Abraar Karan: Should family members be present during end of life medical emergencies?

Is it helpful or harmful for a patient’s family to be present during these efforts, asks Abraar Karan

abraarAnyone who’s ever worked in a hospital knows the dread of the ominous monotone that signals a code blue. The resuscitation attempts that usually follow are difficult to witness as a doctor, but understandably far more so for family members and relatives. This begs a larger question: should family members be present during these advanced cardiac life support protocols?

As a doctor, I see many horrific things done to the human body almost weekly—sometimes warranted, other times less so—in the attempt to save a life. The reality is that advanced cardiac life support is often gruesome to watch. It can include broken ribs, emergency intravenous lines that quickly become bloody, and endotracheal tubes aggressively pushed into people’s throats.

I have a hard time convincing myself that these should be the last memories a patient’s loved ones will have of them, or that this is what the patients themselves would have wanted. As a doctor, do I have any responsibility or even a right to advise one way or another?

During an emergency, I find it necessary to distance myself from the emotional stakes to be able to think clearly and with direction. But when a patient’s family enters the room, it changes the dynamic of the efforts. It’s no longer a man whose heart has stopped beating; it’s also the husband, partner, or father of a person standing next to us. I can say that it admittedly becomes more emotionally difficult for us as well, and in some cases can (and has) interrupted actual resuscitation protocol. Just recently, we ran a resuscitative effort in which the patient underwent an hour of compressions with his wife watching and at one point, she was nearly shocked because she was holding on to his feet when we were calling “all clear.”

While a code event is run in the hope of saving the patient’s life, survival to discharge rates for in-hospital cardiac arrests are only around 20%. If you are witnessing a resuscitation effort on your family member, there is a very high chance that they will either die, or be revived to a vegetative or severely limited state.

In many ways, efforts at the end of life are often in large part for the sake of the patient’s family and loved ones, who may have weighed in to help the patient make the decision to opt in for resuscitative measures. As doctors, our instinct is to protect the patient, but in this case, the extension of the patient in the form of their family as well. I’m not sure if trying to shield family members from what can be a very distressing experience is the correct instinct, or whether it is overly paternalistic to advise them at all. They aren’t technically our patients, although they may be in need of clinical guidance. Furthermore, doctors should be aware that we are bound to be biased by our own beliefs and personal feelings rather than what the patient or family might truly benefit from.

Thankfully, there are some data that might guide us. A 2013 French study published in NEJM found that family members who were invited to witness resuscitation efforts had lower rates of symptoms related to post-traumatic stress disorder, anxiety, and depression 90 days after the event. However, this study was limited to prehospital arrests (in the home). We do not have the equivalent data for in-hospital arrests, which admittedly are very different.

The presence of family in acute trauma situations (post motor vehicle crashes, gun shot wounds etc), as well as in paediatric populations, has been studied more extensively. One study in 2017 examined trauma patients who were brought to critical care units and underwent resuscitation efforts. Study subjects reported afterwards that it had a positive effect, reducing perceived anxiety and stress. Similarly, in another study, the parents of children who had undergone trauma also felt that being present had helped them, primarily by making them feel like they were doing all that they could.

The costs of having families at codes must be weighed against these benefits. Namely, the presence of family may distract code leaders for a number of reasons, including accidental or purposeful interruption of the resuscitation efforts. For some doctors, there is an increased fear of medicolegal repercussions, which may cause them to overthink their response and potentially deviate from protocol. Additionally, in the NEJM study previously mentioned, all five of the study subjects who had subsequently attempted suicide were in the group that had witnessed resuscitation. This finding suggests that there may be a subset of people for whom resuscitation efforts are extremely traumatic, and we wouldn’t know this before we encourage them to enter the room.

Missing within this dialogue has been the voice of the patient in deciding whether or not they would want their family present. For many, this may feel like an invasion of privacy, and perhaps not the way they would like to be remembered. One necessary change this demands is that these questions should become a standard part of the code conversation. Doctors should be asking, “Would you be OK with your family being present if you had to have resuscitation efforts?” “Would you as family members like to be present if resuscitation was needed?” It may also be prudent to mention the data that we do have to help guide decision making.

Ultimately, the death of a hospitalised patient during a code blue is a traumatic, unfortunate end for all parties involved, but whether that trauma is alleviated or worsened by being witness to it is still unclear. For now, we need to at least make sure everyone involved is better prepared beforehand.

Abraar Karan is an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School. Twitter @AbraarKaran

Competing interests: None declared.

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.