I wish we’d talked about this earlier…

Dr. Signout, over at, well, Signout, wrote an interesting piece the other day. It’s a piece that everyone should read and think about while they can, because you never know when you may need to think about this.

One of the most dramatic procedures in any hospital is the CPR, also known as a “code blue”, or simply a “code”. This is the choreographed chaos that takes place when someone’s cardiopulmonary status deteriorates to the point that only immediate and violent intervention will prevent their death. To put it more dramatically, the object of a code is often to forestall or even reverse death. Health care providers hold a range of opinions about whether or not family members should be allowed to witness a code. Current ACLS guidelines take a reasonable, evidence-based approach:

[I]n the absence of data documenting harm and in light of data suggesting that it may be helpful, offering select family members the opportunity to be present during a resuscitation seems reasonable and desirable (assuming that the patient, if an adult, has not raised a prior objection. Parents and other family members seldom ask if they can be present unless encouraged to do so by healthcare providers. Resuscitation team members should be sensitive to the presence of family members during resuscitative efforts, assigning a team member to the family to answer questions, clarify information, and otherwise offer comfort.

Some would argue that doctors have never given up their death-grip on paternalism, but I have argued otherwise. In the case of codes, however, paternalism may still hold sway, at least in a certain way.

Most CPR’s at the major teaching hospitals are run by medical residents. It is an important bonding event for them. Let me give you a bit of a picture. First, when you’re on call, you usually carry a “code pager”. This makes you both edgy and important. When a code is called, usually on the pager and overhead, a dozen or so people converge on a patient’s room. There may be a roommate whose bed is quickly pulled into the hallway (along with the patient). The floor nurses are busy with chest compressions, or checking vital signs, or (hopefully not) panicking. The medical residents, anesthesiologists, respiratory therapists, clergy, medical students, and whomever else is nearby pile into the room. Usually one of the senior residents, or one of the older nurses will yell for all non-essential personnel to get lost. Meanwhile, one of the residents takes charge of trying to save the patient.

There is usually quite a bit of informal debriefing afterward. There are also phone calls to make—to the attending physician, to the family. Of course, if the family happened to be there at the time, it’s more of a sit-down. This can be rather awkward, as a CPR is often loaded with physical violence, sick humor, and flippant comments, all of which serve to make the situation more palatable to the code team, and help bond them more closely. I don’t know of any medical resident who hasn’t said something a bit inappropriate at a code, only to find out the family member is standing outside the door.

And this is where the paternalism thing comes in. We doctors like our rituals, our private sick humor, our intimate time. Nothing (outside of the OR) is more intimate than a cardiac arrest.

Well, families are getting more sophisticated, and it’s time for us to grow up. There’s plenty of time for sick jokes later. During an arrest, we’re going to have to get used to the idea that family may be around.

As part of getting used to this, families are going to have to understand that a code is a last-ditch, usually unsuccessful effort to snatch a human being out of an abyss whose bottom they may have been hovering near for days or weeks. Some diseases can’t be fixed, and death can’t usually be reversed.

And that’s why it’s time for everyone to read the post at Signout and start talking. It’s time, right now, while you still can, to ask the question, “how do I want to die?” No answer is irrevocable, but the discussion is invaluable. We have become very good at creating an end-of-life asymptote, with one axis representing quality of life, the other time. The suffering and expense incurred as the curve stretches out is really hard to understand unless you spend a lot of time around hospitals. Once you have, though, you know you don’t want to ride that curve to the bitter end.