International Journal of Technology Assessment In Health Care, 8:3 (1992), 382-394. Copyright © 1992 Cambridge University Press. Printed in the U.S.A.

THE INTENSIVE CARE UNIT The Unfolding and Ambiguities of Survival Therapy Stanley Joel Reiser University of Texas Health Science Center at Houston

Abstract The intensive care unit (ICU), one of the great achievements of modem medicine, is both a set of technologies and a space with a special function. This essay traces the evolution of the ICU's crucial technologies, and how the space bearing this name was carved out in the hospital. Ethical, legal, and social developments, an important part of this story, are incorporated in it.

The intensive care unit (ICU) is a space within which continuous monitoring of vital physiologic functions is linked to responsive intervention. It is the metropolis of health care, filled with high technologies, the medical equivalents of skyscrapers. But it is a strange metropolis where the technological structures create the noise and the population of patients surrounded by them are largely silent. It is a place where life is balanced on a razor's edge, and the sickest of the sick are given a last chance at survival. Like the modern city, the ICU is expanding into the spaces around it, a growth that some believe will ultimately incorporate most of the hospital into its structure, evoking a future vision of the hospital as an aggregate ICU. The modern debate about use of the ICU is focused on the issues of: How long and intensive should be the reach and energy of its technologic interventions? When is it time to stop? Who should gain entrance to it and when should they leave? The line from a popular ballad about life in New York City, "if you can make it there, you'll make it anywhere," captures the situation of the ICU staff, whose perseverance betokens an inner strength that gives future promise. But the same is not necessarily true of its patients. For them, perseverance inside an ICU has ambiguous meanings. It is a place where what is promising and what is futile therapy is unclear, and where the saving of a life may be a triumph or, ultimately, a tragedy. Thus the dilemma: By what yardsticks to judge ICU therapy? Survival during ICU care? Survival afterward? The succeeding value of existence? These issues make the ICU a lightning rod of social debate about the use and usefulness of the growing resources it consumes. Yet our experience with the ICU is relatively limited because it is young: the modern ICU was born and replicated in the 1950s. But its ideologic, technologic, spatial, and ethical antecedents have a long history whose reconstruction can help us to understand its effects. 382

The unfolding and ambiguities of the ICU IDEOLOGIC COMPONENTS OF ICU

Thought concerning the appropriate boundaries of the medical care of very sick people has origins in the fifth century B.C. in Greece, when Hippocrates and his disciplines, were dominant. A key concept in the literature that they produced concerns balancing efforts to benefit patients against the possibility of inflicting suffering on them. It is discussed in the essay "Epidemics" (7): "As to diseases, make a habit of two things—to help, or at least to do no harm." This passage warns that the intention to benefit a patient may not be an adequate justification for an intervention if it holds small promise of success. The harm such an action may unleash may not only affect the patient, but can be transmitted to the physician and to medicine itself through damage to their credibility. To protect this trio further a concept of therapeutic limit was developed that is best expressed in another Hippocratic essay, "The Art" (8): "I will define what I conceive medicine to be," says the writer. "In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those overmastered by their diseases, realizing that in such cases medicine is powerless." This passage asks physicians to estimate the rational limits of a given therapy, and not to use it in cases where the disease will mute its^effects. Therapeutic futility was a harm to be avoided. A basic alternative viewpoint about therapy was developed as a result of ideas with origins in the Renaissance. Through techniques such as autopsy (23) and experimentation (16), an optimism emerged that one could learn how nature worked and from this knowledge, ultimately, gain the ability to dominate it. As this ethos grew in medicine, therapy became more vigorous, even violent. Oliver Wendell Holmes, a professor at Harvard Medical School, wrote in 1860 of the distrust that physicians had acquired in using nature as a healing force that was allowed to work by itself, and in restraining therapy that had been created through human artifice, both outlooks advocated by the Hippocratics. Their therapeutic perspective was replaced by one that in the view of Holmes used "painful, uncertain or dangerous" remedies applied to great excess to tame and overcome disease, and produced a community of patients who were "overdosed." The public embraced this approach to treatment. "The popular belief," Holmes noted, "is all but universal that sick persons should feed on noxious substances. One of our members was called not long since to a man with a terribly sore mouth. On inquiry he found that the man had picked up a box of unknown pills, in Howard Street, and had proceeded to take them; on general principles, pills being good for people. They happened to contain mercury, and hence the trouble for which he consulted our associate." Holmes so greatly despaired over this problem that he stated: "Ifirmlybelieve that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,-and all the worse for the fishes" (9). Today the ideology of mastering nature through learning its secrets continues to flourish, with the ICU perhaps the most characteristic expression of this view. Beliefs persist, as in Holmes' day, that cause us to use the ICU and therapies like it to excess - a technologic overdosing unchecked by adequate boundaries of appropriateness. THE GROWTH OF PHYSIOLOGIC MONITORING

