Swimming pool in the ICU
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“A swimming pool in the ICU? You must be nuts.” The nurse’s voice was almost lost amidst the whooshing ventilator and infusion pumps. Another nurse snapped, “Look, I’m an atheist and even I don’t think its nuts. It’s dignified. We are granting a man his dying wish!” Five days earlier, we had admitted Bennie and met his family. Decades spent in Southern tobacco fields had left him looking old enough to remember Hoover’s presidency. By my nature and training, I am aggressive about avoiding the use of ICU technology as a means of prolonging the dying process. In Bennie’s case, we were assured by his family that he was a very active 76-year-old man until this week’s new-onset fevers. Now, after his in-hospital complications and “bounce-back” to the ICU, he appeared much more weathered and wrinkled.
From the outset, his diagnosis was bilateral pneumonia; couple that with too much sedation, and he was profoundly delirious. This made us even more thankful for his daughter and son, Laura and Len, who implored “Take good care of Dad. He’s all we have. Being on a ventilator is terrifying, but we believe in miracles.” While loving, I knew that such a mindset could become problematic since his situation had the makings of a fatal illness despite our best technology.
With antibiotics and fluids, Bennie improved dramatically and was taken off the ventilator several days later. That same night, though, a massive stroke paralyzed his entire left side, and he went back on life support. We quickly administered clot-busting medicine, and he rallied again, remarkably regaining movement of his left arm and leg. The following day, the intern reported, “His delirium has cleared, and he’s mouthing words around the endotracheal tube despite his wicked aspiration pneumonia.”
I sensed an unexpected window of opportunity. It was time to flip it.
This “flipping it” is how I teach young physicians to help patients and families prognosticate about their loved one when major life-threatening events begin piling up. Invariably, the first thing Bennie, Laura and Len were going to ask us when our team of 8 walked in the room was some variant of two questions (1. “What is wrong?” and 2. “How long will he live?”), both of which needed to be flipped. So during the difficult conversation, I answered many questions while flipping our focus from “What’s the matter with him?” to “What matters most to him?” Then we transitioned from “How long can he live?” to “How quickly can he die?” It is amazing how much clarity is gained when we switch the camera lens in this way. I emphasized that in no way were we giving up, but that it was imperative for us to put all this in perspective.
We revisited Bennie’s life goals in light of what had happened and spoke directly about the big picture. With his children looking on, I held Bennie’s hand and looked him in the eyes. Choosing my words based on what I knew about his background and the family’s expectation of miracles, I said, “Bennie, just like tobacco plants eventually wither and wilt, so do we. You have improved in some ways, but overall you are very weak. How can we serve you best?”
The next morning, Laura and Len were upbeat, which confused me since Bennie looked weaker than ever. They pointed to words on a whiteboard in the room, explaining they were Bennie’s goals: “Stable vital signs. Baptism.”
I spotted Kelly, our charge nurse, smiling like a cat who’d swallowed a canary. In her arms she clutched a box containing a large vinyl swimming pool. First I made sure this was actually Bennie’s request and not the family’s. My next thought was that we’d have a chaplain anoint him with holy water in his bed, but Laura disagreed. “Jesus wasn’t sprinkled, doc, he was dunked.” A senior physician said “Wait, this man is on a vent! I’ve never seen a baptism like this in 50 years of practice.” Indeed, there was no shortage of opinions about whether this was appropriate, safe, or even possible.
A large area next to Bennie’s bed was cleared and an electric pump inflated the pool. When a multi-person bucket brigade proved too difficult, an engineer rigged dialysis tubing to circulate the pool with a stream of warm water. Bennie was then hoisted high into the air via a patient-transfer lift, and the ventilator was unplugged before lowering him into the pool.
First out of the water was blue corrugated ventilator tubing. Then Bennie’s face appeared around the breathing tube. His huge smile seemed to say “Better late than never.”
When he died a week later, Laura implored me, “Doc, tell other people about Dad. We hope it will make them realize that we can all become strong through our weakness.” In fact, I have seen scores of patients and families use profound “outer wasting” as a catalyst for deep inner renewal. The two most important “frames” of our life are birth and death. We typically associate baptism with the former, yet Jesus spoke of his death as a baptism to indicate the formative next step that dying represents for our journey.
The ICU team’s bold yet careful response to Bennie’s unusual request taught me an enduring lesson regarding sympathy versus empathy. Sympathy is feeling sorry for someone; empathy is feeling with someone. Amidst all the surrounding insanity of the hospital that day, diving deeply into Bennie’s life through his baptism on the breathing machine allowed all the rest of us to be reborn too. Being “with” him in that pool, and rising with him out of it, we walk into other’s lives better prepared to serve.
We recently had a similarly beautiful unfolding of events for both a Buddhist patient and a non-religious but spiritually driven patient in our ICU. At its heart, this story is not at all about any specific belief system, but rather about making the ICU a place where end-of-life wishes and resolutions are respected by the ICU team and achieved by the patient and family. This is, if you will, personification of the “three wishes” concept published in the Annals of Internal Medicine by Dr. Deborah Cook, whom I respect so dearly.