The End of the Code

If you watch TV medicine, what you see are a lot of terrifically successful codes, with patients getting back a normal pulse and blood pressure in a matter of mere moments, and that’s where the commercial break begins; it’d be a bit much if they stood and walked out of the hospital before the commercial, that’s why. When they die on TV, it seems the only one who makes the decision is the doctor, which always strikes me as strange, even given televised unreality.

Real life, as you might expect, is different. Not only are there no commercial breaks, the codes usually end with the patients in the state they arrived: dead. Oh, we do all the right things, give medicines in the appropriate doses (which I’m pretty sure would give a rock a pulse, at least momentarily), shocks, ventilation, etc. And yet the survival rate is abysmal if you arrive at the ED with CPR in progress.

The reason has to do with the cascade of damage required to cause the heart to quit in the first place. Stop breathing long enough for the heart to stop (Anna Nicole Smith) and even the Olympic CPR team cannot recover from the profound acidosis and ischemia that was necessary to stop the heart and attract attention. It’s even worse if it was a heart attack that caused the heart to stop: the damage to the heart muscle needed to stop it is substantial, but once it’s deranged there’s not a whole lot CPR is going to add. (This is not to say CPR is futile, it’s clearly not, so do it). What I’m saying is that if the medics cannot get a patient back in the field there’s not a heck of a lot more that can be done in the ED.

Not that we won’t try. We’ll literally wear ourselves out doing CPR, getting IV access and an airway, and generally being as obsessive about trying to save a life as you’d hope we’d be. Everyone tries hard, and as a group revel in the occasional success, but it’s so occasional we can even get someone’s heart restarted so they can die in the ICU it’s notable. And depressing.

When I was but an EMT lad in an ED I witnessed something I’ve incorporated into my own practice, and I think every doc should do it. When it’s ‘that time’, time to stop the resuscitation, in every instance I say something along the lines of “Okay, we’ve been coding this person for xx minutes, and there’s been (brief summary): does anyone here want to do anything else? If so, tell me now”. This does two things which are important for everyone in the room who isn’t dead: it makes them part of the decision making process, and it empowers them to very easily object should they wish, for whatever reason, to continue. “I’d like to give some (whatever)” is then totally fine, and they’re not having to object in a vague way that they’re not done yet with what can be a terrifically personal struggle to save someone none of us has met, or knows as anyone other than a patient. We give the whatever, and after a while, given the persistence of death, I’ll give my speech as many times as it takes (so far, twice has been all, but I’d be perfectly willing to go on for a long time), because it’s important for everyone involved to acknowledge that they did what they could, and to be comfortable with stopping.

Codes end, very occasionally with a happy outcome, more often than not with a patient under a sheet, but the people who were there need to feel like they had a chance to do all they could.

Death is forever, and so is guilt; I want to make certain the dead don’t take the living with them.


Comments

  1. Back when I was a volunteer in my local ED back home, even if I was just watching the code or if I took my turn at compressions, the doc would even ask me if it was ok to call it. It was a bit simpler than yours, just a “does everyone feel comfortable calling this patient?”, and he’d make eye contact with each team member, who gave a nod. Like you said, it gave me a feeling of being part of the team, even though I was at such a ‘lowly’ position.

  2. That’s a great tip, and one that I’ve seen several docs do. The wierdest one was a doc who actually said “I can’t think of anything else” and left the room to take a call. So my partner (paramedics both) and I took over the code. The patient had a rhythm and pulse when the doc stepped back in five minutes later.

    Oh, and the answer to endless CPR? AutoPulse.

  3. Wonderful post – the damage caused to a healthcare professional’s psyche by the “what ifs” of a code can be avoided with your approach. Preventive medicine at its best. Bravo.

  4. I’ve never felt guilty in an ER code nor after a code…except when we’ve been coding the patient for too long. I hate continuing on after many, many minutes doing whatever (shocking, giving meds, compressions/fracturing the person’s sternum) thinking ‘the best we’re going to get is brain death’. That’s when I, somewhat subconsciously, try to maybe switch into the “feel the femoral pulse” position…more passive.