Technologies that capture fleeting physiological changes in the body have been needed to support a fundamental requirement of ICUs—the continuous monitoring of critical body functions. In this regard heart and circulatory action has been a major focus of research. Of particular significance was the work of Etienne-Jules Marey who, in 1860, described a device called a sphygmograph. It had a level, one end of which was INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:3, 1992

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placed on the patient's artery and the other end connected to a pen in touch with a strip of smoked paper revolving before it. The result of its use was a graphic display of both the beat of the heart and the movements it caused in the artery. Before this invention, these phenomena were apparent only to the doctor's subjective touch (4;20). The tracing appeared, among other things, to detect pathology in the heart and vessels and the effects of drugs on the patient (14). The sphygmograph was cumbersome to apply, and controversy ensued over the meaning of changes in its graphic notations. While, for these reasons, it failed to gain widespread acceptance, it nevertheless prepared the way for the electrocardiograph, introduced in the early twentieth century. It recorded graphically electrical changes in the heart and became a standard modern instrument in evaluating cardiac structure and function. The transformation of heart and pulse data from subjective reports to objective representations meant that groups of doctors could evaluate clinical evidence that was known before only to the individual who was sensing them. It meant too that the symptoms of a disease could be described with a precision through graphic depiction (and its easy numerical conversion) which the characterization of evidence in descriptive, adjective-laden phrases could not provide. Using the machine rather than the person as sensor augured a medidal future in which dependence on varying human capabilities to detect medical evidence would be replaced with the trustworthy gathering of data by unvarying and tireless machines. Significantly, this particular kind of technology provided a continuous rather than an intermittent record of the physiologic status of the patient, although it was taken over a short span of time to make diagnostic observations rather than to monitor illness. However, the graphic form in which its evidence was inscribed did provoke change. Until the nineteenth century, clinical observations of the patient tended at most to be made once a day (often less) when physicians visited the bedside and recorded clinical data in the patient's record. By the last third of the nineteenth century, charts in the form of graphs began to be kept in patient records by nurses in which the temperature, pulse, and respiratory rate were recorded several times a day. The graph produced by connecting the data points of the intermittent observations of these vital signs depicted their course in a time-dependent way. Such graphic depiction thus became a significant way to characterize data in medicine (20). But the intermittent observation of patients, even by connecting the data points and creating graphs, still had several significant shortcomings in relation to the very sick patients for whom the ICU would be intended. This mode of recording missed fleeting changes in critical physiologic indicators of the patient's condition. Further, such random sampling of clinical data failed to detect the basic rhythmic changes in the physiologic functioning of the body. Finally, reliance on the nurse, already overburdened with other duties, to record intermittently the changes in the patient's body functions through periodic measurements of temperature, pulse, respiration, and other measures added in the twentieth century, such as blood pressure, led to errors both in taking the observations and charting them. The space exploration program of the United States greatly furthered advances in continuous physiologic monitoring, which had been developing throughout the twentieth century with the electrocardiograph (introduced in 1901) and the electroencephalograph (emerging in 1929) leading the way. By the early 1960s it was possible, without elaborate wiring, to transmit data from machines that were hooked up to people, to monitors far away. This capacity was needed to observe the effects of space travel on

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the physiologic functions of animals and astronauts, such as their heart rates and rhythms and blood pressure (19). But a significant problem had to be overcome for continuous monitoring to be useful, even when its findings were accurate. What was an observer to do with the tremendous amount of data that the automated system generated? How could one follow the second-by-second account of physiologic activity transmitted from multiple sites on the body? Further, and more perplexing, how could one do so in the brief time that is available to treat a patient in whom such recorded physiologic changes augured medical emergencies? Computers provided an answer. In the 1960s, the computer was introduced into clinical medicine. This decade was a time when information overload was being felt in all branches of medicine. Health care technologies were spawning ever larger amounts of data, and the computer was looked to as a means of solving this crisis of excessive evidence. For the problems of analyzing the evidence of monitored functions and alerting, through alarm devices, clinical personnel when critical changes occurred, the computer was ideal. Thus with the computer and physiological data-gathering technology linked in the 1960s, the monitoring and diagnostic bases of the ICU were in place. DEVELOPING THE TECHNOLOGY OF THERAPEUTIC RESCUE

