Thread by @TheRealDoctorT

The last meaningful decision of his life is a small one.

He decides to look down at the phone on his lap, then lifts it beside the steering wheel to read the text message.

In those few seconds, his 3500 lb car covers several hundred feet.

He never sees the other car. 1/

I’m sitting at a workstation in the Intensive Care Unit, before the unforgiving glare of the monitor.

I click my way through pages of data.

Raw numbers telling a story. A body’s struggle to equilibrate. A downward spiral.

Terminal velocity.

I log off, and exhale. 2/

We have tried everything we know to help bring this situation back into balance, to help this patient.

The cutting edge of medical science is being applied. The patient is bathed in the soft glow of electronic readouts and white light.

The room is a cocoon. Isolating. 3/

Critical care can be a study in contrasts.

Sometimes it’s more like saving lives.

Sometimes it’s more like saving labs.

I’m caught up in trying to chase numbers, but am I fixing anything?

There is overwhelming shock, worsening multi-organ failure. Windows are closing. 4/

“But the oxygen level is 100%! Not even 99%, it says 100% on the monitor! 100%! And that blood pressure is better, right?”

The room is a cocoon.

In its isolation, with all its technology and monitors and readouts, it’s easy to get lulled into a sense of control. 5/

It’s all an illusion, of course.

There’s a difference between monitoring, and being “in control” of a vastly complex biological system in critical illness.

As some family members cling to hope with data points, some of them will start to take a step back, and see. 6/

It’s a subtle line, that’s so easy to step across.

To stop seeing death as a natural endpoint, and start seeing it as a failure of therapy.

If you can use ventricular assist devices, ECMO, dialysis, pressors... well... why wouldn’t you? And why would you stop? 7/

For the vast majority of human history, death was something people were intimately familiar with.

By the time they were adults, most people had witnessed the deaths of numerous people close to them, usually at home.

Death was understood to always be close by.

So close. 8/

By the mid-20th century, something was happening to death and dying in the West.

Rather than being woven into the fabric of everyday life, it became distanced.

Death was being relegated to hospitals, and funerals, and the occasional car crash we drove past, rubbernecking. 9/

Death became a stranger.

A familiar face we had forgotten how to look at, how to relate to.

Closer to us at every moment, with every breath. The darkness within our own shadows, the pause between heartbeats, the light after all dreams fade.

We had lost an old acquaintance. 10/

This is a generalization, of course, with many exceptions.

Lately the pendulum has started to swing the other way with hospice and palliative care services leading to more people making the choice to die at home, in familiar surroundings.

A natural endpoint for human life. 11/

“He’s already gone,” she says quietly, then gestures to all the medical equipment in the ICU room, “I think we’re doing all of this for us, not him.”

It is a powerful moment of insight.

I am frequently awed at the ability of grieving families to be selfless, wise, and kind. 12/

As I’m driving home, my mind is far away. Thoughts on death, and dying, and learning to let go.

Traffic slows to a crawl.

Car crash. Mangled wreckage. Horrific.

I look at it for a fleeting moment as I drive by. Everyone does.

But all we ever see is the road ahead.