As a chaplain in a Level One Trauma Center, I find it disappointing that the doctor didn't think to call in a chaplain to provide care to the patient's wife. In our hospital, chaplains respond to all Code Blues, and our first task is to locate the family. In cases where the family has been asked to remain, the patient's experience of CPR was appropriately ended at the family's request.
I don't understand how bringing family members "on morning rounds" conforms to HIPAA rules. You bring strange civilians into other patients' rooms to hear about their medical conditions?
1
@Cunegonde Misthaven, I believe you've misunderstood the point. The family is included in the discussions regarding only their own loved one.
2
If it "seemed clear he wasn't going to live" why in the world did you put him through the torture of another resusitation? Why was there not a conversation earlier with the wife about the reality of his situation so she could make a decision about whether to put him through this again? To me it just isn't right to do all this worthless torture for no good reason. (And yes, my Power of Attorney for Healthcare is in order with clear instructions to my daughter, brother and son-in-law that I am never to be through this kind of useless "heroics". )
@BA Unless the patient has been made a DNR by the health care surrogate, the medical team is required by law to use all measures. It's unclear in this context why the patient had not been made a DNR. In my experience, families are often reticent to make their loved one a DNR (regardless of age) because they don't want to "give up hope." The TV portrayal of CPR has created a false security and understanding of how brutal CPR is, and how often ineffective it is in returning patients to their baseline health even if successful.
My mother was recently treated in the ICU as Mass General in Boston. The team there always involved me in rounds and then returned to answer any questions I may have had. I knew that my mom was not going to make it, and they were there to help her clarify the decisions she wanted to make. I was so, so grateful for the care my mother, and my family received. The nurses and doctors made us all feel empowered and supported. We were with her when she passed and it is a blessing that we were allowed to be part of her passing.
Our culture unfortunately tends to sanitize death and treat it as something to be feared. Our death is part of our life and we will all complete our life with our death. Our loved ones can be a great support in this final journey. That being said a code scene is not for everyone. Years ago working in a pediatric ICU one of my patients coded in the midst of a leukemic crisis. I will never forget his parents standing to the side urgently calling his name and telling him to hang on. He survived.
5
When I was 22 I had to be taken to the ICU due to complications during a surgery. I had to be put in a comma after a couple of days, the worst part was feeling was knowing I was dying by myself away from my loved ones (they were almost never allowed in there but I knew they were outside the unit). That was one the aspects that made it so horrible. Although I fully recovered after a year or so, I was diagnosed with PTSD not only for the close encounter with death but also from the isolation I experienced during those days. I hope ICUs all over the world would consider this - we should be able to die (or fight to stay alive) with our family/loved ones close by.
8
Every EMT in the country who reads this article will sigh and rolls their eyes at the naivete. We've been doing CPR in front of families for years. We don't get to limit visitors or control the audience in their own home, so it can be entire extended families, never mind a short list of approved visitors in an ICU. No harm comes from it. Life and death happen, and when people see how much sincere effort goes into saving their loved one, I believe it leaves them reassured and with a sense of closure they'll never get from a doctor coming to deliver the news after the fact in a "family room."
12
I am very grateful the hospital allowed me to be present when my husband went into cardiac arrest. I was at a distance, but could see clearly what they were trying to do. He was not aware of my presence, but it was important to me to stay with him. He lived another five months, but was never well enough to come home. Our children and I were with him when he died. I don't know if he knew we were there, but I hope so.
5
@Barbara I am sorry for your loss. I think you and your kids did a wonderful thing by being there to ease your husband's transition into whatever comes next. I wish all of you the best.
5
What a wonderfully written story! I'm sad to say that, as a nurse, I was involved in many "code blues" over 35 years of practice and never once experienced this type of real life.
Perhaps my older years have given me a vision of life to say that family members be given the option to witness these last final, but fleeting tender moments . We, as health care providers, work our fingers to the bone to care for the critically ill and their families. This kindness should be included in "code" protocols.
10
Many of the details of my father's death still escape me. His cardiologist wheeled Dad's gurney onto the elevator with me for yet another test. Between floors, he suffered his final heart attack. We were stopped at several administrative floors without a crash cart. Finally, the gurney, with Dad and his doctor, were pulled off the elevator by a large group of nurses and doctors who spent the next 45 minutes trying to resuscitate him. Too long I thought, but somehow, I did not feel I could tell them to stop. A nurse told me I did not need to stay because I should not remember him this way. I could not believe she wanted my father to die alone, only amongst strangers. I rubbed his feet between defibrillations, spoke to him to let him know how much I loved him and that he was a wonderful father and grandfather. I knew how much he missed my mother who passed away nine months previous. I hoped my presence eased him leaving this earth, knowing that he made a difference, that he was loved.
26
I'm not surprised to read that the author writes for a television show. Some are drawn to high drama.
I have been to many codes. Few succeed. Many go on far too long. One reason they go on so long is because some who run codes are drawn to high drama. The excitement turns them on. The sense of importance turns them on.
In my opinion, there is a complex psychology and sociology associated with CPR that is far removed from realistic medical care. (As an aside, it is impossible to do valid clinical science when it comes to CPR.)
