Thursday, April 12, 2007

PostScript



What Are We Afraid Of?




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?


"PostScript" is a column designed to post moving, comedic, or interesting stories from anybody who works in or is a part of the health professions. All comments are welcomed.

You can send your story to nyemergencymedicine@gmail.com

8 comments:

ERnursey said...

It is better to let them in, although it is optimal if you can have a support person there for them

Surgeon in my dreams said...

The story breaks my heart as I ponder my husband of 3 years who at 52 has several chronic illness'.

I would definitely be able to handle his death better if I am allowed to stay in the room.

I would also be much calmer if he were to be allowed to stay with me in the event I am ever taken to the ER after some traumatic event. Just his presence in the corner - just knowing he is there - would have a calming effect one me and I'm sure others feel the same way.

Adam said...

Surgeon in my dreams,
I am sorry you have to go through this - thank you for sharing your thoughts.

Adam said...

ernursey,
I agree- it is important to have support staff such as a social worker, nurse, or physician close by to explain what is happening. Thanks for the comment.

Judy said...

We once had the father of a patient "remind" the physician carrying out the code that he (the father) was a law enforcement officer and had been permitted to bring his gun into the hospital with him. The baby survived that time, but the family was NOT notified of the next (and final)code until it was over.

Sometimes it's a good idea. Sometimes it just isn't.

Adam said...

Hi Judy,
Thanks for the comment. Yes, sometimes the situation isn't always they way you want it to be. In these situations, as you described, the family should be escorted out of the resus room by social work/hospital security and wait close by.

PJ Geraghty said...

I think it's critical to allow family members to be present for resuscitation efforts if doing so does not interfere with said efforts. The father/LEO mentioned in one of the comments would be the obvious exception.

As a paramedic who no longer does much field work, I find that when I do run calls like this, my skills are often better utilized in working with the patient's family than directly with the patient. There are (usually) many skilled providers who can take care of the patient; relatively few of us have experience and comfort with working with grieving families. Having someone who can do this, explain what's going on, and support the family is of vital importance.

Adam said...

Thanks PJ
I agree with your comment. Roles should be assigned for this, just like they are to take care of the patient. If we decide to have family present, there needs to be someone present to explain what is happening, etc.