Matching the technology of monitoring in the development of the ICU was the growth of a technology of rescue—technologies that sustained vital physiologic functions during a time of medical crisis. Some of the earliest and most publicly visible technologies to rescue seriously injured people dealt with the maintenance of breathing. The technologies used basically fell into two classes: those applying a positive pressure to bring air directly into the lungs, and those producing a negative pressure about the body that caused the lungs to expand with air. One of the earliest accounts of a positive-pressure technique of respiration is found in Vesalius' 1543 work on anatomy, De humani corporis fabrica. In it he describes an experiment with an animal in which breathing was maintained with a bellows by the rhythmical inflation of the lungs (5;23). In the nineteenth century, rescue workers in England used this technique. They were supplied with tubes and bellows to force air into the lungs in emergencies, as for example when people were drowning. However, these positive-pressure techniques were shown to be dangerous, particularly when used to excess by the rescue workers, and thus they were discarded. This problem directed efforts toward machines that created negative pressures. Tank respirators enclosing the body of the patients were developed beginning with one invented in Scotland by John Daziel in 1832. These machines generally worked by having the body-enveloping tanks attached to bellows or syringes that produced negative pressures in synchrony with inspiration. But the technology was largely ineffective (11). In the twentieth century, positive-pressure techniques using tubes and manual ventilation were developed to sustain patients who were undergoing thoracic surgery during the several hours that it took. But these operating-room techniques were only partially successful in meeting even short-term operating room needs; they were wholly inadequate to deal with the long-term requirements of patients with respiratory damage. Of special concern were those patients who had acquired respiratory paralysis during the epidemics of poliomyelitis that swept the world, particularly its children, in the early twentieth century. Their plight greatly distressed clinical personnel. "Of all the experiences the physician must undergo," wrote one, "none can be more distressing

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than to watch respiratory paralysis in a child with poliomyelitis—to watch him become more and more dyspneic . . . silent, wasting no breath for speech, wide-eyed, frightened, conscious almost to the last breath" (15). It was in response to the suffering caused by these epidemics that in 1929 Philip Drinker, an engineer, and Charles McKhann, a physician, developed at the Peter Bent Brigham Hospital in Boston a tank respirator that cycled from positive to negative pressure and employed an electric pump to create this negative pressure or vacuum. Using it, they were able to support the breathing of an 8-year-old patient with poliomyelitis for 122 hours—a record at that time (2). The Drinker/Shaw iron lung, as it was often called, diffused quickly although its results were not always good. It was not effective in treating the severe bulbar form of the disease, although it was in the milder version, and its use was hampered by personnel and ethical problems. Some hospitals lacked adequate nursing care for the patients on the iron lung and physicians experienced in applying it. Delays occurred also in bringing patients to the machine due to the ethical quandary faced by physicians who read reports of difficulty in weaning patients from the machine and worried that they might forever imprison their patients within it. Despite these problems, shortages of the machine existed and produced another ethical dilemma, this one concerning allocation. Doctors were having to choose between giving it to patients who were more seriously ill but with a diminished chance of survival, as opposed to patients whose prognosis was better (15). Such problems with iron-lung therapy provided an impetus for continued work in finding more dependable means of assisting damaged respiratory capability. A watershed was the 1952 polio epidemic in Copenhagen, at the beginning of which 27 of the first 31 patients treated at the Beegdam Hospital died. With the death of the 28th patient, H. C. A. Lassen, the chief epidemiologist of the hospital, called senior anethesiologist Bjorn Ibsen from the operating room into the clinic to give patients the benefit of the techniques of respiration he used during surgery. The anesthesiologist applied intermittent positive-pressure ventilation with a manually squeezed ventilation bag attached to a cuffed endotracheal tube and a tracheostomy. It was found superior to results gained with the iron lung, particularly in the bulbar form of polid, although quite demanding of people to keep the ventilation going. Indeed, during this crisis, the lives of 75 patients were maintained through the efforts of 250 medical students to do the ventilation, 260 nurses to take care of the patients* bedside needs, and 27 hospital workers to change the cylinders and control the technology (13). To accomplish it all, special wards were created to which polio patients likely to have respiratory complications were transferred for checking vital signs and therapy. The outcome of these efforts was a reduction of mortality from 87% to less than 40% (6). The distinctive role that nursing played in accomplishing this result would be carried on into the future development of the ICU, where nursing care would be even more important, in the minds of some, than its equipment (10). Both the success and large personnel needs of the Copenhagen therapy stimulated researchers to develop improved mechanical means of delivering the intermittent positive pressure. This produced in the mid-1950s new volume and time-cycled electrically powered respirators. They rapidly diffused in Europe and the United States and became a mainstay of the ICUs that would soon develop. Other technologies of rescue also were crucial for the emergence of the ICU, particularly to sustain cardiac and kidney function. Although the principles underlying electrocardiac resuscitation had been explored in the late eighteenth and nineteenth centuries, it was only in the 1930s that significant efforts to apply this knowledge to patients were made, notably by Albert Hyman. He placed a needle electrode through 386

