Coding a patient with family in the room

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Zebra Hunter

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Y'all do this often?

I had a patient in my last shift, elderly, multiple comorbidities, non-verbal at baseline and came in in severe respiratory distress, looking like she was at death's door. Family told me they wanted everything done even if that involved cracking her sternum and ribs and placing her on a vent where she would likely never come off it. The son said he just wasn't ready yet to say goodbye to his mother. We ended up intubating her and while waiting for her to go up to the ICU, she coded. I had the idea of bringing the family in so they could watch what a full code meant, but the medicine resident that had spoke with the family at length thought they could not handle it, so I deferred to his opinion. We unfortunately ended up achieving ROSC on this poor woman. Luckily, however, the family saw her condition afterwards and decided to make her DNR.

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Y'all do this often?

I had a patient in my last shift, elderly, multiple comorbidities, non-verbal at baseline and came in in severe respiratory distress, looking like she was at death's door. Family told me they wanted everything done even if that involved cracking her sternum and ribs and placing her on a vent where she would likely never come off it. The son said he just wasn't ready yet to say goodbye to his mother. We ended up intubating her and while waiting for her to go up to the ICU, she coded. I had the idea of bringing the family in so they could watch what a full code meant, but the medicine resident that had spoke with the family at length thought they could not handle it, so I deferred to his opinion. We unfortunately ended up achieving ROSC on this poor woman. Luckily, however, the family saw her condition afterwards and decided to make her DNR.

I'm a huge fan of it. I've had a few codes where the second the family saw what chest compressions actually meant they immediately told the team to stop hurting grandma and this isn't what she wants.

The guilt they have afterwards is almost a guilty pleasure but then I quickly remember that most families have no reference as to what "full code" TRULY means, even with appropriate explanations. Sometimes you can't understand the depth of something until you experience it yourself.

Another part is they literally see the team doing "everything they can" to save the chronically demented immobile institutionalized relative, so in the event that there's no ROSC it makes me feel like they're less likely to question the adequacy of what was done to "save their life."

ED theater if you will.

I'm probably a horrible person but that's my two cents :)
 
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I do it unless I think the family isn't stable. It can be helpful in one of two ways:

1 - Codes that you really want to get back (kids, young and healthy, etc) - I think this may help the family grieve. If a kid dies, the family is in shock and they have a hard time dealing (appropriately so). I think having the family around really helps them know that you truly did everything. I think that can be somewhat cathartic.

2 - Codes that you really don't want to get back (i.e. gomers) - As stated above, a lot of times, people just don't "get it." Seeing your 90 y/o grandmother getting assaulted with an 8.0 ETT, having a big burly tech crack ribs, have an intern with an IO or big needle going at the groin, etc can quickly lead to family saying "oh no, please stop assaulting my family member."

Like I said above, if you have the hysterical "OH LAWD, GRANNY CAN'T DIE!!!!!" fall on the floor and pass out, etc family, they don't come back.
 
For the reasons stated above, I almost always try to get the family into the room to watch the code/resuscitation.

A few times I haven't/wouldn't.

1: visually disturbing traumatic arrest. No need for the family to see the loved one in this condition. They can wait outside for a little while while we run blood and poke additional holes. After calling the code we can get the patient cleaned up and organized a bit before family comes in. That way the families last memories of this patient won't be quite so bad....

2: Disruptive family. Certain, shall we say, "cultures" tend to get very loud and disruptive when dealing with a pending or recent death. It doesn't help anyone if you have several family members in the room screaming "OH LAWDY, DON"T LET HIM DIE!!!"

I'm sure there are other times I will decide not to, but these have been the only two I have come across so far.
 
I haven't seen any research demonstrating harm in allowing family to witness the resuscitation. I've only seen studies demonstrating either lower rates of PTSD or no difference. If the family is not hindering the ability of staff to do their job, then they should be given the option to witness. This goes for pediatric arrests, too.

Also, strong work with the veiled racism, boatswain.
 