As the author wrote about the patient in this article, "it seemed clear that he was not going to last long". That is often how it is. We know that patient has no chance of survival yet we carry on with this ritual called CPR, with the pretense that we are trying to save a life but also with strong psychological and sociological forces at work.
Joseph Conrad wrote The Heart of Darkness. One theme in that book is that it is difficult to see into the human heart. To invite a person to watch CPR on a loved one, and to have so many see this as amazing compassion, speaks to how difficult it is to see into the human heart.
8
@Robert Graham In all the codes I’ve worked during nineteen years in emergency medicine, I never once saw provider ego as a motivator. Doctors are clearly important in health care, as are nurses, techs, medics, etc., but self-importance isn’t the driver during either in- or out of-hospital CPR. Desperation, and too often a fight against futility, are much closer to the mark. And add to those simply trying to think of anything else that can be done.
4
As an RN for 20 years/Nurse Practitioner for 10 at the time of my fiance's sudden cardiac arrest in our home at the age of 48, I had spent my career on the other side of the ER bed. I had never been the family in an ER before. The ambulance let me ride along beside him as they continued CPR, the hospital ER staff allowed me to stay at the bedside-even after a security officer motioned me to leave. This was the most important time that I ever spent in an ER in y 20 years. As a health care provider, I needed to see this. Like the wife in the story, I also asked them to stop after they agreed to show me an ultrasound of his heart. I thought to myself briefly, that is the still heart of the man that I love... I never got to see it beat, but now I know what it looks like as I saved it in my memory. I will hopefully be blessed to continue to work in medicine for another 30 years of my life, and I will always be a supporter of families at the bedside. i will do this with much love and in the memory of my love Rick Goodwin. -Ronda
35
As a Hospice Nurse who has also been in the NICU as a parent and as a clinician, what this Doctor did was the most ethical and selfless act possible. Let’s remember why we’re working in healthcare. Who are we treating? The patient and their family. Witnessing a code is heartbreaking. But, it’s not up to us to decide for families if they should be present. That is THEIR choice to make. We have no right to take that away from them. It’s important that we caution them as to what they may see to ensure they’re not going into it blindly. However, that’s something we should be doing in any situation. Once the team has explained how hard a code can be to watch, and they wish to be present, it’s our obligation to then honor that choice. We are there for them and denying them the chance to be present would be unethical.
13
@Andrea Black This touches all key points I thought about as I read: information and then choice.
Very, very emotional piece. It is nice to see a doctor who is engaging not only to their patients, but also to the patients family. This idea, of asking family if they want to be present during treatment, is cutting edge and i applaud you! i cannot answer which way i would want it, but thank you for the choice!
14
Apart from having no desire to watch a loved one in the final throes of death, how does this not create liability for the hospital?
Both my parents passed away while under medical care and I was not even near the hospitals, and I was at peace that the doctors did what the could both times.
I guess there are others that would like to see the death of their lived one in full gory detail, but it also depends on their grasp of science.
CPR and medical procedures are not magic, they are science and there are statistics involved whether they are successful or not.
As long as they are able to accept the procedures may not work I guess this is alright, but what if they just end up second guessing anyway?
1
@marie It has nothing to do w/people needing "gory details". I'm glad that you were at peace w/how your parents passed. It comes down to choice & what people need to be able to move on. If your loved one is coding & you have no wish to be there, then you don't have to & there's no pressure to change your mind. Hearing "we did everything possible" is quite different from seeing it. For a lot of people, there may be that niggling little thought in the back of their minds: "did they REALLY do everything or did they just let him go because it was one less patient to deal with?" As the article indicated, there are studies showing FEWER cases of litigation & FEWER people suffering from PTSD afterwards. Are there people that are going to try to sue? Of course, but that doesn't mean there's any basis to their cases. Are there people who regret being there during an attempted resuscitation? I'm sure there are, especially right after. Again, I think the biggest takeaway is that we need to give family the choice. I think there is also comfort in knowing that their loved one didn't pass w/no one but strangers there.
16
@marie
Why so self righteous?
By all means stay away from situations you don’t want to be near or experience.
As hard as it is, if I can be close to a beloved up until the time of death I consider it an honor and a privilege.
If my presence could be perceived as comforting I want to be there, as well as a final shared experience.
I think, however, you are right to stay away from death.
As for second guessing doctors, I don’t see that as an issue, although i can see that you might.
6
@BeckyRN
I also wonder how many sue when they didn't see resuscitation efforts, but wouldn't have if they did see them. By viewing them, they might appreciate, viscerally, that everything that could be done, was done and wouldn't have a nagging feeling that the medical staff didn't just "write the patient off".
In some cases it might even be a family member who asks for the fruitless effort to stop. It's a lot harder to justifying suing after reflecting on a death for a few days when a family member present at the scene asked for resuscitation efforts to cease.
My first wife died at home per her wishes at the end of a terrible struggle against mCRC. This stark and agonizing experience remains a final unforgettable bond between us, even though I am remarried and live half a world away.
Whether your vows said "Until death do you part" or "As long as you both shall live" you cannot understand the meaning of your marriage without this closure.
