Life and Death Behind Closed Doors

“I got him into the room alive, and expected to have him back healthy…”

The patient’s son could barely finish his sentence, as tears accumulated in his eyes and his voice failed him. He lowered his gaze to the ground, too proud to be seen by me crying. “It’s OK. You don’t have to stay with me.” So I left the room, and headed towards the computer to draft the death certificate. My own tears of sadness were mixed with rage.

For years now, I have been advocating for family presence during cardiopulmonary resuscitation (FPDR), allowing relatives to witness, speak, and even touch their loved ones while cardiovascular resuscitation (CPR) is being administered. It is the morally right thing to do,[1, 2] it is supported by empirical evidence,[3] and it is recommended by professional guidelines.[4] One of the justifications for FPDR is that relatives could witness the efforts made by the medical staff and thus recognize that the patient was probably beyond salvation.

If the patient’s son had witnessed the code, he would have seen how two nurses, two residents, two emergency medicine attendings, one cardiologist, and one anesthesiologist worked hard to bring his father back to life. He could have seen how they used 6 milligrams of Adrenalin, and used three different suction devices to clear his airway from the gushing pulmonary edema that did not allow the insertion of the endotracheal tube. Through the ultrasound, he could have seen his father’s heart standing still, in a silent protest against all our best efforts. He could have seen the flat, unwavering, green light line on the monitor, defying us, ridiculing us.

The patient’s son could have also heard one resident asking his attendings whether the family could witness the code. He could have seen the attendings and nurses frowning, as they often do. He could have heard the resident’s meager attempt to justify FPDR, an attempt that in any event went unheeded by the medical staff. And he could have heard the resident asking at the end: “OK, who is going to talk with the family?” being aghast as the metaphorical finger of his attendings pointed at him.

Hence the rage.

Equate that with another case, in the same room, different patient, different staff, same resident.

With this patient, three relatives were waiting outside the resuscitation room. I barely had to finish the sentence “can the family come in”? and the attending instructed me to offer one of them to witness the code. The nurses, once again, frowned. Well, let them.

I barely touched the patient, and barely did anything for him. Or, alternatively, I did far more than anyone in that room. I stood by his son, in one of the corners of the room, and explained what was going on. I touched his son’s shoulder and clarified that this father’s condition was grave. And I listened to his son as he was telling me first what happened, and, perhaps more importantly, how his father was a light-weight wrestling champion in the Balkans. He was, in fact, a sort of a ‘kind giant’- always eager to help and support his family and friends. He liked his evening walks, where he could smile to the people walking pass him, exchanging pleasantries with the folks he got to be acquainted with. He did not know this walk would be the last one.

The truth is that the patient was beyond salvation way before he arrived to our hospital. But his son’s explicit gratitude meant that all our efforts were not in vain. We did provide care for someone in that case, but not for the patient. Going out on a limb, I hope that the patient could still hear his son thanking us for trying our best and for including him in the code, and I hope this allowed him to depart peacefully. I want to believe that, as he walked through the white gate with Magen David on top, he felt no fear; he felt loved; he felt he was not alone.

There is no reason to exclude relatives during codes, exactly as there is no reason to exclude partners during births or to withhold antalgic medications to surgical patients. Medical practice should be guided by ethics, evidence and societal considerations, not by the whim of individual healthcare providers. Outdated practices should go into the history books, together with urine tasting and potentially the use of adrenalin during codes.[5]

References

1. Lederman Z, Garasic M, Piperberg M. Family Presence During Cardiopulmonary Resuscitation: Who Should Decide? Journal of Medical Ethics. 2014;40:315-9.

2. Lederman Z. Family Presence During Cardiopulmonary Resuscitation. The Journal of clinical ethics. 2019;30(4):347-55.

3. Jabre P, Belpomme V, Azoulay E, Jacob L, Bertrand L, Lapostolle F, et al. Family Presence during Cardiopulmonary Resuscitation. New England Journal of Medicine. 2013;368(11):1008-18.

4. Lederman Z. Family Presence During Resuscitation- Evidence Based Guidelines? Resuscitation. 2016 105:e5-e6.

5. Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. New England Journal of Medicine. 2018;379(8):711-21.