It was my first ICU call shift as a second-year resident, and my first time holding the code pager, which rested, quiet but not quite forgotten, in my scrub top pocket until around 10 p.m.

The overhead speakers blared to life just as the pager began to beep. I ran to the cardiac ICU, forgetting my carefully organized ACLS cards on my call room desk. The patient was a middle-aged male post-cath after a large MI, and the code lasted over an hour, until the ICU fellow, who I hadn’t noticed enter the room, put a hand on my shoulder.

“He’s gone. Time to call it.”

Although my job no longer includes code leader, I, like many in medicine, struggle with the uncertainty of calling “it.” “It” reflects that tipping point when further medical intervention does more harm than good. “It” is a vague gray area which escapes board exams and lecture halls, where the questions and cases we train with suggest more straightforward decision-making than real-world medicine allows. The physician who recognizes “it” realizes when the most beneficent path forward involves pulling back on medical interventions potentially causing harm, rather than forging ahead at all costs.

“It” represents the point when “could” isn’t the same as “should.”

Sometimes, the tipping point is clear, and the decision is made for us (consider the patient presenting during a different ICU shift via paramedics with his scalp, and exposed brain, half missing). At other times, though, we may question whether, and when, and how, it is the best decision to call “it.” Two ICU shifts after my initial code blue, I struggled to convey the seriousness of a patient’s condition to the family. Did they have to come in overnight? I timidly suggested they “should” but didn’t “have to,” in part due to my own discomfort and shared hope for a miraculous improvement. The patient passed away after a short-lived attempt at intubation and resuscitation an hour before his family arrived in the morning.

I hesitated to call “it.” Or even recognize “it.”

Certainly, part of recognizing “it” is experience. Since those ICU days, I have learned warning signs of death, of deteriorating conditions, some of them physical, some of them medical lore, such as a patient seeing deceased loved ones or telling medical staff that they will be dying soon.

However, “it” remains a heavy responsibility in less dramatic circumstances, too. Consider my current field of oncology. At what point does further treatment do more harm than good? Or might I go further to say, at what point does further treatment help the physician’s unease and need to feel useful, rather than improve the patient’s condition? Ongoing cancer treatments may have psychological benefits for patients when physical benefits are no longer seen, but are we truly doing what is best for patients in situations where we continue treatment despite lack of benefit (and, indeed, evidence of harm)?

Many in oncology understandably hesitate to call “it,” and still more wait until those telltale signs of imminent death present themselves. Again we return to experience. I was fortunate to train at several small, clinically heavy, education-conscious institutions, where I witnessed many patients transition from minimally symptomatic to sick, sicker, and death. However, I think there is also a component of comfort, with oneself, with one’s limits, with one’s own mortality. This is hard to develop, and even harder to teach.

Yet, I think it is crucial for physicians, especially those working in areas where calling “it” can affect patient outcomes, quality of life, and family experience. The uncertainty around “it” also extends into other aspects of medicine. Consider the numerous options for complementary and alternative medicines (CAM) in oncology, many of which do not have the body of evidence and research which standard Western medicine options aspire to. We cannot be certain that an herb or ancient technique lacks anti-cancer properties completely. However, some patients have the luxury of time and health to see whether such techniques will help. Others do not. Still others may choose to pursue CAM instead of standard Western medicine after an informed discussion and reflection.

The physician who has become comfortable with calling “it” can have these individualized discussions with patients about the risks and benefits of CAM, considering disease state, time factors, comorbidities, urgency of treatment, symptoms, patient values and priorities, and available Western medicine alternatives. There are times when Western medicine fails (such as liver failure from a rapidly progressive cancer). There are times when Western medicine falls short (such as treating fatigue after cancer treatments). These may be excellent spaces for CAM. Other patients may opt for CAM in spaces with standard options as well, but the process of striking the balance between respecting patient autonomy and providing sufficient education for patients to make a choice is reminiscent of the process of recognizing and calling (discussing?) “it.”

As time has passed, I have become more comfortable recognizing the point of when “it” arrives; however, actually calling “it” has not become easier. I still feel the same wave of emotions I felt that night in the cardiac ICU. Grief, powerlessness, regret, self-blame. I have gone through the steps of acknowledging mortality, understanding the life-and-death cycle we all face, and recognizing the limits of medicine’s power. This does little, however, to ease the sting that dropping the hammer and calling “it” brings. Perhaps this is simply part of being human, and a piece I have had to carve space out for, instead of avoiding or removing.

Perhaps it is a sign that, when calling “it,” I am mapping the way forward not just for a patient and their family, but for myself as well.

Beatrice Preti is an oncologist.