Tuesday, November 30, 2010

Divine Intervention 2

A 41 year old black female comes by EMS in full cardiopulmonary arrest. She had been "down" for at least 30 minutes before arriving to the ED. EMS had no return of circulation en route. I coded her for another 30 minutes b/c she was young. There was never of a pulse despite multiple rounds of epi. This lady had NO signs of life. There was nothing I could do to save her.

I have no clue what she died from, but that's not the point of this post.

I went to go break the news to the family. As usual, I was accompanied by a nurse and a chaplain. When I arrived to the room, there were about 10 family members holding hands in a circle praying. They were saying "amen" to the prayer leaders pronouncement that the Lord will bring her back and that it was already done.

It was a really awkward moment b/c I had pronounced her dead but they were still praying as if she was alive or had a chance. I just kind of stood there at the door. I didn't know if I should go hide, interrupt the prayer and tell them to stop b/c there was no use, go pretend like I was still working on her, or undo the body bag and actually start working on her again. I don't even know what I believe in anymore....but what if I was ruining a miracle??

I felt like I was in the middle of them and divine intervention. I knew there was nothing left to do for the patient, but man did I feel like I was playing God all of a sudden.

So I asked the chaplain to call me when they were done, which turned out to be less than a minute later. I broke the news, and they freaked like no family I have ever seen. There were broken walls, plants, and doors. The patient's mother ripped my white coat after grabbing me and shouting at me to get back in there and save her daughter.

So.....my question is what should I do if I walk into a family room to tell them their loved one is dead while they are praying for a miracle. Please, no comments on how we play God in medicine all the time, that's not what I am getting at here. More of how to get out of this awkward situation.

-ER Doc


David Wilson said...

Coming from the other perspective as a pastor who has led those prayers, I don't think you would have seen a different outcome regardless of the timing. And you weren't playing God, but you were His messenger.

You know this - people process loss in different ways culturally. Given her age, they weren't pre-grieved like they would have been for grandma. If they got "fired up" and you stepped in and gave them the reality, they weren't going to take it out on God with the pastor there - and you were handy.

One thought in this process though - a chaplain or patient rep could have let the family know how she presented upon arrival at the ER. Doesn't seem like they knew she was DOA.

Appreciate your blog and your work.

SerenityNowHospital said...

Thanks for your comment and tip

ER Doc

mjay said...

As a patient I respect what you did, you gave the family there chance to ask one more time, they weren't ready to loose her yet, you gave them a final chance to be alone with her. I personally am a medical proffesional, but also a christian and i believe there is a very fine balance between the two. God gave you the talent and power to save lives, but you are not God and the final choice is not yours.

SerenityNowHospital said...

Some kind of buffer would have been good. I agree with the first post. If the family is that religious, they would probably take it a little more easily from the chaplain or clergy, who could set the stage for you. I think it's always better when they say, "The doctors are in there doing everything they can," or something similar.

Then when you come back, they might at least realize that death was one of the two possible outcomes.

-Psych Doc

p.s. sorry about your coat.

Anonymous said...

I have had an experience that left me feeling the same way. The family was praying for a miracle to take away a genetic disorder in their baby. I felt like that was very short sighted on the part of the spiritual leader...I thought it was more appropriate to pray for grace and strength to follow god's plan for this child. I guess it's hard for people to accept that there aren't always happy endings.

Pissed Off Patient said...

I am no expert, but, like you, I would've walked away and given them some time.

It wasn't going to go well no matter what you did.

It must have been hard for them to see her just die like that. Sounds like it was really unexpected.

As a preacher's kid, I agree with anonymous, a pastor praying for a miracle in an impossible situation is not a good pastor/one who needs more training.


Anonymous said...

Prayer is sort of meant for impossible situations. However, better training should just as openly remind that "hey this aint the burger king we're talking to and ya can't always get it your way so help us to handle ourselves rightly and not show out now neither"
Perhaps in future encounters it might be best to talk one on one to a family member and let them tell the group.

Chrysalis Angel said...

I agree with David's comments. It would have been a good thing if someone had been able to brace the family that it did not look good from the onset. It may not have changed their reaction; however, it would have been a little buffer. The problem is, there still would be little time for them to process it.

You did the best you could under those circumstances. It isn't easy to face the family when the outcome isn't what you'd all hoped for.

