“Despite her advanced age and severe dementia, the resuscitation team did the whole deal: they put a breathing tube down her throat to ventilate her lungs; they pump hard on her chest for more than an hour (at autopsy, she had three broken ribs); they shocked her heart at least dozen times with powerful electric currents; they stabbed big bore needles in to her neck and groin; they gave her powerful drugs to try to restart her heart, get a pulse, make a blood pressure. None of it worked, not even briefly. They pronounced her death just as Brian arrived.”
Brendan Reilly, One Doctor, Page 262.
As a critical care physician, we often find ourselves trying to pull people back from the brink of death. According to the American Heart Association and the European Resuscitation Council, the survival rate for in-hospital cardiac arrest ranges from 15-25%, compared to just 5-10% for those who experience cardiac arrest outside of a hospital. What many patients don’t realize is that even among those who survive, some are left with significant neurological impairments. Their quality of life may never return to what it was. Many develop post-traumatic stress disorder or depression; others remain in the hospital for extended periods, tethered to machines.
These events often unfold suddenly, catching patients and their families off guard. Yet, in most cases, the patients we treat in the ICU are chronically ill with acute complications and multiple organ failures. We do our best to discuss short-term goals—whether they want to be resuscitated, defibrillated, or intubated if their condition deteriorates. But the long-term consequences of these life-saving measures are rarely communicated with the same clarity. We don’t often talk about the possibility of being connected to a ventilator indefinitely, living with a tracheostomy, or depending on dialysis for the rest of one’s life. We don’t always paint the full picture of what it means to be bedridden with severe neurological deficits. These are physically and psychologically traumatic outcomes, and the prognosis depends on numerous factors, including a patient’s age and underlying illness. Despite the evidence, we doctors continue performing procedures and prescribing treatments in the absence of enough evidence. As Dr. Brendan Reilly accurately describes in his book One Doctor, “medical creep” occurs when doctors operate “outside the box,” venturing into uncharted medical territory without enough clear evidence to guide their actions.
As a physician, and also a student of Stoic philosophy, I grapple with these ethical dilemmas daily. I often ask myself: What would I want if it were me, my wife, or my children? What would Marcus Aurelius have done?
Medicine teaches us to preserve life whenever possible; this is the principle of beneficence. But we also have to practice honesty and justice. This means not only informing patients of their options but clearly explaining the potential consequences of choosing to “do everything” to sustain life. There are times when the better choice—though far more difficult—is to recognize when intervention is futile and embrace the natural course of life and death.
As Marcus Aurelius and Seneca remind us, life and death are natural processes. We should not fear death but accept it with grace and prioritize living virtuously. As a Stoic doctor, I see my work in resuscitation as an expression of virtue, an attempt to help my fellow human beings. But when the limits of medicine are reached, I also believe in having the courage to accept death’s inevitability and tell our patients and families the full picture and long-term consequences.
“It is not that we have a short time to live, but that we waste a lot of it. Life is long enough, and a sufficiently generous amount has been given to us for the highest achievements if it were all well invested.”
Letter 1, On the Shortness of Life
