“There’s nothing you could have done.”
My chief resident collapsed into his chair and rubbed his brow. “No.” He shook his head. “This is not okay. It’s not like she had COPD (Chronic Obstructive Pulmonary Disease) or something. She just needed dialysis. She just needed ventilator-support until we got the fluid off. She would have recovered in a day or two.”
“Her family said she wouldn’t have wanted the ventilator,” his co-resident reassured him.
“Really?” His voice hardened. “How well did we explain things to them? Did we really explain what it all meant? She could have been home in a couple of days.”
As the medical student on the team, I relegated myself to a corner of the room and shared their grief in silence. I had lingered at the patient’s bedside that morning, and when her breathing quickened, I buckled under the weight of my inexperience. She complained of nausea, and her lips paled to the color of nightshade. An instant later the room clamored with a dozen physicians and nurses, along with shouts, syringes, monitors, and oxygen and bag-valve masks.
Urgent conversations with family ensued. Shouts quieted to muffled crying. Hours later, the room fell totally silent.
She had been presented to the hospital in kidney failure from diabetes. When her kidneys could no longer remove excess fluid from her bloodstream, it backed up into her lungs. Medications failed to help, and while she awaited dialysis (a treatment which performs tasks that healthy kidneys would do), she developed respiratory distress. She required a mechanical ventilator to save her life.
She only needed to be on a ventilator for a short time. But in the midst of her distress, she could not consent for herself, and she had no documentation of her wishes. When my team approached her family, they insisted she would never want to be on a ventilator. Period. They gathered around her, and said goodbye.
Few Plan for Tragedy
I did not participate in the family discussion. However, when I reflect now upon her predicament, and upon the conversation among her physicians afterward, I recognize a conflict common to the ICU (Intensive Care Unit). Few people consider ahead of time whether or not they would accept ventilator support,1 and these rare discussions often evolve in overly simplistic terms. Patients either declare they would never consent to a breathing machine under any circumstances, or express their wish to have “everything” done. In reality, questions of ventilator support are far more nuanced.
Medical technology (like a ventilator) pales in comparison to God’s perfect design. When we draw a breath, our diaphragm lowers, our rib cage expands, and the resultant negative pressure gradient siphons air into our lungs. The motion is smooth, unlabored, elegant. In contrast, to deliver a breath, a mechanical ventilator pushes air into the lungs. It is a maneuver of force. We can finely adjust targets in pressure and volume for each breath, however the mechanism, and often the experience for the patient, is unnatural.
Two Types of Ventilators
Noninvasive positive pressure ventilation (NIPPV, also called CPAP or BiPAP) is essentially a ventilator connected to a face mask which permits patients to communicate while they receive support. Awake patients with a quickly reversible problem (for example, fluid in the lungs or an asthma exacerbation) benefit most from this modality. The constant flow of air into the mouth risks stomach distension and vomiting, as well as impaction of oral secretions within the lungs. These latter points render drowsy or confused patients poor candidates for NIPPV. People suffering from claustrophobia also tolerate the mask poorly.
Patients with respiratory distress secondary to a more insidious cause (for example pneumonia or adult respiratory distress syndrome) usually require the invasive approach of endotracheal intubation. In this technique, a provider guides a silicone tube directly into the trachea and connects it to the ventilator.
As anyone who has experienced water go “down the wrong pipe” knows, any object within the trachea is highly irritating. Intubated patients require sedation, and the depth needed depends upon a patient’s severity of illness. Patients on minimal ventilator support, with only intermittent sedation, may still interact through gestures and writing. In contrast, patients with the most stringent ventilator settings necessitate not only deep sedation, but chemical paralysis as well, eliminating the potential for communication.
Things to Consider with Ventilation
The implications of this technology vary between patients. Oftentimes, people who cite wishes against a breathing machine mean long-term ventilator dependence. They may not consider the instances when a brief period of support saves a life. Patients struggling to breathe often report relief after starting the ventilator — in spite of the awkward mechanics.
On the other hand, the challenge of weaning a patient from the ventilator increases as time passes. The more support a machine provides, the less work the respiratory muscles perform. With disuse, these muscles atrophy, and over time patients lack the strength to breathe independently. Mechanical ventilation also increases a patient’s risk for pneumonia, and this risk rises with each day. For patients with chronic, debilitating lung disease, or with advanced terminal illness, a ventilator may inflict undue suffering without long-term benefit.
Although official documents may delineate the question of ventilators with a checkbox, the issue rarely manifests in black and white. How do we differentiate between these varying scenarios, and formulate our directives with confidence? How do we honor our Lord when we consider technology that blurs the interface between life and death?
The God over Medical Technology
Our very lives flow from God’s breath (Genesis 2:7; Job 33:4). He created us in his image to steward his creation, and he mandates we guard the sacred gift of his breath within us (Genesis 1:26; Exodus 20:13). He has blessed us with the knowledge to develop technology in pursuit of this calling.
When we save a life, we cherish the gifts God has poured out upon us. We praise his name (Matthew 25:40). As we envision our own needs, we must carefully discern when aggressive interventions, such as a ventilator, would offer hope for recovery. Euphemisms and checkboxes are insufficient. Deliberations should occur in depth, with a physician, tailored to our individual stories, and before life-threatening illness robs us of our speech. Where the potential for life exists, so does the opportunity to glorify the Lord through fighting for it. We must embrace the question with our hearts and minds set on him (Matthew 22:37–38).
Compassion on the Dying
Although ventilators have the potential to preserve life, as man-made creations they are imperfect. They support patients with respiratory disease, but they cannot cure such diseases. For example, patients with respiratory failure from pneumonia may require a ventilator to breathe, but their recovery hinges upon a response to antibiotics. Without treatment for the pneumonia, the ventilator becomes a permanent fixture.
When patients cross the threshold into ventilator dependence from an incurable, life-threatening condition, the negative effects of the ventilator may inflict suffering without any potential for recovery. Patients requiring tightly-controlled support may describe a sensation of suffocation, as the ventilator disallows them to breathe according to their own rhythm. How much anguish a ventilator inflicts depends upon a patient’s unique situation.
When faced with such scenarios, we must remember our call to love our neighbor (Matthew 22:39). Christ teaches us to love one another, as he loves us (John 13:34). When an intervention prolongs death without hope for improvement, and induces agony in the process, to impose such artificial maneuvers constitutes cruelty. Scripture calls us to “do justice, and to love kindness, and to walk humbly with your God” (Micah 6:8). Patients should feel empowered to decline mechanical ventilation in futile circumstances, and to rest assured that our time lies in God’s hands, not our own (Psalm 31:15).
Sovereignty and Love in the Hospital
When faced with the heart-wrenching challenges of modern medicine, we take refuge in the God who knows us (Psalm 139:1–4). We revel in the gift of his word, which itself is God-breathed (2 Timothy 3:16). While our days in this world vanish on the wind (Psalm 39:5), his breath unseats mountains and weaves galaxies (Psalm 18:15; 33:6). Even if we struggle for air, he is with us. He loves us, and he sent his Son to die for us so that “whether we live or whether we die, we are the Lord’s” (Romans 14:8).
1 Rao JK, Anderson LA, Lin FC, Laux JP. “Completion of advance directives among U.S. consumers.” Am J Prev Med 2014, 46(1):65–70.