joeG

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There are ten minutes remaining on my shift when I hear that a patient is being brought into the critical resuscitation unit. I walk over to the unit and see EMS workers bringing in a stretcher while they are "bagging" a patient. "Doesn't look good," I say to myself. Tonight I am in charge of managing the airway, so I wait at the head of the bed, laryngoscope in hand, for the patient to arrive.

EMS workers barge through the doors. "We have a 45-year-old man, witnessed collapse outside a restaurant, CPR started on scene by bystanders." They continue, "PEA on our monitor, gave dextrose, thiamine, naloxone – no response." He is moved to the resuscitation bed. An intern cuts his clothes off. He is wearing a suit. A gold watch sparkles on his wrist. The patient looks lifeless, grey. Death is lurking – will we make a difference? I open his mouth, not needing the usual paralytic and sedating medications, and insert the laryngoscope. All I can see is a throat full of fluid that splashes around with each CPR compression. I ask to hold compressions. With some suction the airway becomes patent. The endotracheal tube is easily inserted into the trachea. Respirations and compressions resume. I look up and see a middle-aged woman standing across the room. She is well-dressed, holding a pocket book, leaning against the wall, almost tucked into a corner, watching us silently. She is all alone. I can see tears in her eyes. The EMS worker looks at me and says, "That's the patient's wife."

Asystole on the monitor. Medications are administered, CPR being performed. She continues to watch, buried in the corner wall, arms crossed as if she is shielding herself from what is happening around her.

I wonder to myself if this is a good thing – to have the wife of the patient watching us attempt to resuscitate her husband. I know the outcome--we see it day after day. The patient is going to die despite our best efforts.

But what does she see? Her naked husband, vulnerable, dying, lying in blood and vomit? My instinct is to have someone take her to the waiting room to spare her any extra pain. It seems like the appropriate thing to do. Why subject her to this? Will the image of her dying husband be a stress on her life?

We are 20 minutes into the resuscitation, still asystole on the monitor. We all look at each other. Blank faces. We've done all that we can do. The attending physician walks over to the patient's wife to tell her that there is nothing more we can do. I see tears running down her face. The wall seems to keep her limp body from crumpling to the ground.

We stop chest compressions. I disconnect the oxygen from the endotracheal tube and solemnly walk away from the patient. The attending walks his wife over to his body. I see her pick up his limp hand, kissing it. She hugs him and buries her head into his chest. I hear her tell him how much she loves him. The room falls silent, bereavement begins.

Later that evening, I spoke with the patient's wife to obtain information for the death certificate. At this point she was surrounded by family members. As I stood to leave, she said quietly, "I know you did all that you could to save my husband, thank you."

Was it better for her to witness our attempt to save her husband's life? Should we have escorted her to the waiting room to spare her the images of struggle? Though we are sometimes uncomfortable having patients' family members watch, studies show that they prefer it. Being present during the resuscitation often helps patients begin their grieving process—especially if they know that doctors did everything possible to save the patient's life. Being able to touch the body and say goodbye can facilitate bereavement—especially in sudden deaths. And many patients feel that their presence eases their loved ones' struggle.

If this is true, then why do doctors feel so uncomfortable having patients' family members watch? What are we afraid of?
 

EctopicFetus

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There are ten minutes remaining on my shift when I hear that a patient is being brought into the critical resuscitation unit. I walk over to the unit and see EMS workers bringing in a stretcher while they are “bagging” a patient. “Doesn’t look good,” I say to myself. Tonight I am in charge of managing the airway, so I wait at the head of the bed, laryngoscope in hand, for the patient to arrive.

EMS workers barge through the doors. “We have a 45-year-old man, witnessed collapse outside a restaurant, CPR started on scene by bystanders.” They continue, “PEA on our monitor, gave dextrose, thiamine, naloxone – no response.” He is moved to the resuscitation bed. An intern cuts his clothes off. He is wearing a suit. A gold watch sparkles on his wrist. The patient looks lifeless, grey. Death is lurking – will we make a difference? I open his mouth, not needing the usual paralytic and sedating medications, and insert the laryngoscope. All I can see is a throat full of fluid that splashes around with each CPR compression. I ask to hold compressions. With some suction the airway becomes patent. The endotracheal tube is easily inserted into the trachea. Respirations and compressions resume. I look up and see a middle-aged woman standing across the room. She is well-dressed, holding a pocket book, leaning against the wall, almost tucked into a corner, watching us silently. She is all alone. I can see tears in her eyes. The EMS worker looks at me and says, “That’s the patient’s wife.”

Asystole on the monitor. Medications are administered, CPR being performed. She continues to watch, buried in the corner wall, arms crossed as if she is shielding herself from what is happening around her.

