PALLIATIVE CARE

Dilemmas within the Surgical Intensive Care UnitMurray L Wax, PhD, Shawn E Ray, RN, BSN, CCRN

The change of death from a moral to a technicalmatter has come about for many reasons based insocial evolution and technical advance, and the ef-fects on the dying have been profound.1

When death is imminent, recognition, avoidance,denial, and readiness can all go hand in hand for thepatient, family members and professional staff. Of-ten, no one is ready and death still comes. This is whyone faces death rather than masters it.2

The surgical intensive care unit (SICU) is designed tosave the lives of patients who are critically ill, but even ina tertiary care hospital a proportion of patients will notsurvive. Their deaths trouble the relationships amongpersons who are key actors: physicians (surgeons andintensivists); nurses; persons attached to the patient(family or significant others or both); and auxiliary staff(social workers, chaplains). Time pressures render theproblems even more difficult as crises require quickjudgments when the margins for error are narrow andthe time to reflect is nonexistent.

For explicating and interpreting these problems, wewill use the dichotomy of moral order and technicalorder, introduced into medical discourse by Eric Cassellin 1974.1 We will discuss the terms by briefly reviewingthe origin of the dichotomy within the investigations ofanthropologists and sociologists, as these were under-taken in the late 19th and 20th centuries. The value ofthe dichotomy will become evident with a presentationof an illustrative case.

In the discussion of the SICU and the presentation ofthe illustrative case, we will employ the dramaturgicalvocabulary customary in sociology, and speak of the par-ticipants as actors and of their efforts as performances. Insurgical discourse, this is not novel, as the operating

room was originally labelled as the operating theater. Adramaturgical perspective is well-suited for conveyingthe critical interactions among a small team of actorsstruggling to hold death at bay.3

The medical actors—intensivists, surgeons, andnurses—have been trained not only to perform techni-cally but also—less deliberately, less consciously—toperform as social beings within the moral order in theSICU. When doctors and nurses confront a case of aterminal patient, they have the training and experienceto facilitate their handling of the situation. Family mem-bers are far less experienced. They are shocked and dis-mayed by what is being asked of them, technically andmorally, in end-of-life crises. Desperately needing direc-tion, they are conflicted and bewildered by the choicesthey are asked to make. They are particularly troubledwhen those to whom they look for guidance are evasiveor in disagreement. Much of the time, they draw guid-ance from the critical-care nurse.

In the handling of an SICU patient, the central actorsinclude surgeons. In general, they have been trained andmotivated toward preserving life. Their priority is tocure illness and prolong living, regardless of the cost inresources, or the suffering of the patient, or even subse-quent well-being.4 Within that scenario, the loss of thepatient’s life is a sign of defeat, and in some cases isexperienced as shameful.5 They are neither trained norprepared for the alternate scenario of palliative care.

Other major actors include the critical-care nurses,who spend long periods of time at the patient’s bedsideassessing, diagnosing, and responding. Where doctorsrely most heavily on technological cues such as elec-tronic monitors, test results, and physical examination,the nurses supplement by focusing on intimate interac-tive cues, including the social.6,7 They are particularlyknowledgeable about both the physiological and socialaspects of the patient. As part of the investigative processof our research team, we conducted focus groups withfamilies of former patients. When the participants wereasked who was “in charge of the care of their loved one,”their response was nearly always “the nurse.”

As a patient is identified as terminal, the majoractors—physicians, nurses, family—find themselves be-

No conflicting interests declared.

This article is based on work supported by Grant NR 05124, National Insti-tute of Nursing Research, National Institutes of Health, Timothy G Buch-man, MD, PhD, Principal Investigator; Joan Cassell, PhD, Shawn E Ray, RN,BSN, CCRN, Coinvestigators; and Murray L Wax, Research Consultant.

Received May 8, 2002; Accepted May 9, 2002.From the Department of Surgery, School of Medicine, Washington Univer-sity, St Louis, MO.Correspondence address: Murray L Wax, PhD, 572 Stratford Ave, UniversityCity, MO 63130.

