Wednesday, May 10, 2006

Would You Want To Be There?

She died unexpectedly. Well, not exactly unexpectedly - she was a middle aged woman who died from undiagnosed heart disease and complications thereof, but the timing and day of her death was unexpected. It was a sad case because it was so sudden, because she was so full of life, and because, of all ironies, she had been in town on vacation.

She had been recovering slowly and had a sudden decompensation on the day of her death. As she died, 7 physicians and numerous nurses were at the bedside in a lengthy resuscitation that was unsuccessful. For those present during the resuscitation, there was no doubt in anyone's mind that every possible thing was being done, and that when we stopped, we had tried our best, and there was nothing more that we could have done. Still, my heart went out to the husband, who sat alone in the intensive care waiting room, periodically updated on his wife's condition. For him, his wife had gone from ill but stable in the morning to dead by noon, and all this was second-hand information.

Should we have allowed him to stand by the bed and watch the resuscitation? If I were him, I probably would chose to be present. There has been some research indicating that family members have more closure when they are present during the resuscitation, and some hospitals have integrated this into patient care. Others claim that having family members present in the controlled chaos of a resuscitation would be detrimental for the patient - family could get in the way and slow down the resuscitation, or they could be overly emotional and distract from patient care... There is also the issue of being able to tolerate what they will see. Will they understand that dying people gasp for air like a fish out of water? Will they know that the electric shocks are a desperate attempt at restarting the heart? Would her husband have been able to watch as the surgeon reopened her ribcage for cardiac massage after all else had failed? But all these issues aside, deep down, I feel that family should have the choice to be present. They can see, with their own eyes, that we cared, and we tried. And perhaps, for some patients, having family present would allow us, physicians entrusted with the care of the patient, to let go more easily. Oftentimes, we become too attached to the patient, too unwillingly to let go even though common sense states that it is time. It is a fine line to walk, to know when to let go, and when a refusal to do so causes more pain for the dying or dead patient. It is much easier when a family member, someone else who has the patient's best interest at heart, knowing that we have done our best, reminds us that it is OK to step back and let go.


Anonymous Moof said...

Great blog ... found you through Grand Rounds. I'm blogrolling you.

Regarding this post, my gut reaction is that having family (who want to be there) in the room, watching you try to resuscitate a loved one would probably be the best thing all the way around - as long as the family member was calm, and out of the middle of things.

However ... with today's lawsuit happy attitude, I'm afraid that you'd have as many who think you should have done "such and such" ... or tried "this and that" -- as those who would tell you that "It's OK to step back and let go."

Today's litigious legal climate hurts everyone ... the medical personnel, the patients, and even the famlies.

9:52 AM  
Blogger always learning said...

"Today's litigious legal climate hurts everyone ... the medical personnel, the patients, and even the famlies. "

Absolutely agree. The sad thing is the lawsuit crazy ones are such a small minority, but their actions are really detrimental to everyone.

6:58 PM  
Anonymous difficult patient said...

. . .I would want to be there.

5:48 AM  
Blogger bearing said...

I wish I'd been there when my mother died (respiratory failure, lung cancer) a few years ago. She had a DNR in place, so there wasn't a resuscitation. I missed her by about 10 minutes.

Then again, she was a very private person. She may not have wanted me there. I don't know anything --- clinically speaking --- about what I would have seen and heard had I been in that room. So. Perhaps dying felt like something she wanted to do in private. She knew when I was supposed to show up that day.

6:45 AM  
Anonymous Anonymous said...

My dear husband fo 3 years has come down with several serious illness' since we've be together (I hope that is not a reflection on his being with me - lol). He is the light of my life after being married to an abuser for 24 of my 45 years. He has taught me that I too am worth loving, which I had come to believe was not true. He is sweet and kind and passionate. I would never want him to die alone. I know during a resuscitation he may not be aware, but I would and it would help me tremendously to know if he goes I would be there with him untill the moment he was in his Heavenly Fathers arms. PS...I love your blog along with all the other medical bloggers I read daily.

8:19 AM  
Anonymous Anonymous said...

Our baby coded 3 times and I was there for all of them. I had to be there. If he died, I wanted him to die with me next to him, touching him, loving him.

9:24 AM  
Anonymous Anonymous said...

I sometimes read my wife's nursing journals (she's an ER nurse). There have been a couple of articles by nurses in hospitals where they have decided to allow patient's families to be present during codes. My impression from the articles was that having patient's family there was generally not detrimental. Research the experiences of hospitals who have done this before making a decision either way.

