Code Blue: A New Look

My daughter Liz called me the other day.  She is in her first year of medical school and had attended her first code blue a few hours earlier.  A person died as she watched.  She wanted to talk about it.  She felt helpless, useless.  I told her she was just learning, that her job was only to observe at this point.

Codes are not much different in 2012 than when I attended medical school.  Changes have occurred every few years in the American Heart Association guidelines to CPR and Advanced Cardiac Life Support (ACLS), which dictate how we resuscitate patients.  We do the same general things and, although the drugs and the details of CPR/ACLS have changed somewhat, the protocols have actually gotten less complex over the past thirty years as the AHA researched what works and what doesn’t.  Despite that, survival has not improved much during the past forty years.  At best, it hovers around 17% overall and drops significantly with age.  Only 6% of patients over the age of 85 who die are successfully resuscitated, meaning they go on to leave the hospital.

Nowadays I regularly attend codes when I’m on trauma call at my hospital.  In an average twenty-four hour shift, I might be paged once or twice to a code blue or I might be asked to intervene before the patient gets into real troubleMy role as an anesthesiologist in these situations is to ensure that the patient’s airway is secured and that they are breathing adequately.  Usually that means inserting an endotracheal tube into the trachea in order to attach a ventilator to mechanically breathe for the patient.  Sometimes patients are intubated electively before they stop breathing; sometimes things deteriorate quickly and the intubations are emergent.

But a major change that has occurred recently is that families are now present in the room during the resuscitation efforts.  It occurred where Liz saw her first code blue.  The family was understandably distraught.  This was just one aspect of the event that proved unsettling to her.  And it was new to me.

A chaplain is typically present with the family in times of crisis.  In the past, family members—if they happened to be in the hospital with the patient when the arrest occurred—were escorted out of the room while the patients underwent CPR and ACLS.  The gruesomeness of the process cannot be overemphasized.  The dying dusky and then blue.  They often regurgitate stomach material during chest compressions.  Secretions fly.  Ribs are broken.  The patients are repeatedly jabbed for intravenous and arterial catheters.  A dozen people stand around the bed discussing drugs, heart rhythms, timing of dosages and the sequencing of events.  Electrical paddles are applied to the chest and shocks are given which cause seizure-like jolts to the patient.  The individual’s eyes are typically half-open, unseeing.  An anesthesiologist such as myself comes to the head of the bed and sticks a long metal instrument into the patient’s mouth, suctions out secretions, blood, gastric contents, then inserts a breathing tube.  As I said, it’s gruesome.  Liz summarized a code as being “not for the faint of heart.”

I suspect the transition from performing these heroics behind closed doors to doing them with family present reflects not so much an act of compassion as it reflects our current era of transparency and the legal climate that brought transparency into fashion.   I can only imagine that the thinking goes like this: the family, having witnessed the resuscitation efforts, knows that everything was done to save their loved one. Perhaps we will avoid lawsuits with this approach.  And perhaps we will cause some new cases of post-traumatic stress disorder in the survivors.

After doing a little research, I’ve learned that this is being done in more and more institutions, including my own.  I simply hadn’t witnessed it.  My initial reaction was that having family purposefully present for codes seems absurd, cruel, and certainly ill advised.  I would not want to witness the resuscitation of one of my children, or my partner, or my sibling.  I would not want that memory haunting me.  But in my heart, I know memory doesn’t work that way.  And after mulling the idea over, I’ve changed my mind.  I believe the time has come to stop isolating the public from death, as unappealing as that sounds.  And if this is one small way in which we might do that, I think it’s a good idea.

I have not spoken to any administrators about this new policy, so I do not know the details.  I suspect that families are given the option of staying or leaving when the resuscitation begins.  I certainly hope they have the choice.

But we certainly need change in healthcare.  We need not just economic change, and change in methods of delivery, but we need conceptual and philosophical change.  Perhaps it will take a generation to achieve it.  Perhaps it will require that more and more individuals witness the indignities that can befall them in the hospital environment so that they choose to die at home, choose to take more control over their lives and their health and their deaths.  The default setting right now is to do everything to everybody.  Until that default setting gets altered, we will have too much medical care for too many until too late in the game.  And that’s painful for everyone.