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the chest and into the heart of 43 patients in cardiac failure and saved 14 of them. But the press roundly criticized his efforts. In 1956, Paul Zoll introduced the external defibrillator. This device and later versions marked a significant advance in restarting the heart. In 1960 W. B. Kouivenhoven announced a new technique of external cardiopulmonary resuscitation (CPR) that required rhythmic breathing into the mouth of the patient, combined with pressure on the lower sternum. It proved effective in staving off immediate death. Thus as the decade of the 1960s began, essential techniques of combatting the cessation of heart action were in place (11). Research on the clinical therapy of kidney failure occurred through early twentieth century efforts to build a machine to remove waste products from the blood. Lack of an adequate filtering medium and of a means to prevent blood clotting caused these efforts to fail. In the early 1940s in research that he conducted while the Nazis occupied Holland, Willem Kolff produced the first successful dialysis machine, using heparin as an anticoagulant and cellophane as a filter. His technology consisted of long cellophane tubes through which the patient's heparin-treated blood flowed. The tubes were bathed in a liquid contained in a large metal drum. Kolff treated 16 patients in acute renal failure with the device in an effort to temporarily support them until normal kidney function returned. They all died. However, he sustained the seventeenth patient (a woman) for 11 hours: long enough for her to achieve recovery. Kolff reports, whimsically, that upon waking after the acute episode was over, her first words were that she would divorce her husband, which she subsequently did (12). Kolff s dialysis machine was not used clinically after the war ended. In addition to continued difficulties with coagulation and filtration, a basic defect was a lack of an adequate portal connecting the machine and the patient, which is particularly essential for long-term use. This failing was overcome in 1960 when Belding Schribner at the University of Washington in'Seattle introduced a Teflon cannula and shunt that could be implanted permanently. This allowed the ready attachment and detachment of machine and patient, and converted the dialysis machine into a technology that was suited both to emergency use and chronic care for patients whose kidneys had failed. Like the iron lung, the shortage of kidney dialysis machines became a source of ethical controversy, as a selection of patients to use them was required (22). But with the introduction in 1960 of a successful dialysis machine, the technologies essential to maintaining critical organs of life-lungs, heart, and kidney-now were available when disease or injury threatened their function. THE DEVELOPMENT OF THE ICU AS A CLINICAL SPACE

The ICU as a territory that is designated for acute care evolved from spaces designed to deal with the postoperative care of surgical patients and the treatment of premature infants. The technologies of monitoring and the therapy of rescue transformed the use and goals of this space. The setting aside of spaces in hospitals for a range of special purposes has been an important feature of their development. For example, in some large medieval hospitals there were separate medical wards for men and women, as well as a specially designated area for childbirth. It was in the spirit of a functional division of medical tasks that Florence Nightingale in her 1863 work Notes on Hospitals (17) reports that many hospitals in Great Britain designated a small room next to the amphitheater in which operations occurred for the use of patients who were coming out of surgery and generally needed extra care. Unlike ICUs these recovery rooms were meant to keep patients INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:3, 1992

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for the few hours that it took to come out of anesthesia and deal with immediate postoperative disabilities. At this time surgical procedures had increased in number with the availability of good anesthetics, an era that was initiated by the introduction of ether in 1846. Toward the end of the nineteenth century another specialized area appeared in hospitals for a young population group—the premature infant. In France a decreasing birth rate led public authorities to seek ways to reduce the high mortality rate of infants. One result was the development of the first closed incubator for premature infants by two French obstetricians, E. S. Tarnier and P. Budin. Tarnier followed this innovation with the training of nurses to specialize in the care of these infants. At the same time, the link between bacteria and infection became understood with Robert Koch's 1882 demonstration of the bacillus causing tuberculosis. This discovery led to increased efforts to isolate premature infants from infections. By 1896 Budin had designed at the Maternite Hospital in Paris an isolation unit for premature babies—complete with sterilization procedures used on instruments, and nurses who were specially trained for assignment to it. By 1900 the Chicago Lyingin Hospital had in place a similar premature nursery. But it was connected with an ambulance incubator, which could more safely carry such babies delivered elsewhere to the hospital (11). During World War II the shortage of nurses and the consolidation of facilities and staff that it required led to the growth of premature nurseries, just as the same events encouraged the opening of some postoperative recovery rooms. Reports appeared documenting the benefits to patients of being sent to the recovery rooms after surgery, such as the quick detection of airway obstruction and postoperative hemorrhage. But the immediate postwar years of the late 1940s and early 1950s produced little interest in the recovery room despite its demonstrated benefits. Surgeons and anesthesiologists were enthralled by new drugs and therapies; the space within which they were applied seemed less significant (6). However, with the templates for special infant and adult care provided by the premature nursery and the recovery room now in place, events would move in separate tracks to create ICUs for these two constituencies. ICUs FOR INFANTS