I wonder to myself if this is a good thing – to have the wife of the patient watching us attempt to resuscitate her husband. I know the outcome--we see it day after day. The patient is going to die despite our best efforts.

But what does she see? Her naked husband, vulnerable, dying, lying in blood and vomit? My instinct is to have someone take her to the waiting room to spare her any extra pain. It seems like the appropriate thing to do. Why subject her to this? Will the image of her dying husband be a stress on her life?

We are 20 minutes into the resuscitation, still asystole on the monitor. We all look at each other. Blank faces. We’ve done all that we can do. The attending physician walks over to the patient’s wife to tell her that there is nothing more we can do. I see tears running down her face. The wall seems to keep her limp body from crumpling to the ground.

We stop chest compressions. I disconnect the oxygen from the endotracheal tube and solemnly walk away from the patient. The attending walks his wife over to his body. I see her pick up his limp hand, kissing it. She hugs him and buries her head into his chest. I hear her tell him how much she loves him. The room falls silent, bereavement begins.

Later that evening, I spoke with the patient’s wife to obtain information for the death certificate. At this point she was surrounded by family members. As I stood to leave, she said quietly, “I know you did all that you could to save my husband, thank you.”

Was it better for her to witness our attempt to save her husband’s life? Should we have escorted her to the waiting room to spare her the images of struggle? Though we are sometimes uncomfortable having patients’ family members watch, studies show that they prefer it. Being present during the resuscitation often helps patients begin their grieving process—especially if they know that doctors did everything possible to save the patient’s life. Being able to touch the body and say goodbye can facilitate bereavement—especially in sudden deaths. And many patients feel that their presence eases their loved ones’ struggle.

If this is true, then why do doctors feel so uncomfortable having patients’ family members watch? What are we afraid of?

Posted at: www.nyemergencymedicine.blogspot.com

Agreed. At the beginning of my residency there was an article in the local paper that broached this topic, families basically want the option to be there. I think seeing that we are working as hard as possible to make a difference makes a difference to them.
 
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Mary Jane Watson

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I've had the experience where the family tells us to stop not long after they are brought into the room. That is another reason for them to see - not only that we are doing everything, but only then do they understand that "full code" is a pretty barbaric thing.
 

southerndoc

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The PICU and pediatric ED encourages families to watch the resuscitations. Supposedly studies support this, but to my disgrace, I've never read them.

The adult ED and ICU's do not encourage it.

Out of curiosity, is dextrose, thiamine, and naloxone the new front-line agents for PEA by the new AHA ACLS guidelines?
 

beaudubbs

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there are actually several studies that have been done on this subject of families being present during codes and resusitations. it is quite interesting material that i have not read. however, i have attended 2 or 3 presentations reviewing the subject. the consensus seems to be that (in answering the OPs initial question) what physicians fear about these situations is making a mistake in front of the family, with the worst case being litigation as the outcome. "we" are afraid that we will do something wrong at a crucial moment. alternatively, we may do nothing wrong, but the choas in the room may inspire a greiving family member in denial or anger to pursue legal action in relation to an issue the physician may not even control. the available data illustrate several points.

first, the fear we have of litigation is founded in the fact that most malpractice lawsuits are indeed filed about issues that are seen by the medical community as frivolous or immutable.

next, there is a direct correlation between the quality of the patient-doctor relationship and the likelihood that they will sue you. relationship is a vague concept and may be actual or merely perceived (i.e. sitting down in the room or not despite spending the same amount of time with them).

also, the current data suggests that situations in which families are present for codes and resusitations result in fewer medico-legal cases, not more.

lastly, when families are present, the grieving process occurs much more smoothly and completely. families report feeling that they know more certainly that everything that could be done was. furthermore, they feel like their loved one recieved attention and effort beyond what they even expected.

just adding to the discussion what i can recall from these talks. it seems important to give the family the option to watch, if they so choose. best of luck to all.
 

hyperbaric

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Question -

In my (limited) experience, medical codes tend to run 'smoother' than trauma codes. Does your opinion on family in - vs family out - vary for code 'type'?

(Disclaimer: I know 'smooth' isn't the best term to describe a code. I also know that not every code is exclusively medical or traumatic. )
 

beaudubbs

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i'm not sure if code type matters per the data, but i know that the suggestion is that how smooth the code runs doesn't affect the outcome (though i can imagine some limitation to this as well). the point is that the family tends to sue less and grieve better when they are included. FWIW, a lot of the data is done out of pediatric codes actually, as the physician fear is apparently highest there.
 

hyperbaric

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Studies/data aside, I was just curious as to wether or not the practicing docs reading this thread were less likely to allow family into a 'messy' codes.
Death isn't generally pretty, but some are particularly gruesome.
 