  5. more profoundly good advice. I wish someone would share this with the families of some pts. of mine that should be DNRs. Or maybe a video about exactly how violent codes are… at any rate I’d love to see more doctors like you/

  6. That’s a great summary. I’ve seen almost the exact same thing said by a trauma team leader. I didn’t hang around to see the outcome, as this person said it after I had spent about an hour watching 8 people hover around a 22 year old who decided to hop on a motorcycle. It is absolutley NOT like anything you’ll see on TV, and after 45 minutes of almost no blood pressure, tons of epi, shocking, and still no viable pulse, I had to quit watching.

  7. Terrific last line!

  8. HM2(FMF) Heidrich says:

    Outstanding procedure, duly noted.

  9. TheNewGuy says:

    Good on you, Grunt. Your approach is something I’ve done for years, and I’m glad to see I’m not the only one. Medicine is absolutely a team sport, and my code speech is very similar to yours:

    “how many minutes since we started?”

    “OK. We’ve been at this for X minutes. Does anyone have any suggestions or anything they want to try? *Pause* Does anyone have any objection if we call this?”

    “OK. Time of death is (fill in time). Thanks for everybody’s help.”

    Bottom line: we do what we can… but the statistics for out-of-hospital arrest are uniformly dismal, and I make sure my crew knows that. There are too many more patients lined up outside the door for anyone to lose it on a single code. When taking care of life’s many casualties, it’s critical NOT to become one yourself… physical OR psychological.

    Incidently, it doesn’t hurt to occasionally bring family members in while you’re coding the patient, particularly if there’s terminal illness, a questionable living will, feuding family members, or a healthcare power-of-attorney who’s on the fence about whether to continue. In my experience, actually witnessing an ugly, real life, code-in-progress is enough to make resuscitation decisions much clearer for the family.

  10. This approach should be THE gold standard.
    BTW, I practiced at a trauma center that more often than not, allowed at least one family member to stay in the room during a code. They were asked the same questions about ending it. And given the health team’s responses, they always acceded to stopping at that point. It gave them some sense of control with an end point – and it solved the big mystery of what happened to their loved one. (This was an inner city center with more than its share of gangs, violence and the like, so there was nervousness at doing this, but it worked out fine.)

  11. Well said…

  12. Doc,

    Being an active Paramedic with 20 years behind me, I feel CPR is a dastardly way to provide false hope to family members. Running emergency (lights and siren) to a hospital while intubating, performing intravenous access and giving medications has caused more needle sticks and injuries to the Emergency Responders than necessary. When the ambulance arrives at the hospital the Medical Control Physician asks, “How long have they been down, how long have you been doing compressions, and what have you done so far?” This mantra leads to a strip being ran and the code being called. The Paramedics then walk away exhausted as the medical team scatters. Personally I think if the public knew that the odds of them surviving sudden cardiac arrest in the field were less slim to virtually none. They would outlaw CPR.

    ALEX~D~

  13. dana Raugi says:

    great post…

  14. I’m really going to have to remember this approach…I won’t be running a code for at least another year–but your “ending” seems perfectly appropriate.

  15. Great Post. I do the same procedure. I like out of hopsital arrests on old geezers because it is usually a straightforward quick and easy patient with a predestined outcome 99% of the time. Then it is on to the next perplexing abdominal pain or dizzy patient in the rack ……. until the family shows up 30 minutes later and have to deal with all that.

    Now the pediatric codes are another story. I have nightmares about those because they will hang on forever when it is probably better that they are allowed to die with peace and dignity.

  16. Very well-said. I can tell from your writings that you are a great doc. I’ve only been present for the deaths of 2 babies, and for the 2nd one, the neonatology attending who was running the code said, “Are there any objections to stopping now?” I liked that he asked us. Nobody had any objections – we all knew we had tried everything we could.

    With babies, we often have codes where the end result is life. But then a code for us is for such different reasons – often due to respiratory distress as opposed to cardiac death or things like that. So it’s an entirely different world. I have participated in many codes in the last nearly two years, and as I said – I have only seen 2 babies die. I’ve participated in a few codes where the baby probably should have died instead of living a few more days, but babies don’t have advanced directives. And very rarely is a baby given a DNR.

