The prearrival call comes in: “Twenty-five-year-old man, traumatic arrest, CPR in progress, single gunshot wound to the left chest. Thirty minutes of bystander CPR prior to arrival, intubated on scene, ETA five minutes.”
Like a well-choreographed ballet, doctors, nurses, respiratory therapists, and others file into the trauma bay, ready to assume care of the patient. A medical student on her emergency medicine rotation finds a spot in line to deliver chest compressions. We lay a body bag on the bed.
EMS arrives, and we quickly move the patient to the bed to take over the resuscitation. The patient's fixed and dilated pupils, cyanotic mucous membranes, and cool dusky skin foreshadow the outcome. Nevertheless, we begin. One round of CPR, one round of epinephrine. “Pulse check. Hold compressions. No pulse. Resume compressions.”
Soon it is time for the medical student to take her spot at the patient's side and deliver compressions, a first for her. A few seconds in: “Pulse check, hold compressions.” The medical student stands there, hands hovering over the patient's chest, ready to resume compressions on command. Asystole on the monitor, no cardiac activity on bedside ultrasound, pulseless on exam. We have just evacuated a large volume of blood from a chest tube. “Time of death, 21:43. A moment of silence, please, for the life we just lost.”
I look over at the medical student, and I see her, head hung, regarding her hands. Her face betrays a sense of failure as though if she had done better compressions or we had gone for another round of CPR, things would have ended differently. The moment of silence ends, and we scatter throughout the department to tend to other patients.
Later, I find the medical student at her computer and check to see how she is. She confesses that she feels a little unsettled because she has never seen a person die before. This experience is not new to me; as an emergency medicine resident, I often work alongside medical students who have never encountered death so closely.
These experiences always remind me of the first time I saw a patient die in the ED. I was a fourth-year medical student, the patient a middle-aged man who had been in a car crash. We pronounced him dead after a brief but futile code. We later came across his insurance card that listed the names and ages of his wife and daughters. I wondered if these women would not have lost their husband and father if we had tried a little harder. I wish somebody had asked how I was doing because I would have liked to talk about it.
I reassured the medical student that the patient was already dead when he arrived and that we were trying to change that. This is a conversation I have with every student who experiences her first patient death with me. Certainly, we did not cause this patient's death, and our resuscitative efforts should not be looked at as failed. I have found that approaching codes with this mindset displaces some of the emotional burden.
But then I realize a logical fallacy: The patient was dead before he rolled through our doors, but it was only when we terminated the resuscitation that we proclaimed the time of death. This suggests that somehow the patient was not dead until we decided to end the code. Not only is this factually wrong, it unnecessarily puts an emotional burden on the code leader, who will eventually have to decide when to end the code.
I find this practice even more troubling in settings where we know exactly when the patient loses pulses, like in the ICU. Not only do we know the time the patient loses pulses, there is usually a nurse documenting every minute of the resuscitation. Yet, we only pronounce the patient dead once somebody officially terminates the code, again implying that the patient was somehow not dead while we were performing CPR.
For the sake of physician well-being and accuracy, I propose that we change this standard. We should label the time of death as the time the patient goes into cardiac arrest and a code is started. Recordkeeping may require that we specify this as the time a health care provider first determines that a patient is pulseless. It would also allow us to focus learners' experience on the science and help them grow as physicians instead of spending time alleviating guilt that should not exist.
The Uniform Declaration of Death Act, a model legislation approved by the American Medical Association and the American Bar Association in 1980, defines death as the “irreversible cessation of circulatory and respiratory functions.” (http://bit.ly/2LxEzHB.) Changing our practice and relabeling the time of death would be accurate and not contrary to legal standards, and it would not be at odds with the way we already think about death. When we inform a family member of a patient's death, we say things like “Mr. Jones has died. His heart stopped. We tried everything to get him back, but unfortunately, we were not able to.” This conveys that we identify the time of death as the point at which we begin the code.
Despite having spent many hours thinking about this, I still feel despair when ending a code. Until the code is ended, the irreversibility of the situation looms undetermined. During the code, there is no time of death—we have not told the family that the patient has died, we have not pulled a death certificate. It is only when a pulse check ends with “time of death, 18:36” instead of “resume compressions” that we know what began the code was irreversible, what began the code was death. Instead, we could say, “End CPR. Time of death was 18:03.”
Reframing the way we call time of death could remove some of the moral distress that comes with deciding when to terminate a code. More importantly, it could relieve physicians of feelings of guilt, failure, and inadequacy that are not theirs to bear.
Share this article on Twitter and Facebook.
Access the links in EMN by reading this on our website, www.EM-News.com.
Comments? Write to us at firstname.lastname@example.org.
Dr. Chernobyis a chief resident of emergency medicine at Indiana University and was the first graduate from the University of Florida's MD/JD program. She has an interest in clinical ethics, health law, and reproductive health. Follow her on Twitter @KimiSwartz.