9:26 AM  
Blogger patch615 said...

Initialy I was against the idea of family memebers being in the room at the time of a Code, but I think my opinion is turning more towards giving them the decision. It seems like ultimately a moral desicion. My inital disagreement with letting family members be in the room had to do with being slightly overprotective, I think sometimes we as EMTs Doctors Nurses tend to underestimate family members abilities to handle traumatic situations.
I'm rather sure that distraction isn't to large an issue, as durring a code most you're ultra-focused on the patient (as this post said, we tend to get attatched to the patient and not let go when we should).
My view is now that they should be given the option to be in the room, but I would love to see something on the psychological effects, and if they are in the room there should be some mechanism beforehand (if possible) to explain what is (or will possibly) go on.

1:56 PM  
Anonymous Anonymous said...

When I worked in the ER, had several codes where family was present. Most told us after that they could see how hard we worked on their loved one and they felt that we had done all that we could for them. I think it helps everyone in most situations.

4:30 PM  
Blogger always learning said...

Thanks for all the great comments. I think it's important for family to have the option of being present and hope that the medical profession moves in this direction...

9:26 PM  
Blogger Zoe Brain said...

I was there when my Father was resuscitated. I held his hand (though not when they got out the paddles), let him know I was there, and when to breathe.
An Intern came up during the process and asked me how he was doing - I had to answer I'm not a doctor, I'm his child.

Yes, Yes and again Yes, family should be present if possible, and if they can keep their heads and not get in the way, can make a difference.

Unfortunately, for my Father, there was no salvage, and 60% of his heart was akinetic 12 hours later. So we lost him, but at least this time he was given enough morphine so he didn't feel it.

He came back while there was still the smallest chance, and if family are there, familiar voices using a "voice of command", then it can make a significant difference to the patient's survival chances. As well as giving the relatives the chance to say goodbye, and knowing they gave their all to help.

That was 1993. I miss him still, and no girl was ever prouder of her Daddy.

11:41 PM  
Blogger trauma-rn2 said...

I work for the hospital that started it all... well, families at the beside at least. As far as I know, we've never had a lawsuit initiated related to resusitation when the family was at the bedside. Yes, families can get emotional at times...but they almost unanymously are cooperative when we need them to move, etc. And also are so appreciated of the chance to see the efforts we put into saving their loved one, and the chance to say their goodbyes.

1:11 PM  
Blogger Mama Mia said...

From both sides of the bed I believe that families who wish to be present should be present. Then they know their loved one did not die surrounded by strangers, and they know that we didn't just give up and walk away, but that we tried and stopped when it was right to do so.

1:16 PM  
Blogger sunflowergrace said...

it is condescending of those that say 'laypersons' cannot understand what is being done. hello? with trauma television every night even teenagers know that paddles give electric shocks intending to jump start the heart again. i see the same attitude when doctors decide not to tell a patient he/she is terminal. i think it is a gross misjudgement of how intelligent those not in the medical industry are. of course family should be there if the patient or family wants to be. i certainly wouldnt want to die surrounded by medical staff, not surrounded by family. to those of you in the medical field, please give us a bit more credit. we may not have gone through medical school but we are not stupid. we, are family.

5:39 AM  
Anonymous Anonymous said...

I have a slightly different take on the issue. My husband was present when I hemorrhaged and coded during childbirth. The medical staff were so busy with me that his presence was forgotten. He couldn't handle it and walked out of the marriage a week later while I was still in the hospital.
Perhaps it was an issue of not being able to choose, perhaps it was post traumatic stress, but some people can't handle the stress.

12:10 PM  
Blogger always learning said...

Sunflowergrace - I did not mean to be condescending, and I'm sorry it came across that way. I agree with you that some families are more medically savvy, but some are not - for my patients I would rather explain what may seem like very basic things because I'd rather err and explain too much than say something that they do not understand. As for what occurs during a code, as you are probably well aware, TV/reality shows are not accurate a lot of the time, and our reactions may be different when the patient on the bed is a loved one...
I'm sorry you've seen physicians withholding a terminal diagnosis. I don't think that's acceptable, and neither are physicians that don't discuss end of life issues with patients...

Anonymous, thank you for sharing your story. Just goes to show that we are all different and we all respond differently to stress.

4:31 PM  

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