    It’s a sad world, but I agree so much that every person has their time when they are ready to let go. I’ve written a few times in the past about that feeling in my heart that shouts, “No! Don’t stop!” when the monitor is turned off and the baby is going to die. Even though I know in my brain, this is the right thing, I still hate to see them die…

    Take care,
    Carrie

  17. right on doc. i always aske the code team if ANYONE in the room thinks we should keep going OR if we haven’t done something that might help. was taught this in med school by a great ED guy who is the reason i’m doing this in the first place. and of course you are correct about the majority of outcomes, the old “celestial transfer”.

  18. I don’t recall that end of code statement ever being formally taught, or even mentioned, but it’s weird that most of us do it.

    Maybe I saw someone do it once and it just stuck with me, but I’ve always done it that way too.

    Great post.

  19. Thank you for that. That was very well said.

  20. thank you for that! utterly written just on time for me before i start my emed posting. am trembling with excitement and yet intense fear, i don’t take to watching people die before at all, in fact worse than most. so it really really helps in teaching me to let go.

  21. Someone did a study on the outcomes of Codes on TV, as compared to those in real-life ERs. As I recall the results,TV Codes are successful over 80% of the time — and usually the patient sits up, completely unimpaired, and asks “What happened?” In actuality, Codes restore a rhythm compatible with life less than 15% of the time. I tried a case a few months ago in which a patient was Coded for an hour before the team gave up. Our defense witnesses spent a lot of time explaining why Codes are not like you see on TV, and after the verdict, jurors told us they were astonished to learn just how unlikely a successful Code is.

  22. As a former EMT, I can really appreciate this post. There’s nothing more haunting to me about my time working EM having to perform CPR for too long, not being able to code a patient ourselves. Or taking a patient in and not being treated as part of the process. I’ve seen a few saves to have made it all worthwhile and there’s nothing like being on the team that pulled off a save. I never made it to paramedic status; being an EMT where I grew up turned out to be a hazard. It’s one thing to bring in a DOA, quite another when they are school chums.

  23. Great post!

    I can’t remember a single neonatal code where the doc in charge didn’t ask if we were all comfortable with stopping. I also can’t remember a single time where the nursing staff wasn’t already on the same wavelength.

    The only thing I’ve ever asked for at the end of the code is time to ask the family if they want the baby baptized before we quit. If I’ve had time to check the baptism consent, I don’t need to ask, but I do like to let them know it’s happening.

  24. Great post, matched by the comments. Should be a must read for every member of the public…

  25. I remember the day my father came back. I was there as the code team arrived, I held his hand, backed off when the paddles came out, told him firmly to breathe (he was semiconscious) and soon his heart started beating again.

    12 hours later, 2/3 of his heart was akinetic, and I held his hand as he went after drinking a final cup of tea. A few sips, anyway, as he was taken off the ventilator.

    My Thanks go to the cardiac unit, they did everything they could, including the doses of morphine which meant he didn’t feel it when he choked to death again.

    That was 13 years ago. But my heart, and my thanks, go out to all code teams everywhere. Sometimes you win, sometimes you lose, but you have to be in it to win it.

  26. I’ve been having a bad week. So far three codes, and all went bad. And I’m a paediatrician, and often our in-hopsital resus situation has a favourable outcome. Reading this put things back into perspective for me. Thanks.

  27. If i ever code,I hope Alex D isn’t the paramedic that comes to get me.

  28. I’m not a medical professional of any sort, nor have I ever been. However, this still made me get a little weepy. I would want you, or doctors like you, there in the case of myself or my family coding. It’s such a little thing, really, but it truly does mean a lot to have every professional in the room be treated as a.) a respectable professional and b.) part of the team, making that decision AND not being the sole person to bear the weight of that decision.

    With my parents starting to age and with multiple health issues on both sides, I pray that when their time comes, they have such caring professionals at their bedsides. Thank you.