15
CPR is not nearly as effective as laypeople (and, unfortunately, too many health care providers) believe. And, it is brutal. I have brought family members to the bedside during resuscitative attempts a number of times. Often, this was after having previously had a discussion with them regarding the likely futility of a resuscitative effort only to have them insist upon resuscitation being attempted, against my medical recommendation. Only once, after observing the effort for a few minutes has family not asked that our efforts be stopped. Unfortunately, this does not undo the broken of ribs or invasive procedures performed without the benefit of anesthesia/analgesia. As often as I try to remind family that the patient is the one in the bed who will suffer from a futile or low-yield resuscitative effort or that death is not the enemy, dying badly is the enemy, I am too often forced to torture a patient during their last 20 minutes of life. I bring family to the bedside not so much to give them closure but to limit the suffering of my patient as much as possible. If this brings family closure, great. But, I have to bite my tongue in regards to what their insistence on a resuscitative attempt brought their loved one. They may have observed the resuscitative effort but they did not physically experience it.
35
@Michael Freeland As an acquaintance who was a doctor once told me when I mentioned close proximity to good hospital as being a requirement when selecting a retirement destination -- "The goal should be to be at least 30 minutes from the nearest ER" and I didn't get the sense he was kidding.
I'm also reminded of a comment that an EMT once made on an article where he commented on how much they hated calls to rest homes for cardiac arrests where there was no DNR order. He described performing CPR on an 80 year old like crushing a bag of potato chips as ribs broke. (Presumably he was thinking of a bag of chips packaged the way they used to, without all the air they put in now which leaves the chips floating around in a balloon and difficult to crush). Admittedly, this was some years ago and perhaps the equipment and techniques available to EMTs has been refined at least somewhat.
1
@Michael Freeland Thank you for telling it like it really is. Life isn't like the "miraculous" dramatic saves folks see on TV.
I work as a Concierge in our small community hospital and one of my duties is to sit with , hold and hug family that are in these situations. . Family that get to see how hard doctors and nurses work are grateful that all has been done for their loved ones. We have a designated room for family who would rather be further removed , but they always have an option of returning to the patient area. I often act as a go between with questions and concerns between family and docs. And at the end there is always the " what happens next question ". Thank you for being able to allow those that would like to be present there.
15
I am so happy that there are doctors who share these thoughts.I've watched my children bornI've watched a dear friend die.It is the cycle of life-and if a family member can be near me when I die in that situation,I hope a doctor like this one is nearby-very touching, very powerful.And I worked in 2 emergency rooms for 15 plus years as a mental health consultant- watched folks escorted out into the waiting room while loved ones died away from family.
There is no uniform answer but I embrace the choices-kudos
18
I am older sister and only sibling to a beautiful 22 year old woman who was murdered. I can assure all my belief “everything was done to try and save her” when I arrived to the scene where she lay dead, was imperative to my sanity. The kind eyes and reassurance given by a paramedic who stood nearby, still reassures me 23 years later. I now work as a palliative care nurse practitioner and never forget the need we all have to know everyone “tried” to help our loved one, even when the situation is “futile”. I didn’t need to know what was done or the details, just that someone tried and was with her until I came.
19
I inadvertently walked into my mother's "step-down" room at New York Presbyterian Hospital while she was being given CPR. Granted I calmly sneered while I washed my hands, "You just took her out of the ICU!" But otherwise my SCUBA diving training to remain calm during emergencies kicked in). I wondered out loud if she was still alive since her leg was twitching. One intern gently informed me that the movement was merely a reflex. I'm glad I was there near the moment of death. Despite what the intern said, I like to think that twitch was her recognition that I was there.
7
It's vital to not merely witness the end of a loved one's life but also to have someone RIGHT THERE to discuss what happened, once the crisis is past.
Two weeks after I turned 10, my grandmother had a heart attack and died while I was staying with her and my grandfather. Alert until the end, she said she would always love me. I've carried her love in my heart more than 60 years.
My grandfather then understandably went off to the bathroom; I sat on the front step to await our family doctor, slowly absorbing this great loss.
A sudden noise from the den! I raced back inside, rehearsing "Oh, Grammy--we were so scared!"
Her body was flailing on the couch. Her breath was gagging, groaning, gasping. I fled back outside.
The doctor eventually arrived and gave her now-still body a useless injection. Then came a hearse and money-hungry relatives. The doctor gave me "just an aspirin" that knocked me out for hours.
No one every talked to me about Grammy's death. I wasn't even allowed to attend her funeral ("You might get upset!").
Back in 1957, a five minute chat with our doctor would have soothed my soul. Only 40 years later, when a psychotherapist explained the physiology of death throes, could Grammy's love finally erase those moments of sheer horror.
21
@MLChadwick
Oh yes, the "money-hungry relatives. I know of a case where one sister was calling the insurance company while her mother was still in intensive care at the hospital. She wanted to make sure she was still the sole beneficiary on her mother's insurance policies. Yet her sole sibling (while in poor health) had to do all the work on the various insurance policies (despite the fact she was not a beneficiary), identify their mother's body, plan the funeral, etc. while the beneficiary sister counted her future dollars. Ironically last month the non-beneficiary sibling received a call from a creditor stating her sister hadn't paid her Century 21 Department Store bill (non-payment of bills being a frequent habit of the beneficiary sister).
