Critical Care: The Grey Zone, The Heightened Costs and Being a Missionary Physician
September 11, 2017
"Each of you should use whatever gift you have received to serve others, as faithful stewards of God's grace in its various forms" (1 Peter 4:10, NIV 2011).
For every physician who cares for extremely sick patients, there comes a time when you reach a grey zone. A critically ill patient or ambiguous diagnosis confronts you at 2 a.m., and you are unsure of your ability to save the person from death or permanent disability. Should you choose to start life-support measures on someone who is palliative-care appropriate or have a frank discussion with the family regarding the prognosis? It's a place where you sometimes doubt your clinical judgement and knowledge because the case could swing either way. You might think that the patient may survive another 24 to 48 hours or you might think that despite all efforts they will die in the next two to three hours. You feel the weight of every decision you make for the patient and family.
The challenge at a mission hospital is the grey zone looks a lot different due to limitations on level of care and a heightened cost to making these decisions. Cultural and language barriers notwithstanding, I am often making decisions that would be made only after consulting with someone's primary care doctor, various specialists and numerous other colleagues in the middle of the night with limited labs, limited imaging and a limited history. I also have limited leeway in treating a critically ill patient, because ventilators, ICU-level monitoring, dialysis and lack of medications force me to frame my choices in a completely different light. There's often no recourse if someone's kidneys shut down in the middle of the night and their blood pressure drops at the same time. Dopamine is our only pressor (life-support medication to raise blood pressure), and it comes with a host of potential complications.
Even more than adjusting my medical decisions about critical illness is recognizing the impact on the family financially. Since most people here are desperately poor, and healthcare insurance doesn't exist, is it fair for me to charge them more money for a very slim chance of seeing improvement, when it might mean much less money for food, education or basic necessities? While I don't often stop to ask these questions in the U.S., I stop to ask myself them here. Although our hospital has very reduced rates and ways to help the poor, we do need to charge for care. How can I appropriately care for a patient in a cross-cultural ministry, while giving fair expectations, but also excellent and up-to-date care? I've found more and more it boils down to the essence of "being a missionary physician." What does "being a missionary physician" mean besides a good bedside chat with the family, giving hope and prognostic information, but more than that, giving what in my mind is the most important news of all, the news that Jesus has died to save each of us? No matter the level of my medical skills or availability of technology, each one of us will one day have to face our Creator God. If I can encourage, pray and share the hope I have for eternal life, even if I feel limited medically in what I can offer, I am limitless in the impact God can have on their life for eternity. I am adjusting my expectations and understanding of treating critical illness, but I am standing firm in the knowledge that God is more than sufficient for all of my critically ill patients.