I'm sorry for your loss in this as well. It is hard to lose a patient. You handled things the best you knew how.

Anonymous said...

I'm an atheist but on several occasions I have led a prayer with family when it seemed the right thing to do. What I usually say is something along the lines of "Lord, we ask your help for this patient to ease his suffering AND we ask you to help this family accept the situation, deal with the loss etc." In your situation - I would have done what you did - wait for them to finish. Perhaps you could have taken the pastor aside and given him the news first but it probably wouldn't have made much difference.
-whitecap nurse

Dr. J said...

If she had survived the credit was god's and if she died the blame was your's, simple as that...

David Wilson said...

Don't have a problem with science and faith coexisting. My belief in God includes the belief that He uses people - believers or not - in His work. Common grace - where God blesses everyone regardless of their relationship with Him - happens.

When I lead people in prayer during those times, I'm trying to get them to a point where "Your will be done" is the closing thought. I've seen some amazing things happen but they are rare, and any miracle is a temporary reprieve after all.

I'm old enough to have buried both parents, a stillborn grandchild, and several friends. I've prayed some prayers I later regretted simply because it hurts to lose people you love. I was asking for God to set aside the natural order for my selfish desire to have them a little longer. I'll bet some of that family is regretting their reactions today.

To all of you in healthcare - thanks for what you do.

Sarah said...

I agree with the David Wilson. I am a Christian too. There was not a way out of that situation. We will never understand all of God's ways. We can only do what the Bible says- have faith. But the decision is not ours. Sometimes the "healing" we ask for is only found in heaven- where there is no death or disease. But the pain of loss will still be with us here on earth.

Crazed Nitwit said...

Oh my gosh! I've watched my kid die and in no way was I ever violent or destructive to anyone or anything other than to myself. Totally out of line!!

Hope you're ok.

Shash said...

The family's violent reaction was out of line for behavior in hospital but it really isn't a surprising response to the unexpected death of someone who was a vibrant, relatively-young, healthy family member that morning. Especially after they had convinced themselves of her survival through strong group prayer.

I agree with David's response but also believe that the person who led or guided the prayer should also have asked God for strength for the family members should the outcome not turn out as they had wished. The family's expectations were unreasonable given the gravity of the woman's situation.

krystina said...

Wow, I've been in a code like that. It was the other spectrum though, old, old lady, with sons (who after two codes) still wanted everything done. She was dead before we started though. But I agree with the majority, you did the right thing to not interrupt them. But, another option would be to have the chaplain "enter first" and be like, "the doctor's ready to talk to you now." I'm sorry.

wantitall said...

Having been an RN and also in the unfortunate family shoes as well, I always humble myself and just say a deeply heartfelt "I'm so sorry for your loss." I'm not a religious scholar. I'm a person who will try my best for your family member, will replay it over and over in effort to learn from it to help the next patient and I'll even cry with you cuz life's just not always fair. You were in an awkward situation, as long as you spoke with your honest felings, don't feel bad. Their reaction is NOT at all your fault. She was young and they were thrust into a crisis state. Maybe consider a bereavement team?(i know, not in the budget)

ERP said...

It would have been horrible any way you did it. Giving them a few minutes was the right thing to do but unless you told them good news, they were gonna freak anyway.
I hate to say it also but their reaction is cultural. Of course people of all sorts of backgrounds react in all sorts of ways but in my years of doing this, I find that when there is a large, multi-generational family waiting for the news of a dying relative (especially if they are having a very vigourous prayer circle and the victim is not elderly), the chances of destruction of the grieving room is very high. I have seen them literally smash apart the walls of the grieving room, break a shelving unit (an old lady actually did that), nearly assault me, break a window, and destroy the phone on the wall. This is followed by several people throwing themselves on the floor.
Now, I am not saying there is one more "appropriate" way of dealing with an unexpected death of a loved one, but it sucks when the grieving room has to be repaired two or three times a year.

arzt4empfaenger said...

This sounds likean awkward situation no one wants to be in. Obviously there is no easy and fool-proof way-out, but I think David Wilson's view sounds reasonable.

I really didn't know that a prayer circle could end up with such fervent, violent reactions. I'm not christian, but I thought prayer was usually used to support each other and to find strength for whatever would happen (besides, of course, wishing for a good outcome). I'll be warned. Fortunately, not every "failed" prayer circle seems to explode like that.

