Visiting Ethics in Critical Care

by Nadia Boachie

Critical care is not for the light-hearted. If you have been to an Intensive Care Unit (ICU), you have seen several patients on the brink of life and death. They are being kept alive by machines and cared for by hard-working healthcare professionals that devote their lives to people in dire health states. Dr. Ewan Goligher is one such individual working at the Toronto General Hospital as a Clinician Scientist. His mission is to minimize the adverse long-term effects of certain life-saving medical interventions used in the ICU, and to ensure critical and end of life care is delivered in a patient-centered and ethical way.

Dr. Goligher did not always know he was going to be a doctor, but he thought that pursuing a career in medicine would give him “the opportunity to work with people in the moment of vulnerability and weakness, and help people in a meaningful way”. Dr. Goligher further elaborates, “Medicine sounded adventurous, interesting, intellectually stimulating, and a career where you could really connect with people.”

In Dr. Goligher’s 4^th year at the University of British Columbia’s medical school, he had an elective in the ICU at Vancouver General, which was his first real exposure to internal medicine and critical care. Dr. Goligher explained that patients in these units would often have multiple issues. Discerning what contributed to symptoms was difficult, but a challenge he enjoyed.

After completing medical school, Dr. Goligher came to Toronto for his internal medicine residency. He worked with Dr. Niall Ferguson, who sparked his interest in mechanical ventilation. Dr. Ferguson later became his supervisor when he pursued a PhD in the Department of Physiology at UofT. The main goal of Dr. Goligher’s research is to determine how mechanical ventilation can cause damage to patients’ lungs. He wants to prevent the complications associated with prolonged ventilation, so patients can recover and live healthier lives in the long term. Through these goals, he aims to have a global impact on patients who suffer from acute respiratory failure.

Ventilators are designed to replace breathing muscles. However, Dr. Goligher indicates that they can also damage the lungs and principally, the diaphragm. He hypothesized that perhaps ventilators injured breathing muscles and led to their acute atrophy. As a result, muscles that facilitate breathing become too weak and patients fail to breathe on their own. Dr. Goligher’s research asks the questions, “How do we characterize what happens to the breathing muscles when you are on a ventilator?” and “How do we predict those changes?” Currently, he is designing clinical trials to evaluate how to protect patients’ diaphragms when using ventilators.

Dr. Ewan Goligher, MD, PhD, FRCPC. Scientist, Toronto General Hospital Research Institute (TGHRI); Assistant Professor, Interdepartmental Division of Critical Care Medicine, University of Toronto

As a clinician scientist, Dr. Goligher’s responsibilities extend beyond research. Because he often treats patients in their final stages of life, Dr. Goligher constantly deals with challenges pertaining to the ethics of end of life care. Patients are of varied cultural and religious backgrounds, and this may mean that agreeing on the appropriate medical interventions during this unstable period can be a source of contention. He explains that one of the joys of living in Canada is that it is a pluralistic society. Canadians have the opportunity to live and work with people of different cultures, backgrounds and belief systems. Dr. Goligher describes how pluralism can introduce challenges when looking after patients, “it sometimes creates dramatic ethical conflicts about what patients might want and what we as physicians think is good for the patient”.

Cases in which to perform or withhold cardiopulmonary resuscitation (CPR) is an example of a medical intervention where sometimes doctors and patients do not align. Doctors try and avoid prolonged death. However, in cases where the probability of successful resuscitation approaches zero, doctors may deem it medically inappropriate to intervene with CPR. “Anytime you initiate CPR, you end up on life support, so it is a big package of very heroic interventions”, explains Dr. Goligher. When doctors intervene, they often see journeys of prolonged dying rather than recovery. Given the poor outcomes after CPR intervention, performing CPR can trigger tremendous amount of moral stress for doctors, nurses and respiratory therapists. Despite their best intent, it is distressing to see that intervention only leads to prolonged suffering.

Another point of contention are cases of brain death, when patients meet criteria for neurological death where all brain function has ceased. “What is hard for families is to come to grips with cases where the heart is still beating, blood is still flowing, you pick up their hand and it still feels warm,” empathizes Dr. Goligher. For some people, as long as their heart is beating, this is enough criteria to deem that the person is still alive. These conflicts are prominent between healthcare workers and patients or patient families in critical care.

