Hazel's ICU stay

Hazel Grace Lancaster's ICU stay in early April is a medical crisis triggered by fluid accumulation in her lungs, which nearly kills her and forces a reassessment of her treatment and her relationship with Augustus Waters.

Causes and Background

Late in the winter of her seventeenth year, Hazel's mother decided she was depressed, presumably because she rarely left the house, spent quite a lot of time in bed, read the same book over and over, ate infrequently, and devoted quite a bit of her abundant free time to thinking about death. Her mother insisted she attend a weekly Support Group, where she met Augustus Waters. Hazel's cancer—Stage IV thyroid cancer with metastases in her lungs—had been managed by the experimental drug Phalanxifor, which had kept her tumors stable for eighteen months. But the underlying disease remained incurable, and her lungs were chronically compromised, requiring two liters of oxygen per minute through a cannula. The night before the crisis, Hazel had been thinking about Caroline Mathers, Augustus's ex-girlfriend who died of brain cancer, and had told her parents she felt like a grenade, destined to hurt everyone she loved. She went to sleep with a headache, and at just after four in the morning, she awoke with an apocalyptic pain fingering out from the unreachable center of her head.

What Happens

Hazel screamed to wake up her parents, who burst into the room, but there was nothing they could do to dim the supernovae exploding inside her brain, an endless chain of intracranial firecrackers. She thought she was once and for all going, and told herself that the body shuts down when the pain gets too bad, but she did not slip away. She was left on the shore with the waves washing over her, unable to drown. Her father drove, talking on the phone with the hospital, while she lay in the back with her head in her mother's lap. All stimuli made the pain worse; the only solution was to try to unmake the world, to make it black and silent and uninhabited again. People talk about the courage of cancer patients, but in that moment, Hazel would have been very, very happy to die. She woke up in the ICU, alone because the hospital does not allow family to stay 24/7 due to infection risk. She could hear wailing down the hall—somebody's kid had died. A nurse named Alison came in and introduced herself. When her parents came in, crying and kissing her face repeatedly, they told her she did not have a brain tumor; the headache was caused by poor oxygenation, which was caused by her lungs swimming in fluid. A liter and a half of fluid had been successfully drained from her chest, leaving a tube that went from her chest into a plastic bladder half full of liquid that resembled her father's favorite amber ale. A total body PET scan showed no tumor growth and no new tumors; her shoulder pain had been lack-of-oxygen pain, heart-working-too-hard pain. Dr. Maria said she remained optimistic. Hazel's mother told her, "This is just a thing we can live with." Hazel stayed in the hospital for six days, six undays of staring at acoustic ceiling tile and watching television and sleeping and pain and wishing for time to pass. She did not see Augustus or anyone other than her parents. Her hair looked like a bird's nest; her shuffling gait like a dementia patient's. Each sleep ended to reveal a person who seemed a bit more like her. On Friday, Dr. Maria told her she was good to go. Hazel took her first shower in a week, got dressed, and was so tired she had to lie down and get her breath. Augustus came to visit, and she told him she didn't want him to see her like this. He said he missed her, and she admitted she missed him too, but she didn't want him to see all this. She told him, "If we're gonna hang out, it has to be, like, not that." He told her the bad news was they couldn't go to Amsterdam until she was better, but the good news was that while she was sleeping, Peter Van Houten had shared more of his brilliant brain with them—a letter that convinced Hazel to ask Dr. Maria if international travel would kill her.

Consequences and Aftermath

The ICU stay forced a Cancer Team Meeting a couple days later. Dr. Maria led the meeting, and the team discussed the fluid accumulation problem. Dr. Simons noted that most tumors eventually evolve a way to grow in spite of Phalanxifor, but since there was no tumor growth on the scans, it wasn't that yet. The thought was that Phalanxifor might be worsening the edema, but discontinuing it would cause far more serious problems. Dr. Maria said they didn't really understand the long-term effects of Phalanxifor, as very few people had been on it as long as Hazel. They decided to stay the course but do more to keep the edema from building up. Hazel asked about a lung transplant, but Dr. Maria said she would not be considered a strong candidate. Her father started crying. Hazel asked if she could travel to Amsterdam; Dr. Simons laughed, but Dr. Maria said, "Why not?" and argued that they've got oxygen on the planes. Dr. Simons objected, but Dr. Maria shrugged and said, "It would increase some risks, but it's your life." On the car ride home, Hazel's parents agreed she would not be going to Amsterdam unless and until there was medical agreement that it would be safe. But later, Dr. Maria called and made a convincing case that Hazel needed to live her life, and the trip was back on. Hazel texted Augustus: "Still free May three? :-)" He replied, "Everything's coming up Waters." She looked down her blouse at her chest and whispered to her lungs, "Keep your shit together." The ICU stay also deepened Hazel's understanding of herself as a grenade—a person whose death would inevitably hurt those she loved—and it set the stage for her eventual acceptance of Augustus's love and her own desire to live fully, even within the numbered days. The experience of being alone in the ICU, hearing the wailing of another child's death, and the subsequent Cancer Team Meeting reinforced her awareness of her own mortality and the precariousness of her existence, but also her determination to seek meaning and connection before the end.