Navigating Hopes and Fears in the ICU
The overhead paging system calls “Code Blue ICU 7.” I think, “Oh no, I knew this was going to happen.” My heart sinks, feeling the weight of the family’s hopes and the compassion fatigue of the ICU team rushing to attempt to revive this person. I rush down the hallway, pausing only for a deep breath to center myself and saying in a holy whisper, “Lord, have mercy.” I have the privilege to provide a supportive presence to the patient, their loved ones, and members of the interdisciplinary medical team.
I am a navigator in the various intersections of hopes and fears emerging into ethical dilemmas unfolding in the ICU. Within the hospital setting, chaplains offer emotional support and spiritual care services as members of the patient care team while simultaneously addressing ethical considerations by upholding confidentiality and impartiality [1]. I hear the family hoping, praying, and asking the medical team to “do everything.” I see strain on the faces of medical team members as they attempt everything known to benefit the patient and get his heart beating. There I stand, not saying a word. I hold out my hands, offering silent prayers asking for peace and love to find a way. The team achieves ROSC (Return of Spontaneous Circulation). The patient is intubated and mechanically ventilated. The family’s fear is abated. The medical team is relieved to have saved the patient’s life, yet I see their worries and concerns about his quality of life.
The patient is a 78-year-old man with severe chronic obstructive pulmonary disease (COPD) who was admitted to the hospital ICU the prior day with pneumonia, sepsis, and respiratory failure. Over the last year, he had two hospital admissions in the ICU requiring intubation and mechanical ventilation. Now, he is again intubated and on various forms of artificial life support through medications. His numbers appear to be trending in the wrong direction for a recovery and trip home. That’s all he wanted last time—to be able to enjoy life with his family, especially his grandchildren. I know he has a deep faith from my visits and prayers during prior hospitalizations. The family is asked to consider changing his status to DNR, but they refuse.
Over the next 12 days, the patient’s condition is considered “stable” yet still critical. I participate in a family meeting. The doctor provides two pathways: they can either give consent for a tracheostomy tube along with a feeding tube, or they can transition to “comfort measures only” (CMO) as a plan of care focusing exclusively on alleviating pain, symptoms, and distress rather than curing his illness. The patient’s family is conflicted. The wife and youngest daughter want the trach and feeding tube. The oldest son wants his father to be comfortable and not suffer. Stuck in the middle and not sure what to do are the other son and daughter. Two days later, the medical team requests an ethics consult because the family has not decided. Concern is growing that this patient might become a case of medical futility.
Serving as a compass to navigate ethical quandaries in healthcare such as this, we consider the four principles of Beauchamp and Childress bioethics: autonomy, non-maleficence, beneficence and justice [2]. These four core values are fundamental to a bioethics assessment. This patient’s care displays conflicts between the principles of beneficence (what is best for the patient) and autonomy (the ability for the family to have agency) regarding end-of-life care. I listen and advocate for shared decision making between the family and medical team. I support the family progressing towards acceptance of the patient’s life being limited by the objective facts of his current medical condition.
I explore with the family their feelings, and I provide anticipatory grief counseling as they consider saying goodbye. They verbally and tearfully process feelings of denial, guilt, anger, sorrow, and fear. I collaborate with the medical team to ensure the family’s values are heard and their spiritual and emotional needs are addressed. The family makes the difficult decision to transition to comfort measures only. The patient, his family, and the medical team experience peace, dignity, and a sense of closure during this pivotal time prior to death.
1. Vaughn JL. Role of chaplains in end-of-life care: Case studies on healing. Clinical Ethics. 2025;20(3): pgs.189-195.
2. Beauchamp TL, Childress JF. Principles of bioethics 7th ed. Oxford University Press, 2013.