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I'm probably in the minority but I do not like letting family in the room during a legitimate code and whenever possible will avoid it.

A legitimate code (I'm talking about the middle aged guy with vtach/vfib arrest, young overdose, drowning, MVC, etc) is a very stressful environment, particularly for nursing and other ancillary staff, and having "strangers" in there without any medical knowledge witnessing and reacting to the things we do to bring their loved one back just heightens that stress, at the worst time since this is when you want everybody in their A-game. I will bring in the family once I have decided to end the code.

Granted I work nights so most codes come in without any family (reason 1000001 why I love nights). With gomers I do as few rounds as possible and call it. No sense in bringing the vegetable back to life.
 
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I think it is great for children and for old people so the family can just call it once they see what you are actually doing to grandma. Granted I would pay a years salary to never code another child for the rest of my career but I still think it helps the family and you the physician.
 
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I'm probably in the minority but I do not like letting family in the room during a legitimate code and whenever possible will avoid it.

A legitimate code (I'm talking about the middle aged guy with vtach/vfib arrest, young overdose, drowning, MVC, etc) is a very stressful environment, particularly for nursing and other ancillary staff, and having "strangers" in there without any medical knowledge witnessing and reacting to the things we do to bring their loved one back just heightens that stress, at the worst time since this is when you want everybody in their A-game. I will bring in the family once I have decided to end the code.

Granted I work nights so most codes come in without any family (reason 1000001 why I love nights). With gomers I do as few rounds as possible and call it. No sense in bringing the vegetable back to life.

I'm the exact same as the above. I don't like having to focus on two things at once: the patient and the family.
 
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We always allowed family there if they wanted to be. It let them know that we did everything we could, and resulted in substantial reductions in the number of families filing complaints (legal or otherwise) post-resuscitation.
 
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Whenever possible. There is plenty of data that says it helps with closure. I prefer to assign someone to be with the family, but when single-coverage no-chaplain no-night-social-work, I don't always bring the family in before I've had time to get a decent code started and procedures done.
 
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I bring family back for codes after there is no reasonable chance of ROSC, mainly to help their grieving.

If the patient is actively having procedures or I'm trying to arrange cath-lab etc after a 50 y/o vfib arrest w/ ROSC, I usually do not bring them back unless pt is "stable".

If a young person comes in asystole and you work them for a reasonable amount of time, bring the family back for a few rounds. After a couple minutes they usually walk out, after which you can call the code and have the "Your loved one has died." discussion. That way they already know what happened.
 
I generally let them in if I know I'm going to call it. I preface it with an explanation that they will likely die. Also gives them the chance to say good bye.

On a side note, I don't feel bad about putting drain-circlers on life support for a day or two for their family to say good-bye to them in the ICU before they die. Query your non-medical friends and family on this issue. I'm sure they will want their loved ones kept alive long enough for them to say goodbye.

If ICU/ethics/palliative care can't convince them to pull the plug on the vegetative state patients the next day, then you're not going to in the ED during the heat of the moment.
 
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I can't remember the last time I DIDN'T bring a family into a code... I think it is the right thing to do, unless they refuse. I think it helps them, and frankly it helps me connect to them and guide them through an incredibly tough moment. I was a bit skeptical at first, but I am now a strong supporter of this movement.

I would agree that I wouldn't want a family in a "viable" code for the first 4 minutes while I get airway/access/situation all squared away-- but I find it VERY rare the family arrives that quickly. Plus I'm a master at not being distracted-- its what we do!

The most typical pattern is that we've been working someone 5-10 minutes, and the family shows up. Often 10-15 minutes of pre-hospital code as well. Generally I then break away to go talk to them and let them know what the scenario is. The nurses can handle the code on their own just fine for a couple minutes. Most often by this point it looks like we won't get ROSC. I always offer to let the family come back into the room with me, warning them of what they will see. Typically they do want to come back. Sometimes they say they need to sit a bit, in which case I walk back out 10 minutes later to re-update them, and universally they want to come back with me at that point. I think it is important to let them know the whole team is working hard for their loved one. Always get enough chairs for them. I guide them through the equipment, what everyone is doing, what we are seeing. Let them hold hands. I try to sit down next to them... usually not enough chairs and i just take a knee on the floor next to them.

