we would have gone ahead and tried anyways. Certainly in the pandemic our thresholds did change. And that’s certainly a risk that we end up in this world where people say, oh, maybe we won’t offer technology or maybe we’ll decline technology because of a lack of resources and that could lead to people dying earlier than they ought to. And my big concern is watching people die too late. The death dilemma is really about people who we just don’t let go of soon enough, right? They need to go to heaven. Their soul needs to be released, but we’re dragging on with the body’s sort of miserable existence longer than we ought to. But the flip side is that the timing is difficult to determine and we have the technology for a reason. And if we don’t apply it at the get go, what if we’re calling it wrong too early? That keeps me up at night too. That’s why this is a dilemma. That’s why I wrote a book on it, is because it gets really, really tricky the deeper you get into it.
Jordan
And I’m not expecting you to answer the question or else your book would be selling a lot more, probably. But I only have a couple more for you. The first thing is, how should we make that call?
Blair Bigham
You just mentioned that there were sort of some soft rules for who gets a ventilator and who doesn’t, as presumably this kind of technology gets better and better and better at sustaining life and doing things for us. People will be able to sustain on it longer. How do we know how to make that call?
Jordan
Do we rely on intuition of doctors like yourself who have done this thousands of times? Do we have to make hard and fast rules? Do we have to have doctors speak differently to families? What could we do to address the ethical concerns here?
Blair Bigham
So we’ve tried to quantify this, right? We’ve tried to come up with prediction rules. We’ve tried to find hard cut offs where we can be completely certain. And it’s very difficult. We certainly know when someone’s brain dead, like when you’re brain dead, you’re dead. We know that very clearly. Those are well researched, well regimented pathways that have great certainty. But for everything else, I would say rely on the physician’s intuition. But it’s not really our intuition. It’s thousands of numbers that we record on a patient every day from their creatin in their hemoglobin, their oxygen saturation, the pressure that it requires for the ventilator to inflate their lungs. The variables are endless. And we trend those sometimes minutely, sometimes hourly, sometimes daily over time. And doctors, I think, are open to looking at what those trends mean because that’s what we’re trained to do. But families sometimes have trouble seeing the trend. Often times they’ll bring up for me a single digit, they’ll say, but their blood pressure number is higher today than it was yesterday. Isn’t that a good thing? And they’ll say, well, you’re looking at one number. I’m looking at 1000. Right. And how we communicate those trends to family is a very interesting area of research. And it’s something that has been talked about for years, that this is just a communication failure of doctors and families to get on the same page. But I think it’s a little bit more than that. It’s not just about communication. It’s about the understanding that life has limits and that death is coming for all of us. And sometimes it just seems that doctors are either too reluctant to just say that, or when they do that, families just don’t always hear it because they don’t have the preparations. They haven’t done the contemplation to realize that this is the end. That brings me to the last thing I want to talk about, which is our relationship to death and how it has changed over the past. And I’m just going to say 500 years.
Jordan
As technology has ramped up so quickly, how might we have seen these decisions differently in the past? And how might it be informing the desire for families to say, you must do everything possible to keep them alive?
Blair Bigham
Yeah, I mean, I have the most fascinating conversation that I retell in chapter two of the book. Chapter two is the coolest chapter because I talked to this death historian, this guy who just has studied the way we die forever. And his name is Steve Barry. He’s fascinating. He’s from Georgia. And he talks about how in the past, when your heart was too sick to beat, when your lungs were too sick to breathe, you just died. Right? You died instantly right in front of people. Even if a doctor came, the doctor was like, oh, well, your heart is not working. Nothing I can do about it. I don’t have any technology that can keep you going. And so people would just die in their homes, surrounded by their loved ones, and everybody saw what that looked like. And as Steve described it, he says people taught others how to die. They would die in their bed, peacefully, surrounded by family. Family would see that and they would think, one day, that’s how I’ll die. But we’re so far removed from death. In modern day, people die in nursing homes, they die in hospitals. They don’t die at home very often. And so there’s a lot of discomfort around the idea of dying. And our technology has been able to delay those deaths even more to the point where I think a lot of people just don’t expect to die. They expect us to keep pulling rabbits out of a hat time after time and that people will just live on for a long, long time. Forever, it seems. Some people expect. And as a physician, I just don’t have that ability as a humanist. I worry that what you think being alive for a long, long time means to you looks very different to me when you’re being proceduralized, laying in bed, getting ulcers, eating away at your skin for 910 months, this is no way to exist. And families and patients, I don’t think, know that. That’s what do everything looks like a lot of the time.
Jordan
Thank you so much for this conversation. It’s fascinating, and it’s something that I hope we’ll all think about.
Blair Bigham
My pleasure.
Jordan
Thank you so much for having me on. Dr. Blair Bigham, author of Death Interrupted. That was the big story. If this conversation was hard for you to listen to, I apologize. We’ve done a few conversations this year about end of life, and it’s never easy. But as every single expert we speak to about this says, we simply don’t talk about it enough. So if you want it to be easier, if that’s possible later, please talk to your loved ones now about what happens when we get there. You can find the Big Story at The Big Storypodcast CA. All of our episodes are there, including previous conversations about end of life, medical assistance in dying, and other difficult topics. You can also talk to us on Twitter. The Big Story FPN. You can email us hello at the bigstorypodcast CA, and you can call us 416-935-5935. You can find this podcast, as you know by now, in every single podcast player. You can also ask your smart speaker to play The Big Story podcast. Thanks for listening. I’m Jordan Heath Rawlings. We’ll talk tomorrow.
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