6
My dad passed away after we had left the hospital. We were summoned back and his cardiologist told us he was sitting beside him when his heart quit. I doubt being present during resuscitation attempts would have made the loss more real or easier to handle.
However, I was present twice when I rushed pets to the vet hospital and found it frustrating in the extreme to be kept in the waiting room while the team worked on them. We were allowed to be present for euthanasia but I dearly wish I could have been by their side earlier on. Trust the family member to be able to decide what is best for them.
11
I find it hard to believe that this debate remains ongoing. As an ER nurse, this same debate resulted in families being allowed (if they chose) to be in the code room. One staff member stood with them to explain what was happening and to provide support. This was nearly 20 years ago. Family presence also deterred overzealous residents from performing procedures for practice on patients who had already died. I wish my family could have been at my father's bedside rather than being told, "Well, it's all over now".
22
Doctors and medical staff need to understand that most close relatives want to be there no matter what. These are often the last precious moments when life still hangs on, albeit by a thin strand, and there is something that one could call almost holy about them. The saddest and loneliest moment is usually not the death itself, but rather when that initial haze and holy aura, that can last hours or even days and weeks, dissipates, because then the loved one is truly gone.
12
As having participated in more codes I wish not to remember I have a few thoughts:
1: after inviting the family to observe the code and telling them everything has been done , how do you know family members won’t research/video said code and come back asking more questions and wondering why such and such was not done.
2: I’ve participated in codes where we’ve “cracked” the chest and I can plainly state watching open chest cardiac massage is not something I’d want any member to watch.
3: what do you do if the family doesn’t sit on the corner and begins to vocalize suggestions or emotionally breaks down or faints. Now you have 2 pts in the room.
4: in this particular case was there “ the conversation “ where the family is asked which drugs/techniques/protocols they agree to so as not to submit the loved one to futile resuscitations or procedures the pt would have never agreed to have performed.
5: was a study done to see if having a family member in the room influenced the outcome: outcome better vs worse. Are the interns performing for the family or the chief resident or the attending playing liaison.
6: after hearing about family on rounds, lets open it up and have family in the OR for surgery ( we have codes there too) or cath lab or Medical Executive Committee meetings. After all
I apologize for my glibness but while I think its a good hearted gesture, its not a good idea to have family present during codes.
12
@Fly By Night You don't own the patient. Your feelings don't matter. If the relatives have to be escorted out because they "vocalize" (!) or feel faint, then someone can do that.
From the article, it sounds like studies were done that concluded it was better for the family to be close to their loved one should they wish.
I sat for days next to my father in the ICU, watching his heart roll its beats in his open chest, which for medical reasons couldn't be sewn shut, and it was not horrifying. He was my dad, not a body on a bed. Thank God the doctors were compassionate and not as cold as you. Hope you retire soon!
14
@Fly By Night Its not your decision. Thank goodness.
4
the real question of importance would have been IF the wife would want to go ahead with CPR the physician already labeled futile...
7
Dr. Lamas, Your sad but inspiring experience during the last hours of your patient's life and your very kind interaction with his wife brought tears of memory. As a CCU nurse I was assigned a patient brought to the unit after he experienced an MI on a medical floor. A close friend who had been in a coma following surgery had told me she could hear medical staff speaking about her likelihood of dying. Fortunately, she was able to share that experience with me and I intern spoke softly to my patient about his improving health and advised his visiting family to do the same. On my fifth day with him, he opened his eyes and simply said "thank you!" That was in 1974.
21
Dr. Lamas, thank you for your thoughtfulness and understanding that loved ones have a place in the medical process. Sometimes seeing death is less frightening than what we imagine.
27
I don't remember seeing any mention of the presence of a chaplain during a resuscitation attempt. As a chaplain, I find this lack a bit odd. I was often called to just such a bedside
and a family's reaction was usually one of gratitude for the opportunity to say their farewells when the dying person was perhaps still able to hear. Many times, family members will express their gratitude in the future.
9
@Carol Figeroid-Burgi
As chaplain, I was also curious why a chaplain was not called in this situation. While it is wonderful that the physician acted so compassionately, chaplains are trained to provide support to families. Unfortunately I still meet staff who are not even aware that we exist!
7
My comfort comes from science. If a chaplain were called when my mother coded, I would have felt compelled to honor his/her uninvited presence and message. I am glad that I did not have to do this. Instead I was able to honor my mother’s final experience and that of my sisters and I.
1
Watching would certainly end the nagging doubts that the survivor or doctors could have done something more. That is a very damaging recurring thought in many survivors and even more so in an unexpected death such as the one in the article.
17
Thanks, Daniela- The point the resonated with me is recognition of the vital role family members can play--information and continuity in an otherwise changing landscape of clinicians. However, I was surprised to read that at "your hospital" family members are included in rounds. I did not have that experience when my husband was in the ICU at your hospital last winter; in fact, the team did its rounds from afar, not even coming close to where he was to talk to or examine him... I hope that means things have changed!
11
As one who has attended more codes than I can count, I have a life goal of making it out of this world without being coded or even admitted to ICU. May all families who attend a code find some comfort from the attendance. May all who do not attend find some comfort from not attending. In my mind, ask the family. Let them decide. Then support their decision. Well done, Dr.