721© 2002 by the American College of Surgeons ISSN 1072-7515/02/$21.00Published by Elsevier Science Inc. PII S1072-7515(02)01286-3

ing asked to play difficult roles within the unfoldingdrama. In the initial epigraph, E Cassell had indicatedthat we might acquire a deeper understanding of thesedramas by way of the contrast between technical orderand moral order.1 His essay has been influential andmuch cited. We will elaborate on the key concepts, start-ing with the original contrast as developed by the an-thropologist Robert Redfield.

Contraries: Moral and technical order

The moral order develops in intimate groups wherepeople can communicate most humanly with oneanother and come to shape each other through theestablishment of common sentiments and atti-tudes. . . . The technical order is that order whichresults from mutual usefulness, from deliberate coer-cion, or from the mere utilization of the same means.In the technical order men are bound by things, orare themselves things.8,9

Although the two contrastive notions were introducedto medical discourse in 1974, the terminology was ad-vanced by Redfield a generation earlier. From the He-brew prophets and the scholars of the Arabic Renais-sance until the present day, thoughtful observers andcritics have noted the differences between thesmall rural community—relatively isolated, compact,homogeneous—and the urban milieu. The smallcommunity was composed of persons who had knowneach other intimately since birth and was dominated bykinship relationships, by ritualized obligations, and byceremony and piety. Urban life brought the mingling ofpeople, it detached relationships by objectification,alienation, and far greater freedom.9 The German prov-erb is apt: “city air makes free;” but the freedom has aprice.

The emergence of the social sciences during the 19thcentury initiated intensive studies of the urban milieu bysociologists and of the small exotic communities by cul-tural anthropologists. According to Redfield, theoristsearlier in the 20th century identified that there was acorresponding conceptual opposition: on the one hand,small communities (folk societies), and on the otherhand the great city (the metropolis). While that contrastis visibly present, the underlying processes are morecomplex. Within the urban milieu, people are continu-ally attempting to recreate miniature versions of thesmall community. True, urban life has far more interac-tions among persons who are strangers, and this is an

extreme contrast to the small community where peoplehave known each other since birth and will continue toassociate with each other until death. But if one looksclosely at a well-functioning work site (including theSICU), one finds persons building intimate social rela-tionships, miniature versions of the ties characteristic ofthe small community.9 Hence, one can describe and an-alyze these behaviors better by asking whether they aresituated within the technical order or within the moralorder. The contrast between the two is relative ratherthan absolute.

Moral and technical orders are thus not neatly sepa-rable, but are in a continual tension and adaptation. Inany particular milieu, the actors might be guided by thespirit of one order or the other. Redfield summarizes theeffect of civilization on the moral order by stating thatthe integrity and compelling force of the moral order insociety are functions of isolation and a slow rate of de-velopment of the technical order. The moral order flour-ishes as the society is shut away from outside influencesand as the technical order develops slowly or not at all.When new ideas are rapidly introduced and people ofdifferent traditions are moved around into new commu-nications with one another, or when the technical orderdevelops rapidly within an indigenous civilization, themoral order is thrown into confusion and its authoritydeclines. The ethical convictions of man strengthen orweaken with the events of technological developmentand with increased or decreased communications.9 Re-formers of differing perspectives urge that the actors (inthis case, intensivist, surgeon, family, or nurse) be guidedby technical excellence or by moral connections or somecreative integration.

Views of the dying personViewed from the technical order, the personis an organism—distinct, individuated, basicallyphysiological—composed of organ systems.9 The SICUperforms miracles in maintaining troubled systems andrestoring some toward functional adequacy. But, thesemedical efforts might be defeated, and as the systemsunravel, and the patient becomes irrevocably terminal,dying becomes inevitable. Within the SICU, one speaksof multiple system organ failure: physiologically a zerostate.

