Dr. Signout, over at, well, Signout, wrote an interesting piece the other day. It's a piece that everyone should read and think about while they can, because you never know when you may need to think about this.
One of the most dramatic procedures in any hospital is the CPR, also known as a "code blue", or simply a "code". This is the choreographed chaos that takes place when someone's cardiopulmonary status deteriorates to the point that only immediate and violent intervention will prevent their death. To put it more dramatically, the object of a code is often to forestall or even reverse death. Health care providers hold a range of opinions about whether or not family members should be allowed to witness a code. Current ACLS guidelines take a reasonable, evidence-based approach:
[I]n the absence of data documenting harm and in light of data suggesting that it may be helpful, offering select family members the opportunity to be present during a resuscitation seems reasonable and desirable (assuming that the patient, if an adult, has not raised a prior objection. Parents and other family members seldom ask if they can be present unless encouraged to do so by healthcare providers. Resuscitation team members should be sensitive to the presence of family members during resuscitative efforts, assigning a team member to the family to answer questions, clarify information, and otherwise offer comfort.
Some would argue that doctors have never given up their death-grip on paternalism, but I have argued otherwise. In the case of codes, however, paternalism may still hold sway, at least in a certain way.
Most CPR's at the major teaching hospitals are run by medical residents. It is an important bonding event for them. Let me give you a bit of a picture. First, when you're on call, you usually carry a "code pager". This makes you both edgy and important. When a code is called, usually on the pager and overhead, a dozen or so people converge on a patient's room. There may be a roommate whose bed is quickly pulled into the hallway (along with the patient). The floor nurses are busy with chest compressions, or checking vital signs, or (hopefully not) panicking. The medical residents, anesthesiologists, respiratory therapists, clergy, medical students, and whomever else is nearby pile into the room. Usually one of the senior residents, or one of the older nurses will yell for all non-essential personnel to get lost. Meanwhile, one of the residents takes charge of trying to save the patient.
There is usually quite a bit of informal debriefing afterward. There are also phone calls to make---to the attending physician, to the family. Of course, if the family happened to be there at the time, it's more of a sit-down. This can be rather awkward, as a CPR is often loaded with physical violence, sick humor, and flippant comments, all of which serve to make the situation more palatable to the code team, and help bond them more closely. I don't know of any medical resident who hasn't said something a bit inappropriate at a code, only to find out the family member is standing outside the door.
And this is where the paternalism thing comes in. We doctors like our rituals, our private sick humor, our intimate time. Nothing (outside of the OR) is more intimate than a cardiac arrest.
Well, families are getting more sophisticated, and it's time for us to grow up. There's plenty of time for sick jokes later. During an arrest, we're going to have to get used to the idea that family may be around.
As part of getting used to this, families are going to have to understand that a code is a last-ditch, usually unsuccessful effort to snatch a human being out of an abyss whose bottom they may have been hovering near for days or weeks. Some diseases can't be fixed, and death can't usually be reversed.
And that's why it's time for everyone to read the post at Signout and start talking. It's time, right now, while you still can, to ask the question, "how do I want to die?" No answer is irrevocable, but the discussion is invaluable. We have become very good at creating an end-of-life asymptote, with one axis representing quality of life, the other time. The suffering and expense incurred as the curve stretches out is really hard to understand unless you spend a lot of time around hospitals. Once you have, though, you know you don't want to ride that curve to the bitter end.
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When an elderly relative with a do-not-resuscitate order was going into surgery, we were told that the D-N-R is ignored during surgery. Is this typical? Is there a valid reason (from the civilians' perspective) for this?
It's a practical thing. In order to do surgery, a patient has to be placed on a ventilator and often given cardiac drugs, something that isn't done for someone typically if they are DNR. Sometimes it will be discussed what kinds of happenings in the OR will mean call it quits, but usually it's a practical matter that just needs explicit clarification, such as "this surgery may make the patient feel better, and we will breath for them etc during surgery, but afterward, we will let nature take its course."