At the end of World War II, the U.S. government provided assistance to train specialists and provide staff in all fields of medicine, among which was the care of the premature infant. The introduction of technologies for this care also increased: clear plastic incubators made enhanced observation of the infant possible, oxygen was used more aggressively to deal with respiratory difficulties, the introduction of microanalysis techniques permitted closer oversight of blood gases and acid-base balance, and the development of the APGAR index of respiratory status in the early 1950s helped to screen for infants needing the special help, help that was now made easier by improved respiratory-assistance techniques introduced into the therapy of premature infants from experience that had been gained in the treatment of polio (11). These therapeutic advances also helped to change the criteria of admission of these infants to special-care facilities from criteria based on birth weight and age to those based on severity of symptoms. Gradually, during the 1950s, the premature nursery moved from a supportive care mode designed to stabilize low birth weight infants to a more aggressive interventionist one, which treated all forms of illness in newborns in addition to those caused by prematurity. In this process the premature nursery became recast as the neonatal 388

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intensive care unit (NICU), and its new name and technologies began to diffuse among hospitals. Use of NICUs significantly decreased the mortality of very sick infants. The more aggressive interventions also spawned damaging conditions such as retrolental fibroplasia (a visual disorder produced by high concentrations of oxygen), and introduced cautionary notes into the use of intensive care (11). ICUs FOR ADULTS The General ICU

Three catastrophes, the Coconut Grove fire, World War II, and the epidemics of poliomyelitis, focused medicine on the significance of the organized space that would become the adult ICU. In 1942 a devastating fire occurred in the Coconut Grove night club in Boston. Severely burned survivors were rushed to nearby Massachusetts General Hospital, confronting it with an overwhelming therapeutic challenge. Fortunately, preparations that had previously been made to deal with possible civilian war casualties meant that a plan to handle the catastrophe was in hand. Staff physicians, surgeons, anesthesiologists, nurses, orderlies, social workers, and psychiatrists were formed into teams. The patients themselves were brought to units on the same floor, where staff and equipment could be concentrated to treat them. Thelessons of care learned from these patients helped military doctors in the war to better treat trauma and shock (11). . The war itself produced knowledge about acute injury amid the devastation wrought by it, for example on how to use blood with improved effect. The conflict also developed a greater sophistication in applying the idea of triage, derived from the French word trier, meaning to choose. Triage as a specific concept was used first in wartime conditions by Dr. Dominique Larey during the Napoleonic campaigns of the early nineteenth century. In triaging patients one applied rules to sort out who should receive priority in treatment. The selection of patients for treatment based on an appraisal of who would receive the most benefit from a given therapy is one concept upon which triage is based-and indeed it remains most significant in the clinical decisions of civilian life. Wartime produced other priorities upon which to base triage, such as service to the nation. Thus when penicillin first became available to the military in 1943, it was given to men who were disabled with venereal disease rather than those who had been wounded in battle. The former could be cured more quickly than could others who were more seriously injured and hence returned to the battlefield sooner; venereal disease also represented a threat to others because it is contagious, and thus a hazard to the war effort (1). Here the benefit to society of winning a just war became the value dominating triage. The war's end brought much attention and resources to health care. In the United States, for example, in addition to the socially subsidized specialized training for physicians, hospital construction was furthered by funds designated under the 1946 HillBurton Act. The new skills and technology being created dovetailed with wartime understanding of the organization of facilities and the application of the technologies that were needed to handle serious injury. The polio epidemics of the late 1940s and early 1950s, such as the 1952 Copenhagen episode, had spurred the reintroduction of positive pressure ventilator techniques and generated polio wards to facilitate technologic and nursing assistance to victims. They also led, in Europe and the United States, to the creation of designated spaces in the hospital for respiratory therapy. This was due in part to a view that the technology and skills acquired in the treatment of polio should be harnessed and applied to patients with other respiratory disorders. It also was engendered by the presence INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:3, 1992