Viewed from the moral order, the person is a socialbeing, raised by other human beings, with whom he orshe is continuously enmeshed in a web of duties, con-

722 Wax and Ray Dilemmas in the SICU J Am Coll Surg

cerns, privileges, and responsibilities; thereby acquiringlanguage and a self, including a narrative sense of con-joint activities and of who he or she is, a self image rootedin relationships.9 Viewed from this perspective, dying isthe fracturing of these relationships, the organism sobecoming decreasingly social and ultimately a mere sym-bol. Because the person is connected to other beingswith selves, death is not a zero state—a vanishing—butrather a translation of being. Consequently, most of thepeoples of the world think of the dead person as inhab-iting a new social space: present perhaps as an ancestralspirit, or alternately reborn (or reincarnated) within thecommunity.1 This view is tacitly acknowledged by sur-geons through willingness to provide pastoral care andother forms of spiritual support.

So, moral and technical orders offer two different op-tics for understanding the dramas of the SICU. To dem-onstrate how this happens, we offer the case of Mrs B.

SICU conflicts: The case of Mrs BMrs B was admitted to the SICU after emergent repair ofa ruptured abdominal aortic aneurysm. She had a his-tory of chronic obstructive pulmonary disease requiringhome oxygen, congestive heart failure, andhypertension.

The clinical course following abdominal aortic aneu-rysm repair included multiple complications. She re-quired cardioversion for atrial fibrillation with a rapidrate and a continuous Amiodarone infusion. Serial chestx-rays showed development of pneumonia, which cul-tured positive for oxacillin-resistant Staphylococcus au-reus. On postoperative day 8 she required pressure con-trol inverse ratio ventilation to effectively oxygenateafter an episode of ventricular fibrillation that convertedto atrial fibrillation with an acute drop in her oxygensaturation. She was evaluated and treated at that timewith heparin for a pulmonary embolism. This prompteda call to the family that night by the resident to notifythem of the events. They were told Mrs B had “taken aturn for the worse” and that “some decisions would haveto be made.”

Mrs B was active despite the home oxygen and en-joyed going out and having “lunch with the ladies.” Herdaughter, Pam, was her Durable Power of Attorney. MrsB also had executed a living will that stated: “if the ther-apy will have no reasonable benefit to return me to thequality of life I am accustomed, then I do not want it.”She had held discussions with her daughter and son

regarding her wishes if she were ever on a ventilator for aprolonged period of time. In fact, months earlier, shehad required intubation and mechanical ventilation for4 days (pneumonia) and she told her daughter that thatwas “too long.”

Pam and her brother, Tom, talked about what theirmother would have wanted. According to their mother’sstandards, she was already on the ventilator too long.Pam and Tom were prepared to consent to remove herfrom the ventilator if the physicians felt that they had“done everything.”

Comment. The story thus far presents two views ofMrs B. The first paragraph describes the technical order;ie, the medical diagnosis, the tests, the treatments, andthe patient’s physiologic response. Conversely, the fol-lowing two paragraphs describe Mrs B in the moral or-der; ie, her life, her relationships, and her discussionswith her daughter regarding how she wanted to live herlife. During medical rounds, the technical order is pre-sented, as in the first paragraph. When the critical carenurse gives a report, included are not only technicaldetails, but the psychosocial aspects of the patient’s life,as described in the last two paragraphs.

Mrs B’s course became more complicated. In the firstof a series of family conferences, the intensivist told thefamily that, yes, she had an acute event during the nightthat might have been a pulmonary embolism, but shehad since stabilized. Her family questioned her deterio-rating mental status. The intensivist noted that it was 48hours since discontinuing all sedative drugs and she wasresponding with only a slight grimace to deep pain. Herrenal status had improved, with her creatinine down to1.3, after a high of 2.1 postoperatively.

The intensivist felt it was “too early” to consider with-drawal of treatment. Even though she had oxacillin-resistant S aureus pneumonia on top of chronic pulmo-nary disease, her creatinine had come back to normalrange and was encouraging. The family responded thatthey had discussed the information about her conditionwith her family doctor “back home” and he had said,“she doesn’t stand a chance.” A close friend of Mrs B’s,who was also a physician, had stated “Oh, your motherwould never have wanted any of this.” It bothered Pamand Tom each passing day that their mother was on theventilator without signs of progress. The intensivist toldher family that her oxacillin-resistant S aureus pneumo-nia was being treated. He recommended a tracheostomyto facilitate weaning. Pam stated that she did not think

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her mother would want the tracheostomy. The intensiv-ist said “Fine, but we should wait a few more days to seehow she does.”