59
I feel that I was privileged to participate in the attempt to revive my 60-year-old husband as he was having an unexpected “heart attack” in Addis Ababa, Ethiopia 22 years ago. He did not survive, but I, the Embassy physician and the Embassy guards who helped, tried so hard to do all we could. I was devastated, but at least I was there. RIP, Gene.
30
I really don't need to be crying in the office.
8
@wlt Nothing to kickstart the second half of your work day like sitting at your desk, crying and thinking about all your loved ones that you will have to grieve in the future!
I spent 10 days with my dad in the ICU when he was dying of congestive heart failure and secondary liver failure. Being there was very helpful for me to process his death. It was at times gory and painful to watch, but, in the end, I fully understood the severity of his condition and that there was nothing that could be done to keep him alive.
23
Thirty years ago, my husband had cardiac arrest at the hospital. He was 42. They said he had a heart blockage and if the TPA. they gave him didnt work within 8 hours, he would die. He was in ICU and they refused to let me spend even a minute with him. I went to the admin. and they still wouldnt help me to see him. Thankfully the clot broke through the next day and he survived. But, I will never forget the way I was treated by the ICU nurse and all the pain and grief I experienced while curled up in a waiting room chair overnight. We had 4 young children and I couldn't even communicate with them about their Dads condition. I have deep hatred for these people, even today.
64
@Paula Bosanac I am so sorry. How awful that must have been. I'm glad your husband survived.
17
Let’s not forget the patient who is in the process of passing. Even if they appear unconscious or out of it, evidence shows many are aware up to and somewhat beyond the point of clinical death. Knowing their loved one is there, near to them, can be of great comfort. Death is an inevitable outcome of living so the movement away from hiding it is fundamentally healthier for all concerned.
60
"and I wondered whether I had made the wrong choice."
It is impossible to always make the right decision on this matter and on others. Doctors and family members will make mistakes, sometimes under the same circumstances in which the same decision was not a mistake, by the same (or other) doctors and different family members.
The difference is that the doctor ultimately walks away. For the family member, he or she sometimes will never know if they made the correct decision and sometimes those decisions will haunt them for the rest of their lives.
9
Would that the hospital in which my mom was critically ill had been as forward thinking. The fear of litigation certainly guided their decision to limit my visits with her to very short periods when no intervention was required. Her notes stated "lawyer daughter - limit to shortest time possible." I was relieved to have her move to hospice care if only so I could see her.
32
It depends on the family, but sometimes it completes the awful cycle. I was able to be with my husband when he died. It caused great pain, but offered great peace, later, as I processed his death.
31
I feel so lucky (in some way), that I was given that chance. I was beside, when my husband died. It hurted like hell, but I knew, that there was nothing more they could do...
20
This nurse has participated in codes in Hospitals.
Noooope!!!!!!!
I would not be able to tolerate observing my family member or friend being coded.
The scene is chaotic around the bedside.
I have family members who would freak out if they saw how a code is handled.
You have a right to be there to observe but do not do it.
The event will live on in triggers for the rest of your life.
IMHO as a nurse in trauma care etc. retired now. Happily.
14
@nursejacki
Yes a code is far from the peaceful death you would wish for your loved one. Thanks for injecting a note of reality.
9
My mother was an ICU nurse for many years. She often stated she did not want to die in the hospital and vehemently expressed those wishes because of her own participation in codes, herself.
She died at home, alone and of natural causes, but I am confident that it was her decision.
17
I don't understand why this poor man was put through another code when "he was clearly going to die".
And let us talk about how often codes like this are successful; very few people are actually brought back and stay back.
14
@Marti Mart Maybe so, but I have an 11 year old girl and a 32 year old female on my service who are both alive today thanks to CPR. Statistics don’t matter to the survivors and their families.
24
@Ace CPR is typically more effective in younger, healthier populations. CPR is done most often on older, sicker people. It's great that it works sometimes, but it usually doesn't...
12
@Marti Mart In the absence of a valid advanced directive mandating Do Not Resuscitate, the standard of care is to attempt to save the patient’s life.
Especially on our highly litigious country.
I watched my father die in the ICU after his respirator was removed. It was a flailing, gagging, thrashing death that went on for twenty minutes. My life would be more peaceful without this memory.
It's thirteen years later. I'm still waiting for the frightening and intimate knowledge I gained that day to liberate me, to bring me to some higher level of understanding.
14
@Sallyforth
Family was able to say goodbye to a parent/brother/son - he was made comfortable and we watched him slip away. Thankfully - at peace, out of pain, in the company of people he loved and who loved him.
6
My husband never spoke again after he woke the morning of his death and told me he could not breath. I followed the ambulance to the hospital and they let me in to the ICU, once he was prepped. He was hooked up to tubes and machines, I sat there , not thinking he was going to die. Suddenly he flat lined and a whole team came in and started working on him. The hospital had his advance directive and the Dr asked me if I wanted to let him go. I didn't, but I knew that was what he wanted and I said yes, and they stopped. Shortly thereafter he passed and I sat there in shock and disbelief. To this day, I cannot believe he is gone, and I am thankful they allowed me to be with him to the end.
