The road to the ICU is paved with ethical intentions

Have you ever seen the before and after photographs of U.S. presidents? The incredible stress of four to eight years in the White House visibly accelerates the aging process.

As physicians, we have our share of stress, but being privy to the personal stories and involved in the major life events of our patients has the potential to make us wise beyond our years.

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In the 17 years I chaired Burnaby Hospital’s former Ethical Resources Committee, I discovered the moral foundation of medicine that informs every patient encounter. Over 10 years, our team consulted on ethical dilemmas faced by patients, their families and healthcare teams.

All of the patients were no longer capable of independent medical decision-making. Some were unconscious. Others were disabled by severe dementia.

They obviously could no longer speak for themselves and make independent healthcare decisions. It was not clear what the patients would have chosen for themselves. Family members and healthcare providers conflicted in their opinions.

In many cases, patients were in LTC (long-term care) or in the ICU (intensive care unit). Interventions had been started in response to presenting conditions. Feeding tubes provided nutrition when patients were unable to safely swallow. Machines would support ventilation of the lungs when patients could no longer breathe on their own. But in the face of worsening medical conditions and a grim prognosis, we were asked if these treatments should be removed.

I believe it was Samuel Johnson who said: “The road to hell is paved with good intentions.” I used to say: “The road to ICU is paved with clinical practice guidelines.”

That is not a criticism of the heroic and angelic medical teams in our ERs and ICUs, but rather a reminder that our treatments and tests are just the tools of medicine — ethics (not just diagnoses or clinical conditions) guides us in their appropriate use. And at the core of ethics is autonomy — the values and preferences of the individual patient.

In our consultative meetings with families and the healthcare team, we would review the principles of medical ethics and then step back to see the whole patient, looking at not only the medical facts but also significant personal and social factors.

We would seek to understand the individual patients’ personal preferences. What were their values, religious and cultural beliefs, and sources of meaning? What did quality of life mean to the individual?

Had they ever discussed their preferences and who they would choose to make decisions for them if they were no longer able to do so?

Of course, our work would be easier if patients had anticipated and reflected upon the possibility of being incapacitated by illness in the future. An advance medical directive is a written, signed and dated document that explicitly states your wishes for what you would or would not want at a future time when you no longer capable of making your own decisions and who you trust to direct healthcare providers on your behalf. It can take the form of the free downloadable document, My Voice planning guide or a formally notarized representation agreement.

If you would like to know more about advance directives, talk to your family physician or see the Ministry of Health’s website. Search for My Voice at health.gov.bc.ca/library/publications.

We are all prone to forget about the big picture when going about our everyday lives. If we drive without a roadmap, compass or GPS, we can be distracted by detours, accidents, breakdowns, other drivers and the people with whom we travel. We may find ourselves lost and far from our destination – and half of us are less inclined to ask for directions. Ethics is everywhere, and we don’t always see it. But if we consider our values and live by its principles, we can find our way.

In life and health, almost anything can happen anytime. It’s best to look and plan ahead.

Dr. Davidicus Wong is a family physician. For more on achieving your positive potential at every age: davidicuswong.wordpress.com.

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