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It usually happens that the family shows up 10 min or so after the patient and they arrive at the front door. That gives me long enough to get a grip on how the code is going to turn out. If it's going to be a death I keep the code going and go to our "quiet hallway" (quiet room is now the chest pain obs unit) and size up the family. At that point I make a gut call. I'm a big fan of bringing the family back for the code but if they're already screaming, violent, fainting, etc. no code for them. The majority of the time they are cool so I bring them in and at that point I'm really ministering to the family. I have them hold hands, talk to the loved one, whatever. Then I call the code and let them be with the deceased. It usually works well given the horrendous nature of the situation.
 
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beaudubbs

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sorry, i guess i interpreted the post topic wrong. what i am afraid of is definately snakes. see them before they see you.
 

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Paramedics run codes in front of the family all the time. Pretty hard to do it any other way. . .

I never had a problem with a family during a code, especially if you gave them something to do (e.g. clear furniture out of the way). Heck, I even had a son continue compressions on one occasion - certainly did as good a job as anyone.
 
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Agreed. At the beginning of my residency there was an article in the local paper that broached this topic, families basically want the option to be there. I think seeing that we are working as hard as possible to make a difference makes a difference to them.

We already give famililes too many options.

"We want chest compressions but no breathing tube."

"Just drugs but no chest compressions."

"Keep him alive until it is futile."

"Keep my 98-year-old demented mother alive even though she has an ejection fraction of 8 percent and is never, ever, leaving the ICU except in a bag."

Hey, I don't go to my patient's place of employment and rock the Slurpee machines.
 

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I think its very important to ahve the family there and I always ask them if they want to be present. I think most important though is to have one person there who is supporting the family member.... to explain what is going on.


btw, I know the guy who runs the blog adn he is a great guy at a great residency. :)
 

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We already give famililes too many options.

"We want chest compressions but no breathing tube."

"Just drugs but no chest compressions."

"Keep him alive until it is futile."

"Keep my 98-year-old demented mother alive even though she has an ejection fraction of 8 percent and is never, ever, leaving the ICU except in a bag."

Hey, I don't go to my patient's place of employment and rock the Slurpee machines.

Uncle Panda,

I've seen you make reference to this "some of column A and some of column B" approach to resuscitation descisions a few times. Do you really encounter it that often that families want to pick and chose from ACLS?

I'm only a lowly M3 with little ICU experience but every pt I've seen has been either been full code or DNR/DNI...
 

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I think at least half the time in EMS the family is in the area of the code and to a degree it can help. My last one for example grandma dropped dead in the kitchen with everyone around and before we transported our A/C could talk to the family, they could say something to the patient and they could see by what we did what was going on. As well as the fact that grandma was dead as dead could be.
 

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Uncle Panda,

I've seen you make reference to this "some of column A and some of column B" approach to resuscitation descisions a few times. Do you really encounter it that often that families want to pick and chose from ACLS?

I'm only a lowly M3 with little ICU experience but every pt I've seen has been either been full code or DNR/DNI...

I'm with Panda on this one. It happens all the time, exactly like he described. People, for some reason, doesn't like the thought of intubation or chest compression and makes up a nice little Chinese menu of rescussitation choices. I don't believe it should be up to - largely uninformed - patients to decide what they want.

How many times have we heard "well, I don't want to be on a machine but I guess you can give it a shot for a little while".

When I get old and I feel like my time is coming, I'm posting a big POLST form on my front door for so the EMTs know what I want.
 

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When I get old and I feel like my time is coming, I'm posting a big POLST form on my front door for so the EMTs know what I want.

I know a medic who has his advanced directives (he is DRN/DNI/DNH) literally tatooed onto his chest. He showed me. It says:
"My name is _________ _______. My birthdate is XX/XX/XXXX. I do not want to be hospitalized, intubated, or resuscitated." It has his signature, dated every six months, and his doctors' name and signature, also dated every six months.

Granted, he is a bit weird, but I think its the best way to go. You can miss a bracelet or a medic alert tag, but its kinda hard to miss a giant chest tatoo when you're doing chest compressions.
 

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Where do these blog posts come from and did you write them?

Some great posts - thanks - it was very interesting to read your responses. The literature is replete with studies that support having family present during a resuscitation. The posted story describes a case I saw the other night - having the wife in the room felt weird, but after the resuscitation was over, I was relieved I did not ask her to leave.

JoeG


Roja...you're too sweet!:)
 
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I know a medic who has his advanced directives (he is DRN/DNI/DNH) literally tatooed onto his chest. He showed me. It says:
"My name is _________ _______. My birthdate is XX/XX/XXXX. I do not want to be hospitalized, intubated, or resuscitated." It has his signature, dated every six months, and his doctors' name and signature, also dated every six months.