Anonymous said...

What's your hospital policy on letting a family member or their religious representative be at the bedside before you stop coding, so they can participate in the patient's final moments?

In Peds I've seen violent reactions, equipment broken, clothes ripped, it's always awful. Some parents appreciate having the staff pray with them or feel better seeing the staff moved to tears. Some need an authority figure to be the target of their explosive emotions.

No matter how much you try to empathize and treat them gently you will ALWAYS be the bad guy: you're the one saying the words they can't unhear. They can't make family rooms soundproof enough to dull that howl of grief.

The bereaved don't know what to do, often I hear them begging for something to DO. Bereavement team members can give them direction so they can shift their focus from anger to action. We've tried asking, "There is nothing more we can do (for the deceased) and now we want to focus on what we can do for you (the family)?" You can try admitting you don't know how to handle the situation. Ask how you can help them accept this circumstance?

And there are times when security has to stand by. I've seen a surgeon leave the family room with a bloody nose before. In that case, be the bearer of bad news & then hide! Nursing staff are the ones can't disappear, be extra nice to the rest of the staff that have to deal with the fallout.

Anonymous said...

I'm in full agreement with David Wilson, and that the family should have been informed from the get-go that the outlook was grim. (Even if you had gotten a pulse back, she would have been brain dead after 30 minutes down.

I remember someone once said that EMS and ED do their best to fight Death, but sometimes....Death wins.

CAS said...

I think you did the right thing, giving them time before going in to break the news.

I have issue with the 'name it and claim it' style the pastor employed, especially in such a horrible circumstance. At the same time, he prayed for God to 'bring her back' and God did-brought her back to Heaven.

About the destruction they caused-will they be billed for that, or will it just be written off? I always wondered who had to pay for wanton destruction, even if it was done in a moment of hysteria.

SuFu said...

One of the things I'm not looking forward to. They even bring this up in med school interview orientation now since there is an entire class devoted to it.

I didn't think I would need a police riot shield in medicine, but I might have to grab one.

ladyk73 said...

I think the best thing to do is to forgive the destruction of the family room. Maybe it needs to be padded. I would have waited until the prayer circle was broken too. Sometimes the best reaction, and only reaction is too answer questions, say your sorry, and excuse yourself. If the family was destructive, I would step out of the way, guide angry people (looking for something to punch) back into family room.
Sometimes being a quiet witness to someone's grief is the best course of action. Just be there, don't try to search for words.

j said...

Riot proof 2-way video hookup, inform via vid? Just call it telemedicine.. but it seems heartless, etc.

No good answer here. I saw a TV show where the doc took ONE representative back with him, told them, and then let THAT person tell the rest but that was a language barrier situation and a different culture.

Also ladyk73 is hopelessly naive.

SerenityNow said...

- A lot of people will bring the family back during a code to see that we are doing everything and to help them accept the end. Personally, I don't like to do that unless I feel it is absolutely necessary to get the family to withdraw care

- I don't think they will get charged for the damage.

Anonymous said...

I'm sorry for the terrible situation in which you found yourself. I'm sorry for the family's terribly deep loss.

If they are Christians, someone should have reminded them that their prayers WERE answered. The young lady was, indeed, already born to her Eternal Life.

Catholics celebrate the DEATH day of our Saints (with the exception of three)because the earthly death day is the BIRTH day to Eternal Life.

I have learned that no matter how much warning you get, it's never easy to say "see you later" to someone whom you love. It's also very hard to celebrate the birth to eternal life when you are grieving. Oh Death, where is thy sting? The sting is for those left behind missing the one who has passed to the next Life.

They will meet again.

It is a pity that your waiting room, your attire, and your psyche took the brunt of such deep grief.

Hang in there!

Dave said...

This may be just a hair off topic (then again perhaps not) but in many EMS systems across the country, this patient likely would not have even made it into your ER. I can tell you that in my system, and for the last 20 plus years in the largest city in my state (about 750,000 people), a patient who fails to respond to appropriate ACLS in the field and has no pulse and no or useless electrical activity is not transported by EMS. As you likely well know it has been well demonstrated in countless studies, and is a long-held position of ACEP, it is rather useless, costly, and sometimes risky, to transport this type of patient - only to be pronounced dead later in the ER. Those who don’t respond to ACLS in the streets truly are a miracle if they ever walk out of the hospital alive. It just doesn’t happen.

