The Power of Irrational Unshakable Optimism In the ICU
I'm paying for a coffee in Brooklyn when a doctor in Massachusetts calls and asks for permission to intubate my uncle. It's urgent. His lung has collapsed, and he's lost consciousness. There's no time to consider what it means to put an 82-year-old with a slew of health conditions on a ventilator. So I say yes. On my drive to the hospital, another doctor calls to say they need to do a bronchoscopy. I ask if it will hurt, and she says he's sedated. So I say yes again. Just like that, I've put booming, unshakably cheerful Uncle Bear into a system of maximum intervention because of my own panic, not reason, not research. Later, when I look at the statistics, the odds of recovery, or what they call a return to baseline, are not great. There's even a debate about whether the very elderly should be admitted to ICUs at all because of the cost. By 2050 there will be an estimated 19 million Americans over 85 including me, up from 4 million in 2000. I imagined this kind of decision-making would take place in a hospital family room where doctors would lay out the options for me and my sister Ingalisa. Turns out, those conversations would come later, and the choices would include undoing some of what I'd agreed to in that coffee shop. It was late when I got to the hospital. A nurse made up a cot for me in his room. How many times had she performed that small kindness before? I can't really see Bear's face from the cot in the dark, just the shape of the hulking, sighing ventilator. Sometimes it looks as if it's reaching down with its twin air hoses to scoop him up and take him away. But mostly, the sound is comforting. He won't die tonight. That machine won't let him, for better or worse. Uncle Bear remained the family's unalloyed optimist, even after he lost his wife Susie. His outsize intelligence never got in the way of his enthusiasm for almost everything, particularly scotch. The rest of us take after Bear's Irish father, who when confronted with a sunny day would say, only half in jest, "We'll pay for this." My favorite photo of Bear is of him cutting a cake on my fifth birthday, cackling with a lit cigar in his mouth. The ash looks as if it's about a millisecond away from dropping onto the frosting. He doesn't notice. But me? I look as if I'm ready to pass out with worry. Over the next 10 days, the doctors explain the balancing act. Fix one thing and risk something else. It's a corporeal Rubik's Cube. Then there's the ventilator. They can't seem to wean him off it. He's at the cloudy intersection of living, breathing and dying, with the first two states not being the same thing at all. My sister and I gather in the nurses' break room with the ICU doctor and Bear's primary-care physician, who explains that even a young body can't take being intubated for too long, and the alternative is a tracheotomy and a feeding tube, probably for life because of his age. We all get teary at the thought of the voluble Bear being unable to talk or eat. "No, no, no," we say. "That can't happen.", They tell us there will be morphine to quell the air hunger if he fails once the tube is out. A chaplain is available. And there's us the nieces his wife's sister, the magnificent Wissie, who has been propping us up for days with humor and wine plus the grandnieces and friends. And the ICU doctor says gently, "You know, you don't hold his life in your hands. You are not taking anything away from him. It's up to him." I'm not sure if she meant God or Bear, but it didn't matter. We understood. They take the ventilator out the next morning. Bear is sore and disoriented, but he's breathing on his own. Soon, he's cracking jokes about how he's so thin, he's only 8 lb. away from a modeling contract. He thinks he's 62 and owns a plane that can land on water. Bear is untethered from reality, but not from himself. "I hate to be an old prognosticator, but my advice is, Don't give up," he tells a young nurse. "The boat will come back for you." When I show him a photo of his grandnieces, he can't name them but proclaims, "I love everyone in that frame!", Now he's in a subacute rehabilitation facility, emphasis on facility. And this is where the statistics loom again. He's so weak and so thin. And all the conditions that landed him in the ICU are not betterthey're worse. This is the baggage of a life lived with indulgence and the kind of optimism that allows one to ignore medical warnings. Will he have the strength to walk again, or go home?, I think he's wondering too. "Now that those dying things are finished, what's next?" Bear asked me the other night. "Ice cream," I said. Of course he adores the hospital vanilla ice cream in a Styrofoam cup as much as he ever did a meal out in his old Brooklyn neighborhood. I don't know what's next now that we've been granted a reprieve from the tubes and dying things. And I really don't know what I'll do if I get another call asking whether he should be intubated. But I do know that I'm going to stop worrying so much about the ash before it falls. What a waste of precious time.