From an ICU doctor — What we really think about death and dying

The COVID-19 crisis is giving Americans a never before seen, intimate view into the world of the intensive care unit (ICU). The thoughts of breathing tubes and ventilators, associated with the ICU, forms a cloud over America’s consciousness at this time. An uncomfortable truth about the ICU — that it represents our last line of defense for the sick and dying, is forcing Americans to collectively face their own mortality in ways not seen since World War II and the nuclear threat of the Cold War. Culturally, death is a topic rarely discussed in the United States and largely remains a subject of taboo. American’s avoidance of discussing death is rooted in our culture and public psyche. We simply cannot face our own mortality as Americans. In contrast, compare neighboring Mexico’s approach to death. The Day of the Dead (Dia de Los Muertos) represents a 2 day holiday honoring and celebrating the deceased, a tradition dating back to the Aztec empire. The holiday is a festive, colorful ordeal where graveyards are the sights of music, kids and food potlucks.

For many Americans, the topic of death is first encountered in the critical care setting. Although often thought of as dry — even crass conversations — the topic of death can take on a philosophical, even metaphorical tone. The very definition of death for example, has changed recently with medical advancements in critical care medicine. Death and medicine, it seems, are bound by an eternal dance. Consider the ancient Egyptians definition of death — eternal sleep after the cessation of heart and lung function. For almost 5000 years, the concept of life being tied to heart and lung function remained largely unchanged. In the 1950s, Dr. Peter Safar, anesthesiologist and intensive care physician, provided the first modern shift in our understanding of death, shattering a 5000-year-old definition. The founder of the United States’ first intensive care unit in Baltimore, Dr. Safar is also considered the “father of CPR”, as he was the first (along with his colleague Dr. James Elam) to experimentally prove the benefits of mouth to mouth resuscitation and oxygenation. His pioneering work is felt today, as he influenced the creation of the world’s first mannequin for CPR — a training method still used for basic life service certification.

The invention of CPR takes on a philosophical resonance: death, for the first time in history, is potentially reversible. The evolution of the definition of death (up to that point described as the cessation of cardiac and lung function) as a reversible process is central to intensive care medicine. As ICU physicians, conversations of life and death, spiritual wishes and advance life directives — discussing and honoring do not resuscitate orders — are routine.

This “reversibility” of death, implied in resuscitation, is not only pivotal to many of our conversations as ICU physicians, the topic is also deeply rooted in religious and philosophical history. In 1957 Pope Pius XII, seemingly aware of Safars’ advances in medicine, addressed this very issue in his address titled “The Prolongation of Life”, delivered to the International Congress of Anesthesiologists.

Two important, culturally defining statement were issued in this address.

1. Life can be prolonged in an “unconscious” individual and death can only be determined by a physician
2. Physicians can take extraordinary means to “restore” vital functions and consciousness in dying individuals, unless the situation deems hopeless

The Catholic Church was adapting to the medical advances of the time, including Peter Safar’s restoration of vital functions (CPR). The Pope was also setting the stage for another important event in healthcare — the transition of death from the home to the hospital. The late 1950s marks the moment in American history when most deaths occur in medical institutions, marking a major milestone in the culture of death in our country. The philosophical, spiritual and ethical impact of Safar’s advancements in intensive care medicine, along with the scientific evolution of the Catholic Church set the stage for the modern day intensive care unit.

Another momentous step in our understanding and definition of death came in the 1960s. Before that time, the definition of “brain death” was elusive and not concretely defined. The advent of CPR and mechanical life support was highlighting an ethical dilemma — the maintenance of life in the unconscious or neurologically impaired individual. Seeking to answer this dilemma, a group of Harvard physicians convened in 1968 to formally define brain death, or an irreversible coma, as a clinical definition of death.By establishing criteria to diagnose the absence of brain activity, doctors were now able to diagnose a person clinically dead if they met the diagnosis of brain death. The three components — absence of respiratory function (apnea), absence of primitive brain reflexes (brainstem function) and signs of an irreversible coma are still used today as indicators of brain death.

As doctors it is essential to understand the evolving definitions of death throughout history, along with the spiritual and religious connotations implicit in our delivery of care. As Americans get a glimpse into the world of the ICU during the COVID-19 crisis, it is equally as important for the public to understand that behind the monitors, ventilators and alarms is a different world — one that is constantly evolving, bursting with human connection, spirituality and meaning. A world where we are constantly striving to understand and define the very nature of our existence — life and death.