88
I am sorry for your loss.
20
I'd rather see what's being done than not there imagining what's happening inside the curtained cubicle. It is more frustrating if loved ones go without saying anything and later on may feel guilty of not knowing what were the measures doctors had done to restore that loved ones' life - so precious. Thank you for the doctors who had time to think and embrace the idea about family members in this case of emergent 'no point of return' -
21
The imagination can be far more upsetting than reality. Witnessing resuscitation provides loved ones with a better understanding of the health teams efforts to care for and safe the person.
13
We were in the room at the hospital when my father chose to go on a morphine drip due to the tremendous pain her was in stage four cancer. We all knew what that when my father became unconscious, he would not wake again. He told the doctor that he had loved a wonderful life and wanted to pass on the same way.
The hospital kept him comfortable in hospice and he passed peacefully with his family around him a few days later.
It was a beautiful gift that my father shared with us to be able to be near him and love him during his final transition.
43
From my vantage point, this article is about emotional intelligence. It is about empathy - understanding things from the perspective of the family members of patients who die in the I.C.U. It is also about respect - allowing family members to make voluntary and informed decisions, rather than being paternalistic, which is oppressive. It is about the importance of transparency. People cannot make voluntary and informed decisions in the absence of transparency. And, transparency leads to trust. In fact, people tend to assume the worst in the absence of transparency.
As a lawyer turned mediator, I can tell you that my transition in that regard stemmed from my increased understanding of such concepts.
Lawyers tend to be very paternalistic. They work with people whose stress levels caused by fear, anxiety and other such things result in a sense of disempowerment and they further disempower them by taking on the role of their "champion." They tend not to give their clients information that allows them to make voluntary and informed decisions regarding process and approach. The reasons are similar to those set forth in this article -- a false belief because of bias. Communication (other than between lawyer and client) tends to decrease once lawyers become involved. In fact, a game of "hide the ball" begins. And, as transparency decreases, distrust increases. The entire process tends to escalate conflict, rather than de-escalate it.
Thank you for this article, Dr. Lamas.
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Agree completely with all the previous comments but I'd be cautious about asking the family member who happens to be present whether it is time to stop. This is normally the call of one of the medical team. You may not know who the person present is, there might be several with different wishes. If I were the patient, this time I'd leave it to the professionals. Creating an expectation with the family that they have the power to say "keep trying" will not always be right.
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@LMB100 Nope...in the hospital the nurses and physicians are well aware of who the legal decision maker is. One benefit of having family there is that they actually see what happens during a code and usually quickly realize they don’t want that for their loved one. In my STICU we’ve had family refuse to even come in to visit because they KNOW what’s inevitable, but as long as they don’t have to see it they don’t care how long we torture their family member. People die, and we can’t save everyone. Family should be with their loved one when they die...why would you want them to die in a room full of strangers.
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@Lynn Without disputing your points about the benefits of family presence during CPR, if I was the patient whose heart had stopped, I’d be perfectly fine being surrounded by skilled, dedicated strangers doing their damnedest to bring me back!
Allowing family members in provides them with an understanding of what is done to try and prevent their loved one from dying. It cures nothing. It undoes nothing. All it does is buy you time.....time to try and 'fix' what caused the code in the first place. The decision that ultimately needs to be made is :is the disease or the condition, such as trauma, better at what it does than are the health care providers in preventing the death? By witnessing the resuscitation, it allows the family time to decide if allowing their loved one to endure 'the cure' again will ultimately change anything. One thing the family doesn't get to see until later is the impact resuscitation, particularly on multiple or prolonged ones has on the patient both short and long term. It is not a benign process.
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This was very important article about a family’s experience when the husband coded after an illness. Remembering that their rights are more important than established procedure is very important.
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As the wife, or any close family member should be entitled to observe what is being done to the patient. I agree to give them reassurance that physicians did all they could to resuscitate their beloved husband and or family member. Even if its chaotic or whichever the case may be it erases any mystery or secrecy. I personally would prefer to see what is being done and when to call it quits. Thank you for sharing this challenging but very critical situation because I myself and others should be well informed of their rights and not being afraid to speak up for themself or their family member.
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Of course the family should be able to be there during the code. This is their family member, most likely dying, surrounded by strangers. Not the way most people envision their death.
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Beautiful story that illustrates that we medical professionals need to keep in mind that we are caring for the family as well as the patient. On a sour note, wonder what the 'risk management' department aka lawyers would think when they heard about it.
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When my mother died unexpectedly from sepsis after a case of the flu, I was in the room with her (along with my father and two brothers, and my daughter) until her heart slowed and finally stopped. Each member of the medical team worked hard to make sure we knew what was happening, and allowed us to make the painful but necessary decision to remove support. It was explained to us that they didn't really know how long it would take once the support was removed. A nurse stood next to me and said "she's going to do this on her own." We watched as the monitor showed the slowing of her heart, then when it stopped. It was an extremely difficult thing to witness, however we saw first hand the compassion and care that the doctors, nurses, and technicians in the ICU provide not only to the patient but to the people who love them. I am grateful to have been there, and grateful for the care they provided to my mom and to us.
