AJN, American Journal of Nursing:
Lambert, Anna E. MS, RN, CCRN
Anna E. Lambert is associate director of cardiovascular nursing at the University of Rochester Medical Center in Rochester, NY.
Contact author: firstname.lastname@example.org. Reflections is coordinated by Madeleine Mysko, MA, RN: email@example.com.
The gift of family presence.
This was the couple the nurse manager had mentioned to me earlier. The husband was a thin and gray-haired patient pushing his IV pole down the hall, and the wife was close at his side. He'd been transferred here because the ventricular arrhythmia common to end-stage heart failure had been activating his internal defibrillator almost daily, twice leading to falls. And the nurse manager had told me his wife was dissatisfied with the treatment he'd been getting: despite medication adjustment, his arrhythmia was not improving.
Figure. Illustration...Image Tools
I said good morning; they nodded and continued their slow progress.
At about 3 PM, a "Blue 100" code was called on the heart-failure unit. As I approached, staff members were assembling equipment in front of a semiprivate room belonging to the man I'd seen earlier. The nurse manager was at the bedside, and I asked her where his wife was. While administering chest compressions and calling for equipment, she indicated the bathroom. I found her standing in the doorway, arms on the door frame to hold herself up. I glanced over at the patient in the other bed. His hands were clasped in prayer.
Amid the sounds on the other side of the curtain—calls for drugs and equipment, a charging defibrillator, the rustling of packages being opened, an Ambu bag inflating and deflating—I asked the wife whether she wanted to stay in the room. She said emphatically that she wanted to stay close to her husband. I said I'd stay with her, and if she needed to leave I'd help her.
She sat down in a nearby chair. Ten people were on the other side of the curtain, but it was lonely on our side. As we heard phrases familiar to me—"V-fib, continue CPR"—I interpreted them to the wife.
She said, "He told me this morning that he didn't know how much more he could take." And then she shouted, "Come on! Fight! Fight! You can do it. Don't leave me now."
The clock showed that 20 minutes had passed since the initial call. The chaplain entered the room. We each put an arm around the wife. I reached out to the roommate seated on the edge of his bed. We prayed. And from the other side of the curtain we heard, "I have a pulse!"
The wife again called out, "Come on, fight; you can do it!" We heard: "No pulse, prepare to shock." And after a series of cycles, we heard: "Hey, he's moving. Hey, buddy, show me a thumbs-up. Hey, he's awake!"
The problem was, he roused only as compressions were given. If the arrhythmia couldn't be controlled, the only option would be to place a ventricular assist device to provide artificial circulation for his dying heart. Cardiopulmonary bypass would be necessary. The code team called for analgesia and sedation and for the cardiac surgeon.
The attending physician came over to speak with the wife. He kneeled down. He recounted the events of the last half hour and explained the need for surgery. She appeared to be taking in the information in a logical, methodical manner. And then she said, "No. He would not want this. Please stop."
There was a moment of silence. She repeated, "Please stop."
I whispered, "You are a very brave and strong woman," as the attending physician spoke to the team on the other side of the curtain. The group gathered there parted to allow us to approach the bed. Then the wife cradled her husband until there was no further cardiac activity. He passed away in less than a minute.
The wife later thanked us for allowing her to stay in the room, and thanked me for being at her side. While "family presence" during resuscitation can be uncomfortable for the health care team, it can be extremely valuable to the family members. This woman witnessed for herself the professional conduct of the code team: advanced cardiac life support protocols were followed, and everyone showed respect for the patient and his wife. I know that her decision to stop resuscitation efforts was the result of what she saw and heard. She gave her husband a final gift—she let him go—but only because we allowed her to be there.
© 2009 Lippincott Williams & Wilkins, Inc.