I walk in to Mr. W’s room to say hello. He is 73 years old and has been in the hospital for three months, ever since he was diagnosed with Covid-19 and developed pneumonia. He smiles at me when I introduce myself but can’t speak because of the tube down his trachea that delivers every breath he receives from the mechanical ventilator at his bedside.
He is no longer contagious, but he is still critically ill, stuck on the ventilator, weak and struggling to take a breath by himself. He doesn’t have the strength in his arm to wave when I say hello, but I note the twitch of movement at his wrist as he tries.
In June 2021, as the third wave of COVID-19 was ebbing in Toronto, I took over the care of patients in one of my hospital’s intensive care units. It was populated by many patients who were technically Covid-19 survivors because they were no longer infected with SARS-CoV-2. Yet weeks to months after their infections had cleared, they were still in the ICU, still dependent on a ventilator for their breathing, and still without any certainty as to whether they would get better.
This condition of chronic organ failure — in this case the lungs — with a weakened immune system leading to recurrent infections and a range of other complications such as kidney failure, low blood pressure, gastrointestinal bleeding, severe weakness, and delirium, is well-known in the ICU. It goes by the name persistent (or chronic) critical illness.
This isn’t the same as long Covid, which features symptoms such as fatigue, shortness of breath, and brain fog that endure for weeks to months after a person has had Covid-19, although some of the symptoms are similar. The big difference is that people with persistent critical illness cannot survive on a regular hospital ward, let alone at home. Theirs is a twilight existence: alive — some are fully alert — but with bodies too fragile to survive outside the cocoon of whirring ventilators and dripping medications providing life support and the attention of a nurse at the bedside 24-7. They are tended to day after day, week after week.
These patients, their families, nurses, doctors, and other care providers all hope their bodies will heal — enough so they can breathe on their own; enough to fight off the next bout of pneumonia. How long can this last? Many hold on for weeks, months, and sometimes even years.
Newspapers have been filled with vivid descriptions of those in the throes of severe acute Covid-19, battling acute respiratory distress syndrome assisted by mechanical ventilators in ICUs around the world. Most of these individuals will be dead or discharged from the hospital within a month. What is less discussed is that the disease is also creating an army of sufferers trapped in the state of persistent critical illness, tucked away in ICU beds around the world. Some have described it as a “state worse than death.”
Throughout most of history, the inability to breathe on one’s own always led to death. Oxygen therapy was introduced at the end of the 19th century. But if the body was too weak to take a breath, there was nothing more to be done except keep someone comfortable.
That changed in 1928 when two individuals at the Harvard School of Public Health, Philip Drinker and Louis Agassiz Shaw, Jr., tackled the problem of respiratory failure due to polio and developed the first machine routinely used for life support. The Drinker and Shaw respirator, dubbed the “iron lung,” meant that respiratory failure was no longer a death sentence. The machine was a revolutionary change, though Drinker grumbled in his later years that the “damn machine,” and not his other accomplishments, would be what he was known for.
Before the iron lung was deployed, however, doctors worried about its use. What happened, they wondered, if someone couldn’t live without it? The idea of the iron lung was that it would provide temporary support while the nerves and muscles regenerated after acute polio, and would eventually allow people to breathe again on their own. But what if that didn’t happen and someone could no longer breathe on his or her own — ever? In a taped interview archived at the U.S. Library of Congress, Drinker described the possibility of patients living permanently in iron lungs as “disquieting.” The concept of dependence on a machine to breathe, which was something out of science fiction, suddenly became a reality.
As the use of mechanical ventilators broadened over the decades, from supporting those who had polio to aiding those with many other forms of critical illness, such as bacterial pneumonia, stroke, trauma, meningitis, and now Covid-19, the aftermath of such diseases leaves individuals not just dependent on a machine for breathing but with a suppressed immune system, multiple organ failure, skin breakdown, bleeding stomach ulcers, blood clots, and a host of other medical problems.
It is a precarious existence that is even more complicated than dependence on just a machine to breathe — it is a dependence on the ICU itself.
In countries such as the U.S. or Canada, decisions regarding life support rest primarily with patients or their families, and those decisions vary widely. For some, any time spent on life support is too much, while for others it is a religious imperative that life, in any form, be continued.
For many patients and/or families, the choice is to transition away from aggressive treatments and the use of machines after some period of time. Others continue to hope that with more time and more treatment the body will recover sufficiently to allow them to be weaned from the ventilator and regain independence — or at least the ability to leave the ICU and the hospital and spend time at home.
But there is a group of patients who understand there is no possibility of recovery, and they must choose between existence in the ICU and death.
That is fundamentally a cruel choice. Life in an ICU is not a normal existence. It is a state of limbo and invariably involves painful procedures — needle sticks, cleaning of wounds, suctioning of the airway, and the like. Patients experience this daily distress, but so do family members who visit day after day (when Covid-19 regulations don’t forbid it) and those providing care at the bedside. This buying a bit more life is a Faustian bargain.
At times, care provided to people with persistent critical illness prolongs dying rather than saves life. Medicine has no tools to heal an entire body when it is so irreparably broken. Clinicians offer time, nutrition, ventilation, and supportive care. The magic bullet that takes dying bodies and makes them live again has not yet been invented.
Almost a century ago, Drinker and Shaw fundamentally changed the relationship between human and machine and made possible a symbiosis that has saved the lives of hundreds of millions of people. But they also unleashed new technology that creates agonizing choices for patients, families, and clinicians — and a tortured existence for some.
We cannot and should not forget about this additional impact of Covid-19: a new wave of people dealing with the uncertainty and challenges of persistent critical illness.
Philip Drinker understood from the very beginning the potential dark side of his machine, and we are still grappling with its legacy.
Hannah Wunsch is an intensive care physician at Sunnybrook Health Sciences Centre in Toronto, a professor of anesthesiology and critical care medicine at the University of Toronto, and holds a Canada Research Chair in critical care organization and outcomes. This essay is adapted from a longer version that details the development of the iron lung.