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I appreciate this doctor's thoughtful decision-making and that of the other health care providers who have weighed in. There is an underlying question for me, however, about whether the ICU patients and their families were given any choice about whether they wanted those extreme measures. The US "medical machine" grinds relentlessly toward treatment unless that path is disrupted by a resolute, affirmative statement by the patient or family (and sometimes despite it). Where was the palliative care team or other voice that could let them know that violent, futile treatment was not the only option?
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@ccMongoose
This is not a case about which harp on the gross application of futile, invasive medical intervention. Not every dramatic intervention that ends in the death of the patient falls into that category which seems to be of special concern for you but not relevant for this patient's circumstances:
"She wiped her eyes on her sleeve. She was wearing a bright pink sweatshirt with a happy slogan on it. When she had put it on that morning, her 50-year-old husband just had a cold that wouldn’t go away. Now she had learned that he actually had leukemia that had caused his heart to fail. It was too fast, she told me."
Here was a man of only 50 who had undianosed leukemia, a disease with a set robust treament options and much curative success. Sadly, the development of cardiac issues was unsurmountable, but they certainly should have tried to stabilze this man. His medical team had every hope that it might be possible to stabilize a 50 year old man who would then be able to recover from the acute situation and move onto treating his undiagnosed illness. Having worked in an ICU, codes are dramatic, sometimes brutal in their process, especially to a bystander, but can be the essential stop-gap in the recovery of a patient who will leave the ICU and go on to heal. Not every case is Terry Schavo or some 95 year old with pneumonia. You are out of place to bring this issue up vis-a-vis the story of this particular family.
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@Oliver
ccMongoose is not "out of place" to bring this up. It may not have been the case with this patient in this case, but it certainly could be in another case. As others have noted as well, allowing family access and influence could be a mixed blessing - some family members might find it easier to accept their loved one's death after seeing the medical team's efforts - but others might say "Keep trying" even though it is futile. These are vital considerations in allowing family access to the ICU during a code.
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@ccMongoose
Palliative care teams are more often than not 9-5 shift in many hospitals and not around on the weekends or available by phone only. It is difficult to have them present at the bedside in a timely manner.
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This article serves as a prompt to reflect on this question in advance: What would I want to choose in this situation?
It is clear to me that I would want to be there in any likely scenario. Because of this article, I would be more likely to initiate asking to be present.
It seems equally valuable to reflect on this question to make it easier for someone to say no in the emergency without feeling like they are letting their loved one down.
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The acceptance of the loss of a loved one is a very personal experience. I lost my Mother just after I turned six years old and I wasn’t allowed to be at the hospital but even at that young age I understood what death meant and I don’t think I would have wanted to see my Mother in an ICU, rather I have wonderful memories of who she was and of the short time we had together still 60 years later. Likewise I lost my Father and my younger Brother and in different circumstances and I did not get see them in the ER or IUC. I accepted their deaths, never doubting that the medical teams did all they could do, and my memories of both my Father and Brother are of how they lived their lives, not marred by the trauma of their deaths.
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Giving loved ones a choice is considerate, but I think most of us overestimate our ability to handle a violent death. My wife was a child when she witnessed her grandmother’s death and has never fully gotten over the fear it inspired. I lost my cat that was seizing violently in my arms. Those images and my panic, as well as my guilt for not understanding how sick he was, stay with me. I would rather remember him in life, not his death throes, but I cannot unsee it. When my elderly father passes, I will stay by his side, but not if CPR or operating procedures are being done. It is best to know oneself in these situations.
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@voltairesmistress I think you are wise to take this path.
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Assuming that some people would not want to be present during a loved one’s death is parental and heartless. I’ve seen too many well meaning medical folks make this assumption. The key is ALWAYS asking if they want to be present during a code. That includes parents being asked if they want any underage children to be present.
Choice is mandatory because if you don’t offer it to them, that irretrievable moment in their lives is gone forever.,
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@voltairesmistress , while it's true you can't un-see or un-experience awful things, a skillful therapist can help you to reduce the prominence of such traumatic things in your memory. They help you to recognize that traumatic moments, while unfortunately resonant by their nature, are ultimately only moments, just like all the wonderful other moments you shared with your loved ones, and thus don't deserve such disproportionate attention in your recollections.
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unless you are disruptive or violent, you should have the right to be with a dying relative. Keeping loved ones away from dying relatives is old-fashioned.
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As a mental heath professional in the university hospital I have had the fortune or misfortune to witness many cardiac arrests and codes. Some people survived, many did not.
I have also seen people collapse in public.
It motivated me to stay current with CPR techniques and learn to use an AED.
And yes I still would want to be with my loved one. To say goodbye and to know the staff had tried their hardest.
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Sometimes - sometimes not. I am an ER doc, and I have had family members attack me while trying to run a pediatric code. I don’t blame them at all - they were panicking - but the guy was a lot bigger than me and if it had not been for a quick thinking (an ex-military) nurse I would have been flattened and the kid may very well have died.
Emotions run high during life-and-death scenarios - and people get really unpredictable under stresses like that.
