What are the Situations that Trouble Me Professionally?: The Story of “Uncle Fred”

Triage issues are forever a source of moral distress for intensivists. Resources are limited and often deserving patients do not get access to ICU beds. Given this finite resource, there are sometimes patients whose families insist on ICU stay even when physicians deem the care non-beneficial. “Uncle Fred”, as we fondly came to call him, stayed in our ICU for 14 months and 5 days until he died. Mr. C was an unfortunate middle-aged man with a degenerative muscular disease which affected his breathing effectively. He had been admitted to the hospital after having a mild stroke. Previously he lived alone in his four-bedroom HDB flat. He also owned a small business.

I first met Uncle Fred when I was called up to the ward to intubate him when he suddenly became unconscious after aspirating his vomitus. This occurred as he was about to be discharged to a rehabilitation center. He regained consciousness in the ICU but progressively became weaker until he required long-term ventilation. Initially when he first got intubated and was brought to the ICU, he was awake and able to understand things, but slowly over the next few months with repeated infections and strokes, he came to be in a state where he would look “awake” but was totally delirious and oftentimes not responsive. Six months into his care, the ICU team felt that further care for him would be “futile” and he was made DNR. However, his condition was not critical and he chugged along in the ICU. Uncle Fred was far from being a typical ICU patient. Except for his ventilator support requirement, he did not need ICU care. However, the logistics of the hospital precluded him from being ventilated anywhere other than in the ICU. We tried several times to wean him off the machine, but each time he failed and finally, we gave up trying to send him out of the ICU.

Not surprisingly, Uncle Fred developed depression. He would cry silently whilst watching TV and soon anti-depressants were added to his drug regime. The nurses and doctors celebrated his birthday, took him around in a wheelchair to the outside garden and he became part of the ICU. I particularly felt guilty and, no doubt, moral distress at being the one who had admitted him to the ICU in the first place. His muscle weakness made it apparent that he would not be a candidate to come off ventilation easily; however, at the time of admission this diagnosis was not known. After examining him on rounds one day in the ICU, as I hung back holding his hand and watching Cartoon Network (his favourite TV programme), I noticed tears rolling down his face. This was soon after the psychiatrist had ascertained that he lacked the mental capacity to decide his own fate. I suddenly felt myself choking back my own tears and bit my lip. I felt the system, the doctors, life, his family and society had failed him. Here he was a prisoner with no rights to decide his fate and we “kept him alive” because we couldn’t let him die.

Many discussions were held with his family to allow us to withdraw life-sustaining care as his condition would be terminal. Even home ventilation was considered. However, his family always insisted on full ICU support. Mr. C was unfortunately estranged from his wife. He was a man of some means and she had, after his hospital admission, usurped his property where she lived with her “new man” and three cats. MSW, clinical services and the hospital lawyers had tried many times to contact her to use his estate to pay the bills, but she was mostly uncontactable. She would show up every few months to ask if he were still alive but never spent any time with him. His extended family comprised of two siblings and a niece who was the spokesperson. She was a particularly difficult lady who always accused the doctors and ICU staff of negligence. She had sued the wife and was awaiting a...