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of unused therapeutic space. After the polio vaccine introduced by Jonas Salk had greatly reduced the annual number of the disease's victims by the mid-1950s, many of the facilities that had been used to treat polio now had no function. It was decided that some should become centers for managing other respiratory crises such as those occurring in head and chest injury, drowning, and cardiac arrest (15). In 1958 in Toronto, and Southampton, England, for example, units that were devoted to respiratory failure opened. While focused on the disorders of a single organ, they so closely resembled the general ICUs that would emerge at this time that for all intents and purposes they may be classified as adult ICUs. These units had a high concentration of medical staff functioning as a team, who closely monitored clinical signs and made rapid therapeutic responses to changed clinical states—the essence of modern intensive care. By the late 1950s and early 1960s the experiences in organizing the personnel and resources to handle critically ill patients merged with the growth of the technology of monitoring and therapy (such as those described earlier) to create in Europe and the United States the modern adult, general purpose ICU. Early ICUs opened in Baltimore and Uppsala in 1958. The subsequent development of ICUs was influenced not only by technology but also by the mechanisms for hospital payment. In the United States, for example, the prevailing method of insurance reimbursement to hospitals permitted billing to be done after the care was given. When in 1965-66 the federal government began to pay for the health services of the elderly and poor through the Medicare and Medicaid programs, this broadened patient population now receiving financial access to the health care system expanded the ability of hospitals to purchase the latest technologies and charge them off as part of the costs of care. This provided a significant stimulus for American hospitals to develop ICUs. The Specialized ICU

At the same time that general ICUs were evolving, ones that focused on coronary care appeared. Cardiac surgery first drew attention to such care. In one hospital its development was linked to the specialized skills of nurses, indicating, as the Copenhagen polio experience had, their significance for the modern ICU. A physician describes the events: A large room was converted to a daytime surgical recovery room in 1956. Patients following heart surgery, who tended to be sicker than the usual population, increased the work of the recovery room. Usually they had special private duty nurses in their rooms around the clock for the first days. It became standard for the first special nurse to work with the patient in the recovery room, and early it was recognized that the patient's prognosis was correlated with her skill and experience. The cardiac surgeons tried hard to hire special nurses who had worked with their previous patients and as a result, there developed a group of nurses with considerable experience in the postoperative care. Respirators were not yet available and respiratory failure was not clearly recognized as a temporary malfunction which could be alleviated by mechanical ventilation. Few functional measurements other than blood pressure were available; many diagnoses were based in intuition, experience, or subliminal perception. This made good nursing observation extremely important. It was a long and difficult political struggle within the hospital to establish a core of fulltime nurses, paid by the hospital, to replace the private duty nurses. The recovery room became, in effect, a special care center, but not as a result of any clear plan or sudden insight. Rather, it was the result of a sometimes bitter struggle to solve one small but knotty problem after another, often against the tide of current medical opinion. (6).

This account thus reveals, with other evidence previously cited, that the general and specialized ICU grew by accretion in modest steps to solve particular problems, rather than as a result of a grand, preconceived vision. 390

