ACLS, ATLS, ECLS; most intensivists can recite the resuscitative alphabet with relative ease. At some point, though, we cannot save some people. There are those for whom we can do nothing more, or perhaps we simply arrived too late. It’s an awful part of the job, but common enough. A great deal of effort has been sunk into not only the organization of resuscitative efforts, but also criteria/ guidance on when to stop a resuscitation and recognize futility (1). At some point compressions have to stop because, despite our best efforts, a person has died. The actual pronouncing of a patient’s death, however, should not conclude your next code blue. Before excusing the team and starting the process of informing family or the Medical Examiner, a team leader needs to make time for “the pause.”
The concept of “a moment of silence” has permeated popular culture for ages. It acknowledges a solemn event without making assumptions or imposing beliefs and it’s something that nearly everyone can understand. Strangely, healthcare providers have only recently started to articulate its use in a healthcare setting, specifically in the moments that follow a resuscitation’s end (2-4). To date, no organizational protocols or professional organizations have published guidance on doing this. It’s still pretty new…but it shouldn’t be. “The pause” is a moment of reflection the team leader asks of the team to remember that the body in front of them was a person. This was someone’s brother or daughter. This was a family’s rock or a person who told a joke to brighten somebody’s day; the team was just lining, “lab’ing”, and compressing a person…and now they’re gone.
Some might view this practice as a little “hokey,” or at worst that it risks highlighting a team’s failure. I would argue that it actually accomplishes the opposite effect. We all suffer from burnout, and at the root of that affliction is the repeated devaluing and de-personalization of human interactions (4). When a person dies, especially when it’s in spite of a team’s efforts, it’s traumatic. Some will work through that trauma in the gym or cry it out on the drive home. Others may pour out a little extra bourbon, and still others may even succumb to crippling depression. As the COVID-19 pandemic has shown us, the stresses of death and dying are driving some frontline providers to end their own lives (6). A pause acknowledges the trauma that a team of caring professionals just felt. It acknowledges that life is precious, and that the patient was, indeed, a person. It reminds us that we are people trying to take care of each other.
How to Take a Pause
For those who might worry about things seeming awkward, I use a pretty standard script:
- Make it clear that the code is not over: “Hey everyone, before you leave I would like to say something.”
- Say the patient’s name as well as something else. Don’t be afraid to ask or use the wrist band. If I did not know the patient before the code, I usually say: “This was John Smith. I did not know him, but he was a man in the hospital and was trying his best to get well again.”
- Take the moment of silence. Less than a minute is needed.
- After the moment of silence, thank the team. “I know this was hard, but I know everyone did their best for John. Thank you for all that you did.”
Sometimes the fight does not go our way, but we can always maintain control over how we perceive ourselves, and indeed the humanity in others. In a world of COVID-19 visitor restrictions, PPE, and quarantine we all run the risk of dehumanized interactions, possibly for the foreseeable future. When someone dies, though, we need to find the courage to remember who we are and that we are all ultimately here to take care of one another.
- CEASE Criteria, https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201412-552PS
- RN Pause, https://acphospitalist.org/archives/2016/01/q-and-a-the-pause.htm
- EMRAP, Ready Set Pause, https://www.emrap.org/episode/readysetpause/thepause
- VCU News. “Pausing to honor a life.” https://news.vcu.edu/article/Pausing_to_honor_a_life
- Stephen Trzeciak, Anthony Mazzarelli. Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference. 2018. ISBN-10: 1622181069
- NYC Emergency Physician Suicide. https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html