Granted, he is a bit weird, but I think its the best way to go. You can miss a bracelet or a medic alert tag, but its kinda hard to miss a giant chest tatoo when you're doing chest compressions.

We were just talking about this last week. Tatooed instructions on the corpus proper are not legal documents. After all, the "signature" isn't an actual continuous thing made with indelible ink.
 

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I have heard at least one person only give pt's the choice of full code or dnr. That person explains that codes are hectic so there are only basically two options: dnr vs full code (none of this compressions but no intubation.....the list goes on). Maybe someone can tell me if this is kosher.
 

gutonc

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I'm with Panda on this one. It happens all the time, exactly like he described. People, for some reason, doesn't like the thought of intubation or chest compression and makes up a nice little Chinese menu of rescussitation choices. I don't believe it should be up to - largely uninformed - patients to decide what they want.

How many times have we heard "well, I don't want to be on a machine but I guess you can give it a shot for a little while".

When I get old and I feel like my time is coming, I'm posting a big POLST form on my front door for so the EMTs know what I want.

I too have run into this more times that I care to think about. It's one of the problems w/ having this discussion when people are critically ill (which is usually when it happens). If PCPs had time (and got paid) to have this discussion w/ patients and were able to document it in a way that it would be easily available to EPs and ICU docs it would make life much easier (yet another reason I think that CPRS should be mandatory for health care facilities/providers accepting any gummint money but that's a different thread).

POLST forms are great (and a good way to have the discussion in the outpatient setting) but it can actually make things more difficult as there are enough options (at least on the Oregon state form) to muddy the waters in an emergent setting.

I've gotten to the point where, when I present the code question in the inpatient setting, I try to make ithem understand that what we do will be basically automatic. "If your heart stops or you're not breathing, we'll give drugs, shocks, chest compressions and put a tube in your throat to help you breathe and put in some central catheters to do invasive monitoring of your blood pressure and heart function." Period. You either get that or you get a nasal cannula and 5-20mg morphine.

During one of my ward months earlier this year, we had 3 of 6 patients we admitted in one day (it was a slow day) answer the code question with "I don't want to be a vegetable doc." So we made them DNMV.
 

roja

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Joe, you aren't supposed to tell anyone that! jeez.. you'll ruin my hard worked for reputation. *rolls eyes*


I disagree with not giving patients options. Its easy to superimpose your own 'when its my time' onto others, but this isn't really your job. Your job is to give patients the option and then abide by thier decision. If the family wants intubation but no compressions, then I explain that it will probably be futile but I will respect it. If they want everything done on thier 90 year old granma, then I do it. Even if I disagree. Obviously, I am not going to code someone for two hours who is 90. but I will still give it a go, if nothing else to help the family grieve.

I think this is a dangerous and slippery slope. If you don't believe in contraception, are you going to just decide not to offer it to your patients? Are you going to transfuse a jehovah's witness even if they need it? Where do you draw the line and what doctors values will set the standard?
 
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I disagree with not giving patients options. Its easy to superimpose your own 'when its my time' onto others, but this isn't really your job. Your job is to give patients the option and then abide by thier decision. If the family wants intubation but no compressions, then I explain that it will probably be futile but I will respect it. If they want everything done on thier 90 year old granma, then I do it. Even if I disagree. Obviously, I am not going to code someone for two hours who is 90. but I will still give it a go, if nothing else to help the family grieve.

I think this is a dangerous and slippery slope. If you don't believe in contraception, are you going to just decide not to offer it to your patients? Are you going to transfuse a jehovah's witness even if they need it? Where do you draw the line and what doctors values will set the standard?

This is what I tell family (with interspersed dramatic pauses): "If we don't have any directions, or directions to 'do everything', we err on the side of life, since we can't undo or fix death. (pause) At the same time, what we do, in truth, borders on barbaric. (+/- here specifics) The only patient I've ever done compressions on where I didn't break a rib was a 42-year old man. We don't want to save your (insert loved one's name/position here), only to have him/her die two days later in the intensive care unit, with all their ribs broken, both lungs blown out, and a breathing tube in, waiting for all the other organs to fail. Now, the question you are thinking that you are not saying is that "I killed mom (or whomever it is)" [the "I" being the family member], and that is NOT the case. Everyone WILL die, eventually, but there can be some peace and dignity, or, at least, not the indignity of the invasive and barbaric nature of what we do trying to save the life."

Then I give them some emotional support, or time to think about it.
 

emtcsmith

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I can understand pick and paring a DNR for out of hospital care, but if your going to treat someone then it should really be an all or nothing game. Someone to is "intubate but don't CPR" really seems like they just don't understand the treatment or end result.
 
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