Dr. Brent Peery on family presence during codes

Families at Codes: A Beneficial Practice

“Stop! Just stop it! He has suffered enough.”

These words were from the son of a patient who was undergoing cardiopulmonary resuscitation (CPR), administered by the code team of a large academic trauma hospital. He was in his father’s hospital room when his father suddenly had a cardiac arrest. The code team was called, including the chaplain on duty, who responded very quickly. As the rest of the team worked with focus, skill, and haste to restart the patient’s heart, the chaplain stood with the son in the corner of the room and attended to his emotional and spiritual needs. Ten minutes into the code, the son tearfully asked the team to allow his father to die in peace. They complied. One by one the team members gathered their equipment, expressed their condolences to the son and exited the room. The chaplain remained to support the son as he expressed the mixture of grief and gratitude that comes after the death of one long-loved and lost.

This personal experience is one of many that illustrate why I support our hospital’s policy of allowing family members to be present at codes. This policy is in accord with the American Heart Association Guidelines. The Guidelines cite research demonstrating a variety of positive outcomes from the practice, including compliance with family wishes, family value of, and comfort from being present for their loved one’s final moments. It also assists in families’ grief adjustment. These Guidelines conclude, “Thus, in 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.”[1]

There are other reasons for allowing families to be present. It helps them make decisions that are reality-based regarding the treatment of a family member. Many people have their notions of CPR formed by what they see in fictional media where CPR is performed briefly and almost always successfully. In reality, codes are violent, lengthy, and only successful a minority of the time.[2] Family members need to understand what they are requesting for their loved one.

I have seen families experience peace after a death, knowing that great effort had been expended by the treatment team to prolong their loved one’s life. Conversely, preventing families from being present during codes can create or enhance mistrust of the treatment team (i.e. “What are they hiding?”).

At codes in our hospital, the chaplain on duty (we have 24/365 in-house coverage) locates any family immediately upon arrival at the scene of the code. If the family wants to stay in the room, the chaplain helps to ensure that the family is out of the way of the code team and attends to their needs allowing the rest of the team to focus on the patient. Some families choose to remove themselves from the situation. There have been requests to watch from the hallway outside the patient room. Some choose not to be present and move to a waiting area down the hall. In these cases, the chaplain has remained with the family and periodically returned to the scene of the code to acquire updates for the family.

Chaplains, by being present with the family during a code, can enhance the care of patients and families. They can explain the benefits of family presence at codes, and facilitate the healthy experience of this practice by supporting the family and helping them to understand what is happening to their loved one.

What are other chaplains’ experiences when family members are present at codes? Do you think that it has been helpful or harmful? How have the doctors/staff dealt with the family being present? Does your hospital have a policy? Does it include the presence of the chaplain?

 

Footnotes

[1] “2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Part 2: Ethical Issues. IV-9. Supplement to Circulation. 2005; 112: IV6-IV11.

[2] Robert Wallis, MD, stated in the May 2007 Memorial Hermann Healthcare Clinical Ethics and Palliative Care Newsletter, “The currently accepted rate for in-hospital CPR survival by adults is only 15% for observed and essentially nil for unobserved arrests.” Though there are numerous variables that affect outcomes, a survey of current medical literature reveals no studies with a survival rate until discharge of greater than 42%.

 

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