The family wanted to then speak with the surgeon,but he was out of town. The surgery fellow happened tobe available on the unit and was happy to speak with thefamily. He explained how he thought she was doing andeven gave percentages: “20% chance of making it out ofthis unit given her age and rupture.” They told him theirmother did not want to be on the ventilator for weeksand she really would not want a tracheostomy. He agreedthat waiting a few days would be a good idea. Pam andTom, on the other hand, were ready to make a decisionthat day.

After the meeting, Pam, Tom, and Pam’s adult daugh-ter Katie sat and talked. A few minutes later, Pam camelooking for the critical care nurses to speak with themagain. They were all in tears. They requested anotherfamily conference for Friday (the following day) at 2:00PM. They did not want to wait a “couple of days;” 24hours was long enough. “We don’t want this to go on anylonger than tomorrow. She would not want that.” Tomand Pam said the only reason they were waiting untiltomorrow is so they could grieve. They requested aCatholic priest in order to administer the Sacrament ofthe Sick to their mother.

Comment. The story further illustrates the drama ofthe SICU and the embodied conflict among the actorssituated at opposite poles within the moral and technicalorders. On the one hand, the patient’s family (son,daughter, her daughter) present the wishes of the patientas these have been discussed prior to the rupture, namelya restricted range of treatments. On the other hand, thephysicians were thinking that the patient’s medical prob-lems could be reversible, and hence they should notabandon treatment (and hope) until proven otherwise.Almost stereotypically, the family is viewing the crisisfrom within the moral order, while the physicians areoriented toward the technical. The family and the phy-sicians do not share a common basis for decision. And,the patient being in “the territory” of the intensivist, andwithin his care and subject to his orders, the family findthemselves especially frustrated. The frustration is inten-sified when relevant physicians (notably, the surgical at-tending) are not available for discussion. The one personwho might mediate between the two positions is thecritical care nurse, who empathizes with the adult chil-

dren, while being keenly aware of the motivations of theintensivists and other physicians.

The nurse summed up the perplexities:

“What will we do? She has told her daughter shedidn’t want to be on the ‘vent’ for a prolonged periodof time and the docs think she’ll eventually get off.She’s still on 100% (fraction of inspired oxygen) afterthat episode last night. Her secretions are awful!. . .and I haven’t seen her respond for the last threedays; maybe a grimace to deep pain.”

The story has a further and not untypicaldevelopment.

Family disagreementsThe following day, the story became more complicatedby the appearance of another son, “Andy,” of whomneither Pam nor Tom had spoken. Andy was here to seeMrs B at approximately 12:00. He told the nurse, “Mybrother and sister are trying to kill her; please don’t letthem. I’m trying to block this. My son is a senior lawschool student and we’re going to court to block Pam’sdecision-making capability. She’s not smart enough tomake such decisions. The whole town thinks they’retrying to kill her.”

At that point, Andy was referred to one of the physi-cians who gave him an update on his mother’s condition.Tom and Pam happened to request to visit shortly afterthis and saw Andy in the room. They asked to speak tothe nurse in order to request that Andy be removed fromMrs B’s bedside. Tom said to the nurse: “Neither mymother nor my father would ever approve of Andy beinghere. He’s been out of the picture for 25 years and hedecides to come by now. He’s from a religious commu-nity that thinks everyone can be saved. Well, he doesn’tknow my mother’s wishes.” Further complicating mat-ters, Tom and Pam would not visit their mother untilAndy left. The nurse felt “caught in the middle,” whilethe intensivist remarked, “I wasn’t sure what we weregoing to do.”

Another family conference was held the following af-ternoon. The intensivist asked the family to give theirmother “a few more days” and even offered to removehimself from the case if the family disagreed. Pam andTom agreed to wait “a few more days.”