  29. Judd Bailey says:

    Just retired from 35 years as a fire service EMT/PM. Truths I hold self evident based on those years: (1) Every code in the field is a cluster****. (2) If the present code has not yet turned into one, you are overlooking something. (3) Light/siren trips to the ER for code pts. postpone the familys confrontation with death, sometimes by years, but usually by just 15 minutes.(4) I worked every infant and pedi code like it was my own, no regrets. (5) I would rather face 100 families to tell them their loved one has died than listen to 1 more ER Nurse who feels a duty to loudly advise me she could have run the code better in some respect. She has no idea how close she is to “witnessing” workplace violence at that moment.(6) 97% of medics think the usual code due to chronic bbq overdose is a purely mechanical process, no more exciting or critical than baking a cake, but the moment we perceive a chance to win one, the search for and interventions against reversible influences becomes an art form. (7) Traffic is more dangerous to EMS crews than all the mean dogs, mad mommas and “harmless” drunks combined. (8) “Critical stress debriefings” are an embarrasment to the field of psycology. Nobody hopes for a CSD after “that” call. We want to (a) hear our spouse/kids voices, (b) be with our peers, (c) abuse adult beverages and fried foods at the Missing Cat Chinese Buffet (“Open 24 hours, except Sundays when we close at midnight.”). Maybe if you came there we’d talk to you. (9) Less than 7% of all physicians have any business stopping at a trauma scene. Most of the other 93% never make this mistake twice. (10) Nice guys may finish last but at least we don’t get sued by pt. families.

  30. Vanessa says:

    After that successful revival of a 31 min code the other night I will now be referring to you as GruntDoc, the Death Destroyer!

  31. Im an EMT/Medical assistant. I had a code a while back that really put me in a balancing act. It was only my third code in my career. The pt was old (80something), multi-system organ failure, just had some kind of abdominal surgery, a question about possible abuse, had prior stroke so was a talking vegtable, was an amputee, just alot of things going against him. He came in complete asystole but we worked him for I think 40 mins. We actually just called it and everyone was cleaning up. I went to start counting and throwing things away, I turned around and I heard a beep looked up at the monitor and sure enough saw sinus brady. You know when they have a rhythem you have to treat them so I yelled for the team to come back. We got him stabalized but later the family let the pt go. At the time I felt ‘yes we got the pt back’ but now looking back on it, why did I feel that way when the pt was so bad off to begin with. We in the medical field fight with ourselves all the time but to date I have no regrets about the decisions Ive made in my career. I think thats all that matters and that we take care of the patients to the best of our ability and moral character.

  32. I really wish that even *one* doctor back in my paramedic days had done this. I don’t remember it happening a single time.

    The other thing I wish I’d seen more of was calling the code sooner. We all know, as has been stated repeatedly here, that they are usually futile efforts, and I used to just get so incredibly upset when some idiot of an intern or attending would want to keep pumping everything in the crash cart when there was clearly no more point, and everyone was already completely exhausted.

    I started my career in Pennsylvania, and we were allowed to pronounce death and call our own codes in the field. When I moved to CA, it was a big shock to no longer have that authority. The indignities perpetrated upon the patients and their families as a result was an outrage.

  33. I have never seen a good outcome from a patient who has come in to ED with CPR in progress.

    I have seen a few patients who did survive but with profound brain damage to go on to live miserable lives in some nursing home – endless cost to the taxpayer and just prolonging the misery for the family

  34. I thought about your approach, and then quickly inventoried the hundreds of codes in which I’ve been involved since 1965 when I assisted at the first.

    What comes immediately to mind is that it was the most excellent physicians who ended a code as you suggest; that correlation holds up to this day. The techniques have changed, but the outcomes don’t seem to have changed all that much. The best docs are team leaders who keep everyone apprised of what they’re doing and what they’re thinking. The worst ones seem to think that knowledge is power and it is best shared sparingly. Ironically, it’s the ones who keep the team in the loop, share their mental model, and verbalize the thinking process that goes into decisions, who wind up being the best and the ones with whom everyone wants to work. I’m fortunate enough to still work with several who meet those criteria.

    Jim
    Former 8404 HM3 ’66-68
    Former CPT AN ’88-98