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In 1962 units devoted to heart disease patients, such as those having myocardial infarction, opened in Philadelphia at the Presbyterian Hospital, in Kansas City at Bethany Hospital, and in Toronto at the Toronto General Hospital. They concentrated efforts on heart monitoring, cardiopulmonary resuscitation (CPR), and the defibrillation of cardiac patients. Early experience in these coronary care units (CCUs) showed that the existence of a space for intensive care and of technology that was effective in monitoring and treating life-threatening conditions were not enough for success. Without good protocols to direct their use, the technologies and staff were ineffective. Hence, early evaluation at the CCU in Toronto showed that it produced only small gains in mortality from previous care. This failure was traced to the therapeutic delays inherent in the initial written protocol, which instructed nurses how to proceed when cardiac arrest occurred. Among other things, the protocol required the nurse first to call a physician, next to wheel the patient, while still in bed, to the nurse's station to shield other patients in the CCU from witnessing resuscitative efforts, and then to place a board under the patient's chest. All of this had to occur before the actual efforts at resuscitation could occur, which even then could be thwarted if a defibrillator was not available. Revisions of procedure in this and other hospitals—which involved shifting control of CCUs to cardiologists, educating" house staff and attending physicians about the procedures, changing protocols to improve their efficiency, and retaining patients longer (for example, several days after the disappearance of the last major arrhythmia)—all acted to improve the outcome. Thus at New York Hospital an initial mortality drop over standard care of about 3% (32% to 29%) when its CCU began (its inefficiencies were comparable with Toronto's) was lengthened to a difference of about 20% when these improvements occurred (6). The success of these early general, respiratory, and coronary units in staving off death led during the 1960s to the spread of ICUs to over 95% of all acute care hospitals in the United States (11). Although World War II and the Korean War in the 1950s had demonstrated the significance of a good system of transporting the injured person to the site of acute care, these events had left the civilian ambulance system in many countries basically unaffected. In the early 1960s, for example, American ambulances continued to be largely regular model cars, such as Cadillacs. They were narrow, low, and did not permit medical personnel the space to stand and shift around in therapeutic efforts. These spatial limitations also hindered the placing of much equipment in them. The ambulance attendants themselves generally were given little formal education in emergency care, and thus could make mistakes that created additional injury. Furthermore, the communication between ambulance and hospital was poor, so that the hospital often was unaware of the condition of the patient who was being brought in. These limitations were explored in a 1966 study by the National Academy of Sciences in the United States, "Accidental Death and Disability: The Neglected Disease of Modern Society." It brought attention to the large influence that trauma had on disability and death, particularly among young adults. In this same year, the U.S. Congress passed the Highway Safety Act. It provided training and funds to improve the personnel, technology, and planning of the emergency care transportation system (3). Now the ICU was the center of a hub, whose ambulance-formed spokes radiated outward to bring an even larger population to it. Ethical and Legal Issues of the ICU

To this population, the ICU increasingly became a symbol of the best therapy that the high technology medicine that was blossoming in the 1960s had to offer. Concentrated in the ICU space were machines that seemed capable of substituting for any INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:3, 1992

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body part or function. This technologic armory seemed strong enough to keep death at bay, while skilled clinicians took the steps to remake patients as they were. In the United States, this led the public to expect increasingly that any serious medical event should, logically and humanely, be accompanied by an effort at ICU rescue. Allied with these public expectations in the United States were legal pressures that caused physicians to apply ICU therapy to excess. While medicine remained driven by the ethos of subjugating nature, which induced many doctors to remain indomitable in the face of life-threatening illness, legal anxieties pushed them further into therapy than they often wanted to go. Physicians feared that failure to try the most hightechnology form of medical rescue, represented by the ICU, even when it offered virtually no hope of success, would open them to claims by the patient or family that appropriate therapy had not been given, and thus to legal penalty (21). Such actions by the public and the clinicians also mirrored their uncertainty about how to analyze the ethical considerations of applying, withholding, or withdrawing intensive care. Taken together these social, legal, and ethical issues, along with the new technological capabilities, greatly increased the time that patients spent in ICUs. Thus the ICU increasingly became a place for long-term care rather than the brief intervention and stay that characterized the premature nursery and postoperative care units from which it had evolved. This lengthening of stay was particularly advanced by a series of complicated ethical issues surrounding the use of intensive care. They had been present virtually from its beginning, in the late 1950s as essentially respiratory therapy. In 1958 positive-pressure respiratory care was available in hospitals throughout Europe, including one in Vienna that was overseen by the chief of anesthesiology, Dr. Bruno Haid. As he applied this technology to patients suffering from stroke, drug overdose, coma, and other ailments, he was gratified that in many instances it provided critical support to physiological function, giving it time to recover and so to restore the patient's health. Yet in a number of cases he found himself perplexed. With the breathing machines in place, these patients were saved from death. But as days, weeks, or months went by, the picture emerged of people who never would recover. They would remain suspended between life and death, in a state of lingering that the respirator seemed to ensure was permanent. Both medical staff and families gathered around the bedside of these patients, ethically confused. They had questions: Should the respirator, having been put in place to sustain life, be removed to end it? What values should be introduced into this question? By whom? Who had priority and right of decision? Family? Physician? Courts? Others? This puzzlement led Dr. Haid to write a letter to Pope Pius XII in which he related these concerns. He told the Pope that the ethical issues of applying the artificial respirator were more difficult to decide than the technology issues concerning its use. Medical traditions, he said, did not offer adequate guidance, and so he turned to religious authorities for help. The response of Pius XII was measured. He too was greatly troubled by these issues and unsure if his views were adequate to meet them. But he would try. He declared as he reflected on his religious tradition that neither physicians nor families were obliged to continue aggressive treatment of patients whom the therapy could not benefit and whose prognosis was death. Withdrawal was morally acceptable. He declared that "human life continued as long as its vital functions—distinguished from the simple life of organs—manifested themselves" (18). His letter said other interesting things too numerous to detail here. It had great significance as one of the first major published analyses of the ethical questions raised by intensive care and the technology of rescue. 392

