Dr. Sam Shemie is a Canadian pediatric critical care physician known for his work in the field of organ donation and transplantation. He has contributed to research and policy development related to organ donation and transplantation. What follows is our attempt to capture, in blog form, the content of his thought-provoking podcast recorded in 2023.
What do Critical Care Physicians do? Life sustaining support and offering hope.
Working on the frontlines of intensive care, an ICU doctor often finds themselves at the nexus of life and death. Discussing their role, an ICU doctor may be described as an “oxygen delivery doctor.” Fundamentally, their task involves identifying life-threatening conditions which compromise oxygen delivery to organs, a formula of cardiac output multiplied by oxygen content. The intricate dance of improving heart rate, contractility, managing preload, afterload, and enhancing oxygen content, all revolves around one primary objective – delivering oxygen to cells for mitochondrial respiration and energy production.
The practice of critical care traces its roots back to the 1960s, evolving from traditional cardiopulmonary resuscitation to various life-sustaining therapies, from mechanical ventilation to ECMO (extracorporeal membrane oxygenation). However, every intervention made in the pursuit of sustaining life is based on a presumption – the belief that either time, treatment or transplant will reverse the underlying condition. Yet, the question lingers: What if all these efforts prove futile? Critical Care Practitioners often grapple with the realization that they cannot restore the patient to a satisfactory quality of life and that they face a crucial decision point. In cases where all aggressive life-sustaining treatments fail, and neither time, treatment nor transplantation offers hope, the doctor must confront the challenging ethical question of what to do next.
Brain death and the hope that remains.
The uniqueness of the brain adds a layer of complexity to this dilemma. Unlike other organs, the brain cannot be supported or replaced. The presence or absence of brain function becomes the defining line between life and death, despite the remarkable advances in supporting or replacing other organ functions. Brain death may be aptly characterized as “legally enforceable futility.” The concept of death shifts from the death of organs or organism to the death of a person defined by the complete and permanent arrest of all brain function. The ICU practitioner inevitably becomes a philosopher, reflecting on the essence of life and death. Is critical care support merely about oxygen delivery to every cell and organ or is it about sustaining brain function for neurological recovery?
Educating colleagues and families about brain-based death poses unique challenges. The absence of consciousness, motor responses and brainstem function are clear indicators, yet the visual contradiction of a beating heart and rising chest complicates understanding. The term ‘life support’ is better replaced with ‘organ or body support,’ emphasizing that the person has died – only their body parts continue to function. ICU physicians are not advocates for organ donation, but ensure that clear practices are in place, offering the option to families when death is imminent or established.
Conclusion:
The ICU’s role expands beyond saving individual patients to fulfilling a societal obligation to save as many lives as possible. The integration of end-of-life care, neuro-prognostication, and organ donation represents a holistic perspective. As ICU physicians navigate this delicate balance, they uphold the integrity of death determination while recognizing the potential to offer life through organ donation. In the end, the ICU doctor’s journey involves not just preserving life but also understanding the profound implications of letting go when the boundaries of medical, ethical, and legal considerations are met.
Further Reading:
- Shemie, Sam D et al. “A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline.” “Une définition cérébrale du décès et des critères pour sa détermination après l’arrêt de la circulation ou de la fonction neurologique au Canada : des lignes directrices de pratique clinique 2023.” Canadian journal of anaesthesia = Journal canadien d’anesthesie vol. 70,4 (2023): 483-557. doi:10.1007/s12630-023-02431-4
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