The nurse spoke with the residents on Monday con-cerning any weekend events. The “crazy” brother (asTom deemed him) was in again on Sunday and wanted

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to be sure that they were not “pulling the plug,” andreiterated to the residents that he was trying to get acourt order to block the decision-making capability ofPam. This matter was discussed on rounds and all agreedthat this son could not block the Durable Power of At-torney. The team notified hospital Risk Management ofthe situation.

The estranged son, Andy, has not been connectedwith the family for 25 years. He does not know thewishes expressed by his mother, nor does he wish toknow, yet he feels that has the right to determine hertreatment. One surmises a feeling of guilt in his de-manding “full support” for his mother, while refusing torecognize that she has already died spiritually and men-tally. He is thus unable to integrate the technical infor-mation with human needs, values, and desires, whichemerge only with a more intimate level of interpersonalrelationships, as is manifest in the vigilance and care ofPam, Tom, and Katie.

At this time, Mrs B’s condition had not improved.Although she was “off sedation” for 6 days, she exhibitedno response to deep pain. Her creatinine was starting torise again, and now she had another “difficult to treat”organism in her lungs for which she would need addi-tional antibiotics. She was not coming off the ventilatorany time soon.

At the family conference Monday afternoon, a newSICU attending physician was present, and the situationwas again discussed with the family. Pam and Tomshowed him the Living Will and Durable Power of At-torney. Pam stated, “My mother did not want to be onthe ventilator any more than a few days. It says there that‘if the therapy will have no reasonable benefit to returnme to the quality of life I am accustomed, then I do notwant it.’” Pam stated that she has been on the vent muchlonger than she had ever given approval for, and eachdoctor was, each day, asking for “a few more days.” Theintensivist insisted that he could not guarantee shewould get off the vent any time soon, but that she standsa reasonable chance of getting off “somewhere down theline.” Pam stated her mother would never have wantedthat. Her mother’s friends verified this in Pam and Tom’sdiscussions with them. It sounded as if they had talkedabout this a great deal. The intensivist then stated,“Well, if those are her wishes, then we are ‘there!’” Butthen he suggested the group speak with the AttendingSurgeon before care was withdrawn. The family agreed,

but felt peace of mind when the intensivist agreed “wewere there.”

The family waited until that evening for the discus-sion with the surgeon. In fact, the family did not want towait any longer. The intensivist called the surgeon, whostated on the phone, “If they want to kill her, that’s fine.”The intensivist, along with the nurse, then spoke withPam and Tom regarding the timeline and sequence ofevents in the withdrawal of care plan. At that time, Pamand Tom called their “crazy” brother to let him knowthey were removing her from the ventilator.

The contrast is vivid. At one extreme is the vascularsurgeon, who having repaired Mrs B’s aneurysm, nowsaw his patient “being killed.” The other physicians tendto agree but are not as forceful in their statements. At theother extreme are the family cluster of Pam, Tom, andPam’s daughter, who regard themselves as faithfully car-rying out Mrs B’s expressed wishes. Also, from theirviewpoint as pious Catholics, her death is a transfer to adifferent status where they will continue to venerate andaddress her. Between these two parties are the criticalcare nurses, who well understand both positions.

The therapies being directed at Mrs B were fairly rou-tine for an SICU, and the physicians were not able tostate that her situation was terminal. Generally, deeminga case “terminal” will spark a discussion with the physi-cian and family regarding withdrawal of life support.Mrs B merely stated her desires to not receive ventilatorysupport for more than 4 days. How does it happen thatit becomes so difficult for the medical professionals toaccept this?

By entering the hospital, Mrs B was placing herselfunder the authority of its physicians. She was choosingto be “saved” (or her children were choosing to save her)by seeking care for her abdominal pain, which turnedout to be a ruptured aneurysm. The vascular surgeonperformed his heroics in life-saving surgery. He is willingto stand by Mrs B for the “long haul.” He was disap-pointed when her wishes were known and projects thestatement, “If they want to kill her, go ahead.”

But the critical care nurse saw the perspective of thepatient. “Why wouldn’t we comply with her wishes? Shetalked about it a lot with her son, daughter, and herfriends. She would probably never be able to ‘have lunchwith the ladies’ again, which was her idea of quality oflife. She could have chosen not to come to the hospitalfor her abdominal pain and died at home.” The nurse

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brings the humanistic perspective to caring for patientsand families in the critical care environment.