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As a older nurse that was part of the culture that protected patients this practice is both helpful for the staff and the family. It helps to see the patient as a real person and I think would help staff from feeling totally useless. Even if the person dies there is a harder job to do . I for one would insist on this. I have been there for everything , why not this. Thanks
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I would have been grateful to be near my loved one, rather than out in the waiting room, imagining the worst, and having to wait for the notification. In this case, it was very important for her that she herself was able to recognize that he had died.
Should it be standard? I don't know. I do know that many who weren't with their loved ones at the time of death wrestle with unanswered questions about the last moments, and that can be worse than facing the immediate reality.
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@cheryl The choice to be present or to be elsewhere is something that should be standard. Anyone who chooses to be present during a code should also know they have the choice to leave at any time.
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You did exactly the right thing. Having been involved in many codes and trauma's in the ER, the one that influenced me the most was a young man badly injured in a car crash. During CPR, the staff trauma surgeon quietly asked for a warm wash cloth. He cleaned up the young man, as compressions and rapid infusions continued. He wiped up the blood on the floor and he asked me to get his parents. He spoke to them briefly outside the room and asked if they wanted to see him. At that point, it was clear he would not survive. His parents were there to witness his death as the code was called and we were there to express our condolences and to let them know we cared for their son with compassion and professionalism. They reached out to us a month later to let us know they appreciated being there and allowed us to stay in touch with them which was healing for all. You are thoughtful and compassionate and each situation should be evaluated individually.
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@Annie RN
A death like that would be traumatic for staff as well as a parent's worst nightmare. That surgeon was thinking with great sensitivity about the parents, knowing what they were going to have to endure from that moment forward. Thank you for the work you do, Annie RN.
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Like most everything else, it depends. Some family members will do fine, some will become hysterical and belligerent, even violent. Just be prepared, and follow their cues. I would definitely limit it to one or two Family members at a time.
Good luck.
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mare rose i agree that it waS very considerate nad very good that he did it for have been in that there and neeed to know what was happening. also i also have been the patient and it made him feel better stressful but knew what was happening to me after that accident . i was in icu for two months i know
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A week ago we took the elderly family dog who was yelping in pain to the vet who thought there was a brain tumor. She was given an injection to suppress the pain, went to sleep, and about 5 minutes later another shot to shut down her heart. I waited a minute or so and covered her with a blanket. The process gave a unexpected but welcome closure. One would would hope for the same with a human family member.
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@Bill R ....only the human patient won't get the shot that calms them, or suppresses their pain. The animal gets a better deal, I think.
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@Sallyforth Maybe, maybe not. My dear grandmother-in-law, over 100 and with compromised circulation in her mesentery, was kept very comfortable on a morphine drip and had a very peaceful exit with nearly everyone in the extended family able to see her before the end. A gentle exit for a gentle soul.
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As a nurse, I strongly suspect that the 'thank you" was as much for your "caring presence" as it was for the opportunity you offered her so sensitively. The wife witnessed & will remember that event through an entirely different lens than if she was standing alone at the bedside.
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Having been through several life-and-death medical emergencies with loved ones, I can say they are often massively emotional events. These events become memories that you come back to, over and over, for the remainder of your life, re-living each moment as part of the hard work of comprehending what has happened. Each bit of experience helps the survivors make sense of what has occurred, because while it is happening everything seems surrealistic.
I can see why ICU professionals might have reservations about letting family members observe procedures. But unless family members are disruptive or hysterical, I think they should be offered the option. Be honest about what is going to occur and support them if they DON'T want to watch. Ideally, a calm and supportive family member can be with the person, but even if not.
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@Madeline Conant
That’s what I would want...give me some idea what to expect so I know what I’m getting into, and let me decide.
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@Madeline Conant
I agree … the only downside I see here is if this becomes the norm, people start feeling guilty if they DON'T want to be present, when staff encourages them to be present.
Also, I think age matters - I don't think small children should be invited to watch their parents die. Maybe some would benefit, but I think mainly they would be further traumatized.
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The gift you gave was the wife truly knowing everything was being done, but none of it was working.
Then she saw that, and had the knowledge to say no more.
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Good, this individual was not shut out of the process of saving a life, she was a witness. This also allowed her to express her grief knowing that the time to say goodbye had come. From a faraway room, it is difficult for a family to see, and understand.
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How unbelievably moving. I don’t know if I would want to watch CPR done to a loved one. But it certainly seems like it helped this wife to be able to say please stop now. And I imagine you were a great comfort to her.
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As a nurse, it’s heartening to see physicians embracing this practice. It’s been in the nursing literature for more than twenty years, beginning with pediatric emergency departments. Seeing the extreme efforts expended by the medical professionals (with a knowledgeable person beside the family to explain what’s going on) helps reassure families that everything possible was done. Brava.
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@Barbara - As a former Labor & delivery nurse, I have unfortunately witnessed a still birth or neonatal resuscitation in the delivery room. Having the parents there allowed them to have what might be final moments with their child. What made the difference was a staff of nurses who were educated and aware of how to deal with the parents and families. Being sensitive to how families react and how to support them is critical but all to sadly lacking in the medical education arena. Nursing through our National League for Nursing has been championing end of life care education for nursing for years. We need to share with our other healthcare professionals.
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