Usually we work it for another 4-5 minutes with them in the room, and then we do an echo, check the monitor, check pulses, etc. Hopefully at this point we've made some type of empathetic human connection. And I tell them that despite everything, the heart is not coming back, and we need to tell their loved one goodbye. And we turn off the machines and mourn.

Needless to say, this is a bit different if it is a pedi patient you'll be coding for an hour, or someone that keeps hoping from Vfib-->ROSC-->PEA-->Vfib-->ROSC every 5 minutes...
 
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Also, strong work with the veiled racism, boatswain.

Culture does not equal race, and race does not equal culture. You may learn that some day.

I don't "veil" anything. Some day when you're out of residency you may be single-covering a small ED coding a 13 yo asthmatic with about 15 family members all coming in and out of the ED, and room, with seemingly half of them WAILING at high volume. Yeah, that particular cultural reaction tends to upset you, the nursing staff, the ED tech, the lab tech, the rad tech....and the other 8 patients waiting for you.

Of course, you would likely call me a misogynist if I told you which "half" of this cultural group was wailing at high volume.

It's a cultural thing. This was the way their culture deals with death, especially the death of a young person. They needed to have an appropriate location to express their cultural norms without being detrimental to the staff and other patients.

And I'm pretty sure you wouldn't call me a racist, or misogynist, in person.
 
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Culture does not equal race, and race does not equal culture. You may learn that some day.

I don't "veil" anything.

You're actually right. You didn't veil anything: you quite clearly put the word culture in italics. It's in quotes because "culture" is merely a euphemism here for "race."

If you don't already know that racists now use the word "culture" instead of "race," then you may be watching too much Bill O'Reilly.

And I'm pretty sure you wouldn't call me a racist, or misogynist, in person.

I'm certainly not calling you a racist, and I don't think Carbonized did either. Instead, Carbonized simply said that you used veiled racism, which you did.

The reality is that you yourself would hopefully have more sense not to use such veiled racism in person.
 
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My codes usually go like this:

1. Code the patient with my team - we run an efficient code, the family gets its first update that their family member has lost pulses and we are doing everything we can
2. 15min ish (give or take each individual case is different obviously), family gets second update that the code is not going well, we are still doing our best
3. At some point in the next 15-30 minutes, it becomes clear that there's absolutely nothing happening, DW family the patient is probably going to die, offer 1-2 family members who are closest to the patient and who have maintained their composure to come in and see the patient
4. While we are coding the patient, tell the patient to hold their loved one's hand and say good bye (IMO to the patient, while we are doing CPR, the patient is still alive). This is the saddest part but necessary for everyone's well being - everyone is crying - a lot of times my staff will start crying too.
5. Do another few min of CPR, show no cardiac activity on ultrasound to family, call time of death.

Obviously every code is different, it will be much faster if it is a 90 year old with unwitnessed arrest versus a 20 year old. But in general, this is the approach I like to take. It gives the family some time to think about what's happening, to come to terms with it, and to say goodbye.
 
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My codes usually go like this:

1. Code the patient with my team - we run an efficient code, the family gets its first update that their family member has lost pulses and we are doing everything we can
2. 15min ish (give or take each individual case is different obviously), family gets second update that the code is not going well, we are still doing our best
3. At some point in the next 15-30 minutes, it becomes clear that there's absolutely nothing happening, DW family the patient is probably going to die, offer 1-2 family members who are closest to the patient and who have maintained their composure to come in and see the patient
4. While we are coding the patient, tell the patient to hold their loved one's hand and say good bye (IMO to the patient, while we are doing CPR, the patient is still alive). This is the saddest part but necessary for everyone's well being - everyone is crying - a lot of times my staff will start crying too.
5. Do another few min of CPR, show no cardiac activity on ultrasound to family, call time of death.