Perhaps this patient did not meet the current guidelines/protocols but if she did, she should have been pronounced in the field - thereby avoiding everything that happened to you and your facility. Problem solved – or more accurately – location of problem changed.

ladyk73 said...

"j said...
Also ladyk73 is hopelessly naive"

Naive? I am social worker. I currently work with homeless MICA (mentally ill, chemically addicted) clients. I did hospital social work. I focused on discharge planning...so I admit not having alot of experience with death in the hospital.

Naive? hmmm.... It really takes alot of yelling and screaming and drama to get me startled.

SerenityNowHospital said...

Re Dave:

You bring up a great point. I'm in a huge city as well, but unfortunately our ems system doesn't work that way. Each ems system has their own rules and protocols. Ours hates to pronouce people. They can do pretty much what they want and they always bring them to us. Probably less paperwork for them. I get tons of dead nursing home people that come in with unknown downtime and signs of lividity bc ems didn't want to pronouce them.

And ladykill, I didn't understand why he called u naive. Ur comment made sense and his didn't.

ER doc

WhiteCoat said...

There is never a good way to break the news of the death of a patient. Usually I try to get the family talking about what happened before the patient got there, then describe in detail how the patient had no heart beat and no pulse ... and how despite our best efforts we weren't able to get the patient's heart beating again.

I don't care how grief stricken anyone is, there is no excuse for breaking doors or other property. They should be arrested and forced to pay for every penny of the costs of repair. I also think they need to be charged for assault for coming after you.

As for your approach, if they were able to grab you and rip your jacket, then you violated one of the first rules of working anywhere in a hospital:
Never let anyone get between you and the door. Never.

SerenityNowHospital said...

Re White Coat:

Man I was standing in the door way b/c I knew it was going to be bad. But as soon as that mom saw me coming she jetted towards me before I even started talking. There was no way around it.

I usually do the same thing...ask them "what do you know about what happened?" before I give them the speech.

At least it was my coat and not my glasses

Chrysalis Angel said...

I agree with you, WC. As I read this post, I thought the ones that needed to ask how they should have handle things - were the family in this instance. You don't assault someone because you didn't get the outcome you'd hoped for. It doesn't give anyone the right to destroy another's property or threaten their person.

The doctor handled this the best way he knew how under these circumstances. He will be even more careful for his own safety in the future. (He did try to guard that) It's a shame he has to think about such things at all. People can be quite volatile and unpredictable.

Very difficult situation.

girlvet said...

When people start getting violent, for whatever reason, police should be called, people should be arrested or at the very least, thrown out. No one has the right to do this. They sound like they were crazy. They disgraced the memory of their loved one. They don't deserve anyones understanding. And the whole cultural thing? Gimme a break. No excuse for bad behavior.

Dorothy Moody said...

That really is a difficult situation and I think you handled it well. There is no good way to deliver that kind of bad news. I hope you weren't hurt in the aftermath. Usually I would say there's no excuse for that behavior, but given the loss they suffered...

Being the sarcastic bitch I am, I probably would have said, "See, I'm right. There is no such thing as a god."

Before any of you start whining and complaining -- unclench. Nothing wrong with a little levity, folks.

MLee said...

Don't think there is a good way. I always call pastoral care no matter if the family is religious or not, just to have a buffer with them the entire time. We let the pastor know what is going on and they give us a heads up of who is the leader of the group, or who is at risk to explode when we break the news.

Anonymous said...

Makes me remember back to being a student nurse (sydney Australia) - was working the night shift on a ward with an RN.
A patient was expected to die during the night - the family were Middle Eastern and they seemed to come from nowhere and by the dozen.
Security could not control them or their numbers.
The RN went into the room to check and came out and had a cry. She told me not to go into the room at all. She said they had said something to her but would not say what it was - said it was too distressing.
The relatives showed no respect for other patients and wailed and screamed and carried on, when the patient finally did die.
What worried me was how many of them made it to the ward during the night and how security could not control their numbers - relatives were in the room / corridor / waiting area / outside the ward.