Posted by One night last week, with not a whole lot going on, I strolled into the MICU to say hello to my friend Tom, who was working overnight.
“Wanna go for coffee?” I asked.
“Can’t,” he said, leaning against the nurse’s station. “Probably gonna code the lady in room five sometime in the next half hour.”
I thought he was kidding; people anticipating an impending resuscitation are usually too preoccupied to lean on things. He saw my raised eyebrow and explained: the woman had been terminally ill for months. At her daughter’s insistence, she had had every life-prolonging intervention, even beyond the point of medical futility. Now, she was actively dying, breathing ataxically and leaking fluid from her blood vessels at an impressive rate. Her daughter had been called and was on her way in, Tom said, but the patient wouldn’t make it another fifteen minutes without ACLS.
“Do you want me to hang around?” I asked.
“Got anywhere else to be?”
I checked my email. I picked a hangnail. I leaned on the nurse’s station next to Tom. Finally, a nurse walked up and grabbed his elbow. “It’s time,” she said.
We went through the usual algorithms at the usual pace, only without the usual sense of urgency. At about five minutes in, she was pulseless, with the monitors demonstrating erratic cardiac activity. Glances were exchanged around the room, but we kept going. It was quieter than most codes I’ve seen.
At ten minutes in, a nurse standing next to me said something out loud: “Could someone watch down the hall for her daughter? She doesn’t need to see us doing this to her mom.”
The charge nurse replied: “No, let her come right in. This is exactly what she needs to see.”
A few moments later, the small crowd near the door parted to allow in a petite blonde woman. The resuscitation was so quiet that I could hear the sound the mattress made when she rested her elbows on the bed. As an intern did chest compressions a few centimeters from her face, she pushed her mother’s hair behind her ear and whispered to her. I could not hear what she said.
We watched her do this, then watched her stand and turn around. She said, to no one in particular, “You can stop now.”
We did.
It has often seemed to me that witnessing a loved one’s resuscitation–especially a failed one–would be the worst punishment imaginable. It’s difficult to understand what meaning emerges from seeing a loved one surrounded by chaos and needles and beeping machines, their ribs cracking and blood all over the bedclothes. I wonder how much worse that image might make a person’s grief, and how much more graphic it might make their nightmares.
Despite my own misgivings, however, families are asking to attend resuscitations of their loved ones. Even stranger to me, they’re usually glad they did.
In one review article on the subject of witnessed resuscitations, families who had been present for a loved one’s resuscitation overwhelmingly said they would choose to be present again. Their reasons? Witnessing the resuscitation “helped them comprehend the seriousness of the patient’s condition and know that everything possible had been done, and it eased their grieving.” Indeed, in one teensy study of family members who had witnessed their loved ones’ failed resuscitations, scores on one validated grief questionnaire suggested that there was a real difference–for the better–in the grief suffered by witnesses compared to non-witnesses.
Still, the perceptions of the people actually doing the resuscitation substantially limit family presence during resuscitation, much as they nearly did in this patient’s case. A more recent review of staff attitudes suggests that on the whole, most see more risks than benefits in family presence. Many staff in the studies reviewed cited concerns for psychological trauma to witnesses of resuscitation (not really a big issue, if you believe the limited data noted above). Some staff noted that when family members were present, they felt pressure to do more or less than was medically indicated.
Interestingly, in several included studies, the more experienced the practitioners–both in general, and with witnessed resuscitations specifically–the more likely they were to be in favor of family presence during resuscitation. I have to wonder what we see and hear that changes our minds about this as we gain experience.
I don’t wonder, however, whether seeing her mother die–and calling the code herself–was exactly what this daughter needed. Whether or not it was standard procedure, or what we would have wanted for ourselves, it gave her the luxury of time to whisper in her mother’s ear whatever she needed to whisper. And after months of telling us to keep going, it allowed her to tell us to stop.
I can’t imagine what more we could have given her.
August 26, 2008
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