October 29, 2019

In most ICUs, it's standard practice to send relatives out of the room when a patient codes, but a growing body of research—and one doctor's personal experience—suggests relatives should be allowed to witness the medical team's efforts, Daniela Lamas, a doctor at Brigham and Women's Hospital, writes for the New York Times' "Well."

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Why most hospitals don't let families witness a code

In residency, Lamas writes, she was told that the typical response to a code in the ICU was to send the patient's relatives away. "This is not a spectator sport," she explains. "Ribs break. Limbs flail. Blood sprays. Dignity fades." Plus, there was a perceived risk that family members could get in the way during a code, Lamas writes.

But new research suggests this move to keep relatives away "might have been wrong," according to Lamas.

She explains that studies show that family members don't distract the medical team, and that doctors don't feel any added pressure to prolong or cut short CPR when family members are present. The research also finds no increases in legal ramifications, according to Lamas.

"Perhaps more important, allowing relatives to be present for CPR doesn't leave them with higher rates of anxiety, depression or post-traumatic stress disorder," Lamas writes. In fact, some research suggests that family members were less likely to experience PTSD when they watched clinicians attempt to "bring a loved one back from the brink," according to Lamas.

One doctor's experience inviting a patient's wife into the ICU

Lamas shares her own experience as a physician caring for a man suffering from unexpected heart failure.

The man's downturn had been shockingly sudden, Lamas writes. Earlier that day, he and his wife had brushed off the early signs of illness as a likely cold—but when he reached the hospital, they discovered "he actually had leukemia that had caused his heart to fail," according to Lamas.

"By the time I met him, it seemed clear that he wasn't going to live," Lamas writes. "So when he went into cardiac arrest for what I suspected would be the last time, I headed out of the unit to find his wife."

Lamas found the woman in the family room and explained that her team was doing CPR again. "Then I asked her what might seem like a strange question: 'Do you want to be there while we do CPR?'"

The woman hesitated at first, but then agreed.

"Inside the room it was chaos," Lamas writes. "[A]n intern in the midst of chest compressions while another drilled into her husband's shin for emergent IV access. For a moment I wished that I could take the question back and purge the image from her memory."

Lamas turned to the woman and asked if she really wanted to stay. "You don't have to," she said.

But the woman chose to witness everything, telling Lamas that she needed to see so that "she could believe it was true," Lamas writes.

Lamas gave the woman some tissues and led her to a chair in a corner of the hallway. "That way she could watch what was going on without seeing too much or getting in the way," Lamas writes.

A broader effort to incorporate families

For Lamas, allowing families to observe CPR is part of "broader efforts to bring families into critical care." At Lama's ICU, clinicians invite relatives to join morning rounds, which she writes has been helpful for the family members and clinicians.

"There is nothing like a tearful relative to keep us accountable and to remind us daily that this 'great case of respiratory failure' is in fact a person," Lamas writes. "And for better or worse, that relative often provides the best continuity in a fractured medical system."

In the case of Lamas' ICU patient, the wife eventually asked—after witnessing lengthy efforts to revive her husband—whether he would be OK. When Lamas shook her head no, the wife told Lamas the medical team should stop.

"I know you tried," she said to Lamas. "Let them stop."

When the team finally called the man's death, Lamas heard the "patient's wife beg[in] to sob. … I had never seen grief so naked, and I wondered whether I had made the wrong choice."

But just as Lamas began to doubt the protocol, the woman looked at her and said, "Thank you" (Lamas, New York Times, 10/25).

Next, get URMC's end-of-life conversation prompts

When it comes to end-of-life care, most organizations struggle to meet patients' needs. In a recent poll, 87% of Americans age 65 and older said that they believe their doctor should discuss end-of-life issues with their patients; however, only 27% of those polled had actually discussed these issues with their doctor.

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