Very, very good post. Thank you for sharing your thoughts. I have been to a number of codes myself (in my previous life at a private hospital, before going into Public Health), and the jokes and comments were plenty. There may or may not have been a spark and some burnt chest hair that made for lots of anecdotes, some even at the patinet's funeral. Growing up is hard to do, and I can see there will be some growing pains in the process of "toning it down" during CPR's. Again, great post. Thanks!
My plan is to wait until I get "old" (Whenever that happens to be,) and have DNR tattooed across my chest. I have seen that end of the life cycle, and I want nothing to do with it!
When my time comes and if I'm the subject of a code, my only regret will be that I probably won't be conscious to participate in the sick jokes. I'm usually the first one to make them! I've found that my inappropriate jokes during medical situations (mine) usually makes the doctors/nurses rather uncomfortable. It would be nice to be in an environment where they would be appreciated. :D
Good point, CyberLizard. I recently underwent a thoracotomy for a collapsed lung. When I came to in the recovery room, apparently I looked at the nurse and said "That which does not kill me, only makes me stranger." That's the point where my father said "He's going to be fine."
I guess some people have that sort of humor, and some don't?
EMTs don't have the option of telling the family to clear out, so we got the "riot act" treatment several years ago. After a while, it sinks in -- the last couple of times I've had to deal with unresponsive patients, even with no witnesses, the rest of the crew leaned on the ones who didn't keep strictly to business.
At my rehersal dinner, my Dad suddenly asked everyone to make room on the banquet while he lowered my Grandfather-in-law-to-be onto the bench checked him at the wrist and neck, listened to his chest and then wacked him hard on his midsection. We were all still in shock when the old gentleman opened his eyes and struggled to sit up. My Dad asked some how are you feeling questions and watched him like a hawk for the rest of the meal, but Grandpa's color had returned and he joined what part of the conversation he could hear. He lived another 3 or 4 years.
A simple cardiac arrest, foiled by a simple GP? My Dad thought so. One wonders about Tim Russert.
I had an aortic valve replaced some years ago, and when I left the cardiac ward I asked some of the nurses to share their best sick jokes. They were all, "Oh we wouldn't do something like that", but I'm sure they were lying, and I'd have been better for a good laugh.
Out with it, health professionals! We patients want to hear the good ones!
Recently I visited my 93-year-old grandmother, and was kind of disturbed at the number of copies of her DNR she had all over the house. She wanted to be sure that, if something happened, there would be no confusion.
It seems that a woman in her retirement community had a DNR, stopped breathing in the night, and the woman's husband panicked and called 911. The paramedics didn't see the DNR and did bring her back around, unfortunately to a vegtitative state.
Which makes me wonder if there is a med-alert tag that says DNR? Since many people who would want one might not be up to a tattoo.
I'm really glad to see this post, but it raises a question for me: if electrical defibrillation, part of CPR, is really a "a last-ditch, usually unsuccessful effort to snatch a human being out of an abyss whose bottom they may have been hovering near for days or weeks", then what's the point of all the AED machines in airports and shopping malls? They're rarely going to really do any good, are they?
IANAD, but I understand that the sooner a person gets defibrillated, the better their chances of recovery. So while the odds are not good from the moment the person goes into arrest, their odds are vastly better if someone gets out an AED than if someone does CPR until the paramedics arrive.
And AEDs have saved lives. The thing is, somebody who goes into cardiac arrest at the airport is probably in much better shape than somebody who goes into arrest at the hospital. So the odds of saving the person in the hospital are probably quite a bit lower to begin with. That's not to say it's never worth trying. It all depends.
Fascinating - and I second JustaTech's question about the DNR tags. I don't think I'd wear one yet, but I'd like to have the option. Which is what this post is about, after all...
just over from signout. I am most jumped up out of my chair and shouted halelluia! when I read your bit about growing up.
I've just spent a harrowing year watching my daughter move through the NICU and the healthcare system. It has me thinking a lot, and asking that question about the how I want to die and no one seems to want to talk about it. Guess I'm a little ahead of the curve on that.