Lessons from the case history

The Pygmies express various degrees of illness by say-ing that someone is hot, with fever, ill, dead, com-pletely or absolutely dead, and, finally, dead forever.10

Although the events in the illustrative case will be famil-iar to most critical care personnel, the tensions underly-ing the events are useful to analyze and interpret.

In some cases, SICU patients follow an unambiguoustrajectory culminating in life or in death. More often,the outcome remains uncertain. Also, even when physi-cians feel that they have arrived at a judgment that deathis nigh, they might still temporize because outcomes areproblematic. Of patients apparently terminal, perhapssome few among tens of thousands will miraculouslyrecover. Whether or not to wait out the remaining pa-tients, or for how long to sustain the total aggregate ofthe metaphoric thousands, is a question that can be per-plexing, given the discomfort of the patients in question;the anguish of families; the rival claims upon limitedresources; and the fact that the act of discontinuing careis frequently regarded as a statement of medical failure.In this case, an attending physician skillfully temporizes,and by so doing pressures the family to violate the fam-ily’s covenant with the patient. From the perspective ofphysicians, the choice to temporize cannot be faulted,for perhaps the patient might survive—although in whatstate or what quality of life is not expressly discussed.Nevertheless, the family could forcibly declare that theircovenant with the patient must be honored, except thatthey are in the precincts of technology, and thus feelingsubordinated to the judgment and authority of its ex-perts. But yielding to that authority means that thefamily—and in particular the individual who bears med-ical power of attorney—is violating the covenant with aperson to whom each is deeply attached.

Beyond the uncertainty of survival, equally uncertainand disturbing are the possible vital outcomes of theperson and the body. The body might still function, butthe social person ceases to exist forever; nursing homeshave their complement of such beings. In some in-stances, the social person might be somewhat functionalyet inhabiting a body that functions so poorly that it is asource of continual distress. It has always been the casethat for a few persons there was some temporal uncer-

tainty about the arrival of death. In 19th century Eu-roAmerica, there was a popular hysteria about being“buried alive,” which possibly fueled the more sensa-tionalist writings of Edgar Allan Poe. The Pygmies of theIturi Forest, when studied in mid-20th century by ColinTurnbull,10 spoke as noted above.

Within the technical order, death is an absolute noth-ingness. Living is conditional on the body, and if thebody is gone, so too is the person. Within the moralorder, death is a translation of state rather than an abso-lute terminus: the deceased will remain present in thehearts and minds of others, particularly those withwhom he or she was intimately interconnected. Thismight be true to such an extent that the family willremark that they do not want to see the patient in a stateof such misery or psychic incompetence. In many soci-eties, the deceased is present as an “ancestral spirit” con-tinuing to affect the daily lives of its offspring and rela-tions. The judgment of the attending physician thatphysiological death constitutes a personal and medicalfailure might be rhetorically translated by a family mem-ber so as to brand the discontinuing of aggressive care as“killing” or “murdering” the patient. By that verbal tac-tic, that family member is removing the patient from themoral order and situating her within the technical order.This rhetorical tactic comes naturally to a son who hasbeen alienated from his mother. Possibly this technolog-ical orientation is in consonance with the discomfort,even guilt, that might characterize the alienation. Onemight also note the likelihood that a prolonged detach-ment between persons formerly intimate (as mother andson) might conduce to a “frozen image” in which the realperson—with real body, real feelings, real anguish—isdisplaced by imprinted memories. In the illustrative casein question, the remainder of the family views the pa-tient as a social person who has voiced her decisionsabout potential care. In short, the role of the physician isakin to that of a chemical catalyst. If he (or she) acceptsthe extreme likelihood that the patient is terminal, thisgives permission to the family to accept her stated wishesnot to be subjected to aggressive treatment beyond acertain point. Consequently, when the physician evadesthat frank judgment, then the family is at the mercy ofcontrary sentiments: whether or not to honor the ex-pressed and written desires of the patient (and hertrusted relatives), that she not be subjected to furtherdiscomfort (and possibly propelled into an undesirablequality of life).