Obviously every code is different, it will be much faster if it is a 90 year old with unwitnessed arrest versus a 20 year old. But in general, this is the approach I like to take. It gives the family some time to think about what's happening, to come to terms with it, and to say goodbye.


Wow your codes take a long time. If they are elderly AND have unwitnessed arrest, or are at least 30 min with no SROC, then I give 1 epi and call it. My nurses would absolutely slaughter me if I used your above procedure.
 
Wow your codes take a long time. If they are elderly AND have unwitnessed arrest, or are at least 30 min with no SROC, then I give 1 epi and call it. My nurses would absolutely slaughter me if I used your above procedure.

He did qualify his process as being case by case. I can see this process being for those codes where there's some hope of ROSC and not your example of the elderly unwitnessed arrest
 
We always allowed family there if they wanted to be. It let them know that we did everything we could, and resulted in substantial reductions in the number of families filing complaints (legal or otherwise) post-resuscitation.

Aren't you a student? One day you are and the next you are not.
 
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On a side note, I don't feel bad about putting drain-circlers on life support for a day or two for their family to say good-bye to them in the ICU before they die. Query your non-medical friends and family on this issue. I'm sure they will want their loved ones kept alive long enough for them to say goodbye.

Agreed completely. The extra day or two totally will calm down the hysteria, and allows for an even greater case to be made against life support, like an EEG showing complete brain death etc.
 
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Agreed completely. The extra day or two totally will calm down the hysteria, and allows for an even greater case to be made against life support, like an EEG showing complete brain death etc.

Now if I can only get people to stop promising EEGs when a clinical exam works.
 
On a side note, I don't feel bad about putting drain-circlers on life support for a day or two for their family to say good-bye to them in the ICU before they die.

And in doing so you've filled up an ICU bed with a patient for which I can do nothing.

Query your non-medical friends and family on this issue. I'm sure they will want their loved ones kept alive long enough for them to say goodbye.

Follow that question with "would you want us to make them suffer for those two days?" I'd wager you'd get a different answer.
Sometimes the person is so far gone that they just lay there like a brainless slug for those two days. Other times I can't give them enough pain/sedation meds to keep them from thrashing without tanking their BP, so we press the heck out of them and their fingers start falling off. (extreme examples both ways, but generally it's closer to the medication conundrum side of things...)

If ICU/ethics/palliative care can't convince them to pull the plug on the vegetative state patients the next day, then you're not going to in the ED during the heat of the moment.

Ah, but you've missed the opportunity to make it a quick process. I'd bet that you know which patients aren't going to do well from the moment you walk into the code. Those are the ones that don't need a long code. If you walk into the room and it's a contracted emaciated NH resident with multiple decubiti, just call the code right then and there. You don't even need to do a round of epi. Just because someone is full code does not obligate you to do it.

Agreed completely. The extra day or two totally will calm down the hysteria, and allows for an even greater case to be made against life support, like an EEG showing complete brain death etc.

It does not. The longer their body survives, the more entrenched a lot of family members become. And it's the ones that are coming from out of state. They have separation guilt; they haven't seen mom/dad/grandma/grandpa for months or years and they think that by refusing to make them comfort care they are somehow showing how much they love that person. As soon as I hear "relative X is flying in from california and will be here tomorrow" I know that the window to take this person off life support is closing.

If they were hale and healthy and were suddenly stuck down with some devastating event, then ok, I can keep them going for a day or so for family to arrive. If this was something that everyone saw coming a year away, then no; those are the ones that it becomes an intractable battle (usually between factions within the family and the patient is the one caught in the middle).
 
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Ah, but you've missed the opportunity to make it a quick process. I'd bet that you know which patients aren't going to do well from the moment you walk into the code. Those are the ones that don't need a long code. If you walk into the room and it's a contracted emaciated NH resident with multiple decubiti, just call the code right then and there. You don't even need to do a round of epi. Just because someone is full code does not obligate you to do it.

Agree completely. I usually do one round of epi (as it takes very little time), 2 minutes of CPR and call it.
 
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