Dr. Goligher’s belief regarding the decisions of “whether or not to administer CPR” or “when to remove someone off life support in the case of brain death” is based on his worldviews. Understandably, it may be different from the patient’s perspective. “What is the purpose of the patient being in the ICU? Is it to keep them alive? To sustain their heartbeat?”, Dr. Goligher questions. “We live together, we learn to get along together, but sometimes it can create these massive conflicts”, he explains.

Dr. Goligher believes medicine is a very human endeavor. Over the years, he has learned that taking the time to listen and understand where people are coming from and how they see the world is half the battle when dealing with conflict. When people feel heard and understood, it can be a trust building experience for more effective decision making. However, he adds, “it does not mean that all the differences of opinion go away”.

Understanding the humanness of medicine is how Dr. Goligher copes with the trauma of his work environment. Dr. Goligher explains that physicians put up a metaphorical wall. Doctors cope with the pain and suffering by working on the assumption that such events do not happen to them. When suffering does break into the lives of doctors, they are humbled and forced to recognize that like the person on the other side of the gurney, they are human too. “I feel the brokenness of the world”, shares Dr. Goligher. Doctors get the experience of what it is like to be human, including the consequences of weakness and vulnerability.

Dr. Goligher shares an instance where he experienced the humanness of life when his son was born with a physical abnormality. He began to imagine the difficulties that his son was going to have that other kids might not. “It is challenging and difficult and sad”, he articulates, “but there is a lot of triumph in it as well.” During this difficult time in Dr. Goligher’s life, he remembered that he is not exempt from the consequences of being human. His experience in the ICU has further taught him that he is not there just to fix their problems. “I am there to accompany them on a difficult journey”, Dr. Goligher enlightens. Though it may be difficult to form meaningful relationships in the ICU as patients are non-interactive, sedated, or comatose, he is able to do so with their families. For Dr. Goligher, a doctor’s job is not to only fix the patient’s problems. Rather, it extends to attending to the human experience of the illness.

Patient-centered care has always been Dr. Goligher’s focus. He strives to increase knowledge about ways to improve outcomes of patients that need mechanical ventilation. Currently, Dr. Goligher is at a pivotal point in his career. With the help of collaborators, based on trials they are planning, the results may change the way that ventilation is applied worldwide. “This is a junction where there are so many opportunities, there are so many really interesting questions to answer and time is really the only limiting factor”, claims Dr. Goligher. Motivated by the belief that his research is very rewarding, as he understands more, Dr. Goligher will be more compelled to look for answers.

IMS magazine spoke with Dr. Goligher sometime after his initial interview and asked him how COVID-19 has impacted his ICU unit and his current research on ventilation. Dr. Goligher explained that “COVID-19 proved to be a huge challenge for the whole health system”. Specifically, “in the ICU we completely redeployed to focusing on caring for patients with severe COVID-19. They were often challenging to manage with severe derangements in gas exchange and a very prolonged recovery process.”

COVID-19 has delayed but not cancelled the research Goligher and his team had planned. Goligher explained how the research studies they would normally conduct were shut down so that staff could stay at home. He explained how the “opportunities to continue mechanical ventilation research on the diaphragm were limited.” “We were able to collect some data on lung function in these patients and we are working on describing our findings. Even as the pandemic settles in Canada, we’re continuing to work on developing a pandemic ventilator that can ventilate many patients at once in case of future need” Dr. Goligher added.

Despite research stopping, doctors and hospitals were able to gather crucial information about how bets to care for patients. “Treating these patients raised important questions about how we decide when to put patients on a ventilator and how best to maintain their oxygen levels once they are on the ventilator. These will be important areas of future research in the ICU.” Dr. Goligher concludes. It will be interesting to see the amount of information that has been generated out of the global pandemic. The world continues to look to doctors and researchers like Dr. Goligher to help in recovery from the pandemic and to prevent or better handle any future outbreaks. Recently, the Toronto General Hospital was ranked the 4^th best hospital in the world for excellent standard of care. According to Newsweek’s top 100 list, Toronto General was ranked behind Mayo Clinic, Cleveland Clinic, and Massachusetts General.¹ The hard work done by doctors and other medical staff, like Dr. Goligher, is recognized on a global scale. Doctors and researchers are working together to provide the best care to patients they can.