726 Wax and Ray Dilemmas in the SICU J Am Coll Surg

The foregoing configuration is recognized to occurwithin SICUs. The change of death from a moral to atechnical order has been critically observed by somenurses and some intensivists, although these perceptivepersons might find it difficult to intervene directly. Be-cause it has been so perceived, reformers have hoped toinstitute changes, the most notable recent reformativeproposal being the SUPPORT program, which provedineffective.

The case presented in this article illustrates the ten-sions and dissatisfactions surrounding spiraling demisefollowing major surgery. While the details vary from onecase to the next, several features can be extracted thatsuggest different approaches. First, patients and theirfamilies need to be presented with realistic descriptionsof options and estimates of outcomes, including the pal-liative care option. Accurate descriptions of risk, qualityof life, and longevity are an ethical responsibility, andshould reflect the unique circumstances of each patientas far as possible. Second, patients and families should bewidely encouraged to complete advance directives thatstate, as explicitly as possible, descriptions of the carethey wish to receive. Since many health-care personnel(including surgeons and intensivists) are uncomfortablewith the legal jargon that frames ordinary advance direc-tives, they might recommend that patients at risk for apoor outcome consider completing a “5 Wishes” docu-ment (http://www.agingwithdignity.org/5wishes.html)that includes the components of advance directives in auser-friendly format that acknowledges death as part oflife’s cycle. Third, both surgeons and intensivists mustrespect the authority of the agent (attorney) appointedto make health-care decisions for the patient. The eva-sion illustrated in this case is, unfortunately, common asdoctors try to reconcile personal beliefs about what is“right” for the patient with the directions of the agent.Duly empowered attorneys for health care have both theright and the responsibility for decisions when the pa-tient cannot make decisions for themselves. Failure torespect those decisions is at best unethical. Fourth, thecritical care nurse should be allowed considerable free-dom to revisit the goals of care with the patient/agent,family, and doctors as required by the changing status ofthe patient. Such reviews of what is possible, what isprobable, and what is desired maintain the difficult butessential balance between the moral and the technicalorder in the surgical ICU when doctors, family, and the

patient together must confront spiraling decline despiteintense care.

Author contributionsStudy conception and design: Wax, RayAcquisition of data: RayAnalysis and interpretation of data: Wax, RayDrafting of manuscript: Wax, RayCritical revision: Wax, Ray

APPENDIX

Surgical Palliative Care WorkgroupGeoffrey P Dunn, MD, FACS, Erie, PA, Series EditorPeter Angelos, MD, PhD, FACS, Chicago, ILPatrice G Blair, MPH, Chicago, ILKaren Brasel, MD, FACS, Milwaukee, WITimothy G Buchman, PhD, MD, St Louis, MOSusan Jo Bumagin, Med, Gloucester, MAIra Byock, MD, Missoula, MTJohn L Cameron, MD, FACS, Baltimore, MDJoseph M Civetta, MD, FACS, Farmington, CTAlexandra M Easson, MD, FRCS(C), Toronto, ONDaniel B Hinshaw, MD, FACS, Ann Arbor, MIJoan L Huffman, MD, FACS, Upland, PAWendy C Husser, MA, MPA, Chicago, ILDennis L Johnson, MD, Hershey, PAOlga Jonasson, MD, FACS, Chicago, ILThomas J Krizek, MD, FACS, Wesley Chapel, FLRobert S Krouse, MD, Tucson, AZK Francis Lee, MD, FACS, Springfield, MALaurence E McCahill, MD, FACS, Alhambra, CARobert A Milch, MD, FACS, Buffalo, NYAnne C Mosenthal, MD, FACS, Newark, NJGretchen Purcell, MD, PhD, Durham, NCAjit Sachdeva, MD, FACS, Chicago, ILA Reed Thompson, MD, FACS, Little Rock, ARDavid Weissman, MD, FACP, Milwaukee, WIH Brownell Wheeler, MD, FACS, Worcester, MA

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