Defining the space between life and death: Fatal critical illness.

E . C. was 23 years old when he died. His younger brother looked at his surgeon (T.M.S.) and said ‘‘If he dies, you killed him’’; he was 15 years old with a tear tattoo on his cheek. His voicewas calm but implied real threat. He said it in a family meeting, during which we explained why we were going to remove E.C. from venovenous extracorporeal membrane oxygenation (ECMO), and the certainty that he would then die. E.C. had been shot in the chest and undergone a traumatic right pneumonectomy 3 months previously. He then developed adult respiratory distress syndrome causing right heart strain and was placed on ECMO. He recovered and was taken off ECMO, only to develop a bronchial stump leak with worsening respiratory failure. He was placed back on ECMO. Many surgical attempts were made to contain the leak including direct rerepair, muscle flap coverage, and repair via a sternotomy, but the bullet had injured the bronchus at the carina, and all failed. He developed renal failure requiring continuous renal replacement therapy (CRRT), methicillin-resistant Staphylococcus aureus pneumonia, and a pseudomonal blood stream infection. Despite all of these, he would stabilize for days at a time and interact with his family. He then developed bowel ischemia requiring a hemicolectomy and, on the day of the meeting, emergent exploration at the bedside during which dead small bowel was removed. He subsequently developed ongoing intra-abdominal bleeding. At the time of the meeting, E.C. was somewhere between alive and dead, and rather than saving his life, it seemed as ifwewere prolonging his death.He hadwhatwe have recently started calling fatal critical illness. E.C. had an insoluble problem, an unfixable bronchial leak, continually soiling his chest cavity, dysregulated coagulation causing both mesenteric ischemia and coagulopathy and now intra-abdominal bleedingprimarily related to his coagulopathy. He was dependent on ECMO, with little intrinsic lung function. However, he appeared ‘‘save-able’’ to his family. Depending on definition, they were right. He was intermittently neurologically intact. Furthermore, with the use of high-volume blood and product transfusions and CRRT, he improved for hours at a time. If left on ECMO with full intensive care unit (ICU) support, he would likely survive for days or weeks, but there was no chance of his being able to survive without continuous high-intensity ICU-level care. Cooling after cardiac arrest, ECMO emergent left and right ventricular cardiac assist devices, CRRT, and improvements in mechanical ventilation all save lives. This technical edge is continuously moving forward as the oxygenators are getting smaller and the catheters can be placed percutaneously. Venoarterial ECMO is being used increasingly during cardiopulmonary resuscitation, for both in-hospital and out-ofhospital cardiac arrest, with survival rates of more than 50%, almost of all of whom have good neurologic outcome. E.C. exemplifies a principle we have yet to fully acknowledge; there will always be three groups of patients, those who live, those who die, and thosewho cannot come off support without dying. We have created a space between life and death. While we are prepared for the first two eventualities, as a medical society, we have not really begun to address the third; as a result patients, families, and physicians often twist in the wind. When we are being honest, we know that death as a result of critical illness is hard, painful, and a tremendous drain on resources. Since patients are continually in the process of dying, they often require 1:1 or even 2:1 nursing for days at a time. Prolonged multisystem organ failure is supported with ventilators, CRRT, and ECMO circuits. This level of support can be maintained, but indefinite support is not possible.We are missing defined end points of care or even a definition of fatal critical illness. As a result, there is no conceptual framework on which to base medical decisions. These issues are perhaps more common in surgical and cardiac ICUs. The pathology that brings the vast majority of patients to our units is (1) sudden (trauma and emergency surgery) and/or (2) treatable (oncologic, transplant, and highrisk elective surgery); furthermore, the treatments are often aggressive and extreme. Many of the patients are young with little comorbidity and have never considered end-of-life issues. Complicating matters, there is little to no data about survival or quality of life in the young and critically ill. The medical ICU is very different. The patients are older and often have lifethreatening comorbidities or terminal diagnosis prompting their ICU admission. Often, quality of life and limits of care have been discussed. Perhaps more importantly, there is the concept of chronic critical illness on which to base family and medical discussions. Surgical units are built for the save, from top-to-bottom, through and through. As a result, we are uniquely challenged when presented with patients who are incurable, especially if the incurable disease is critical illness, rather than the presenting pathology. Furthermore, the critical illness is often a direct result of lifesaving therapies and procedures. Physicians are personally invested in the success of interventions and can get wrapped-up saving the patient. For many of us, when these patients die, it is a personal and public failure. Laced into all of these, we are willful people, used to succeeding against the odds. In both our personal and professional lives, we do not plan for failure or admit to it. When it occurs, as in E.C. ’s case, we likely failed to adequately prepare his family. CURRENT OPINION