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The unfolding and ambiguities of the ICU

As the 1960s ended, the time at which this essay concludes, ethical issues concerning the purpose and scope of intensive care continued to be raised. They were made more urgent by the financial costs of this care, which had become the most expensive form of medical therapy. CONCLUDING REMARKS

Intensive care is a symbol, a space, a technology, a clinical concept, an ethical imperative, a last resort. It attracts, it repels. It burdens, it helps. It bankrupts, it enriches. We would not give it up, but at times we wish we could. To some its machines sound a reassuring refrain; others hear it as a siren's song whose heartening meter will eventually become a dirge. The reaction of patients who are the recipients of intensive care, of family who are its reluctant observers, of staff who are its labored agents, and of society who is its uneasy supporter betoken ambiguity: about selecting and removing patients from it, about the criteria of its success (discharge alive, length or quality of life after therapy), about its means and ends, its inputs and outcomes. Are they appropriate and proportional? All are matters to assess as the technology and presence of intensive care grows. REFERENCES 1. Beecher, H. K. Scarce resources and medical advancement. In P. A. Freund (ed.), Experimentation with human subjects. New York: George Braziller, 1970, 105-15. 2. Drinker, P., & McKhann, C. F. The use of a new apparatus for the prolonged administration of artificial respiration. Journal of the American Medical Association, 1929,92,1658-60. 3. Eliastam, M. Action with dispatch: Technology in the emergency department. In S. J. Reiser & M. Anbar (eds.), The machine at the bedside. New York: Cambridge University Press, 1984, 105-18. 4. Floyer, J. The physician's pulse-watch. London: Sam. Smith and Benj. Walford, 1707. 5. Grenvick, A., Eross, B., & Pouner, D. Historical survey of mechanical ventilation. International Anesthesiology Clinics, 1980, 18, 1-10. 6. Hilberman, M. The evolution of intensive care units. Critical Care Medicine, 1975, 3(4), 159-65. 7. Hippocrates. Epidemics II. In W. H. S. Jones (trans.), Hippocrates I. Cambridge, MA: Harvard University Press, 1923. 8. Hippocrates. The art. In W. H. S. Jones (trans.), Hippocrates I. Cambridge, MA: Harvard University Press, 1923. 9. Holmes, O. W. Currents and counter currents in medical science. In O. W. Holmes, Medical essays. Boston, MA: Houghton, Mifflin and Company, 1833. 10. Jennett, B. High technology medicine. Oxford: Oxford University Press, 1986. 11. Koch, E. B., & Reiser, S. J. Critical care: Historical development and ethical consideration. In I. A. Fein & M. A. Strosberg (eds.), Managing the clinical care unit. Rockville, MD: Aspen Publishers, Inc., 1987, 3-20. 12. Kolff, W. First clinical experience with the artificial kidney. Annals of Internal Medicine, 1965, 62, 608-19. 13. Lassen, H. C. A. Preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen. Lancet, 1953, i, 37. 14. Marey, E.-J. Researches sur lepouls au moyen d'un nouvel appareil enegistreur, le sphygmographe. Paris: E. Thunot et Cie, 1871. 15. Maxwell, J. H. The iron lung: Halfway technology or necessary step? The Milbank Quarterly, 1986, 64, 3-29. 16. Newton, I. Opticks: A treatise of the reflections, refractions, inflections and colours of light, 4th ed. New York: Dover Press, 1952. 17. Nightingale, F. Notes on hospitals, 3rd ed. London: Longman, 1863. INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:3, 1992

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Reiser 18. Pope Pius XII. The prolongation of life. The Pope Speaks, 1958, 4, 393-98. 19. Radcliffe, G. The necessity of physiological monitoring in the general hospital. Transactions of the New York Academy of Sciences, 1960-61, 23, 52. 20. Reiser, S. J. Medicine and the reign of technology. New York: Cambridge University Press, 1978. 21. Reiser, S. J. Malpractice, patient safety, and the ethical and scientific foundations of medicine. In P. W. Huber & R. Litan (eds.), The liability maze: The impact of liability on safety and innovation. Washington, DC: Brookings Institution, 1991, 227-50. 22. Sanders, D., & Dukeminier, J. Medical advance and legal lag: Hemodialysis and kidney transplantation. UCLA Law Review, 1968, 15, 366-68. 23. Vesalius, A. De humani corporis fabrica libre septem. Basel, 1543.

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