Cardiac arrest resuscitation, with wife as witness

The patient arrived in cardiac arrest. He had been brought to our emergency department in the middle of the night. Although he had a significant cardiac history, he was only in his late-forties. His transport from his house to our department had been less than ten minutes and, along the way, the pre-hospital team had done an excellent job of intubating this patient and establishing an IV.

His wife was with him. Less than fifteen short minutes before their arrival, her life had been altered forever when her husband had woken her, from a deep sleep, to complain that he had intense chest pain. Seconds after, she witnessed him become unresponsive.

On arrival to our ER, we found this patient to be in pulseless ventricular tachycardia, a malignant, life-threatening electrical rhythm of the heart. Following ACLS protocol, we shocked this patient several times while performing CPR and administering multiple doses of medications to combat this rhythm.

After several very intense minutes, we were able to regain a sinus rhythm and a pulse on this patient. Despite this, he remained unresponsive and his blood pressure was minimal. We continued our efforts to stabilize this patient as we awaited cardiology’s arrival.

Despite our aggressive medications and interventions, this patient returned to a pulseless ventricular tachycardia. More shocks followed. More medications were given. And, once again, we were able to break the bad rhythm. But, not for long.

Cardiology arrived and together, we continued to fight for this man’s life. His rhythms were very fragile, and it seemed that he alternated between a normal rhythm and these continued life-threatening ones, now including asystole (a flat-line, so to speak). Asystole is bad, very bad, and is rarely survivable.

We were running out of options. If we were going to be able to intervene any further, we needed this patient to remain in a more stable rhythm. Getting him into a sinus rhythm had been hard enough, but nothing we seemed to do would keep him there. His heart, from previous infarctions and damage, was resistant and stubborn to our best efforts.

As the cardiologist and our ER team continued with resuscitation efforts, I went to the family room to speak to his wife. She was obviously upset, and I explained her husband’s dire situation. Our reality was that time was not our friend, that the longer he continued in asystole and ventricular tachycardia, the less chance of his survival. She understood my words. “I always knew it would end this way,” she said, her honest words reflecting her inherent sense of the situation.

I invited her back to be with her husband, to witness the momentous efforts we were all giving him. She wholeheartedly agreed, embracing my invitation.

Returning to the oversized room, filled with people and shiny medical equipment, I looked at the resuscitation through her eyes. Three nurses, each scurrying with a focused determination, documenting our efforts and pushing IV medications. Two techs, one actively performing CPR while the other was readjusting the patient’s blood pressure cuff. Two respiratory therapists, standing at the head of the bed, one using an oxygenated bag to ventilate this patient via his airway tube while the other prepared a mechanical ventilator, ready to be used in the event of our resuscitation succeeding. The cardiologist, standing at the patient’s open side, dictating the next course of medications. The pharmacist, standing with the crash cart outside of the patient’s door, repeatedly handing in the next dose of ordered medication. The patient’s wife. Me.

And the patient. Lying on the hospital cot. Unresponsive. In asystole. Again.

I guided her to his side, where she grabbed his hand.

Despite this many people in our big resuscitation room, the air seemed open, the frantic energy palpable. The team moved purposefully and in sync. Their caring, their vigor, their sadness, their intensity was obvious, witnessed by the patient’s wife.

Unfortunately, the patient’s heart became refractory to all of our best efforts and our medications no longer had any effect. I had the tech hold CPR and we confirmed asystole on several cardiac monitor leads. The portable ultrasound was brought to this patient’s bedside. It confirmed our worst fears, that his heart had no squeeze, no motion, no life. His wife saw the stillness of his heart on our black-and-white screen.

Forty or so minutes had passed since the patient arrived and, as I had explained to the wife in the family room, time was not our friend. We had no other options of treatment to save this patient.

“Please, stop,” the wife said. “Please, just let him go in peace.”

A powerful moment.

With no objections, we ceased resuscitation efforts. Time of death was proclaimed. I thanked my team. I crossed myself. I conveyed my sympathies to the wife. The crowd of people slowly withdrew from the room. The lights were dimmed. The patient was covered in nice, clean blankets. The patient’s wife was brought a chair, along bedside, where she sat, continuing to hold her husband’s lifeless hand within her trembling own. A box of Kleenex somehow found her lap.

The family doctor was called. The coroner was notified. I dictated my note.

All methodical parts of my job. When I was done dictating, I went back into the room. As I expected, his wife was still there.

“I’m so sorry for your loss,” I repeated.

She nodded. “I know you tried your best.” She paused, taking a deep breath, before continuing. “Thank you for letting me be with him in the end. I needed to be here.”

I walked back out of the room, thinking about how much medicine has changed. Not only with newer drugs and newer procedures, but newer thinking. A few short years prior to this patient’s arrest, it would have been unthinkable to invite a family member to bear witness to resuscitation efforts. Some literature has evolved since, strongly in favor of presenting this as an option. Clearly, this wife was empowered, her view clarified, by being with her husband at the end. It was necessary for her closure, to witness our heroic attempts.

What would you do?

Me? I’m not so sure. I don’t know if I would want to bear witness to such an event of a loved one. I probably would. I have to wonder, though, if my indecision or hesitation is, in part, from doing this job for a living or just my inherent spiritual make-up. Obviously, witnessing such a dreadful event may not be for everyone.

Let’s just hope that we never have to make this decision.

StorytellERdoc is an emergency physician who blogs at his self-titled site, StorytellERdoc.

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  • http://www.mditv.com/blog Drew

    This post almost moved me to tears.

    I think you made the right decision by allowing her to be next to the husband’s side during his final moments. As for myself, would I want to be there as my wife slipped away? Yes. As long as I was not in the way of any efforts trying to revive her I would want to be as close to her as possible. If I received the news that she passed while I sat in the waiting room would leave me questioning the hospital staff efforts for the rest of my life.

  • NS

    I read this and wondered if the man had been gay, would you have let his partner be by his side?

    • Lannie

      How interesting, i had the very same thought My niece is gay and has been with the same partner for eight years. They are a united couple and i would hope that she would be allowed to be with her loved one. You know I don’t have to completely believe that her situation is the ideal one but she(my niece) is a big girl now and I would not even try to change her mind).
      Very good piece, I know that i would want to be back there with my husband, no doubt about it and it is not a common practice where i come from. I hope I am never faced with that problem.

  • http://storytellerdoc.blogspot.com storytellerdoc

    Hey Drew and NS

    Drew, I think my thinking would be the same as yours. I’d probably need to see that something was being done…still, let’s hope our lives don’t involve making that decision, ever.

    NS, to your question. A resounding YES. I haven’t walked in your shoes to understand the perspective of your question, but I wouldn’t hesitate to involve and invite a loved-one, regardless of how society defines a relationship, into the room. Yes, yes, yes.

    Thanks all. Hope your day is a good one.

  • http://www.blisschick.net Christine (Blisschick) Reed

    Actually, knowing StoryTellER Doc in real life, NS, I can answer your inquiry with a resounding YES. He is one of the most compassionate, loving physicians I have ever met. Ignorant would not be an applicable descriptor.

  • Ron Pittenger

    I thought you might like to know what is is like to be on the receiving end of this attention. At 53, I “died” on 28 October 2000, late on a Saturday afternoon. I had been under stress for months at work, and had finally gotten a day off. I took my wife to an early dinner and returned home.

    I found I was “breathless,” though I had no pain. Knowing my family history, 3 of 4 grandparents had died of sudden cardiac arrest, as did my mother, I suspected something serious could be going on. I took two aspirins, changed out of my clothes into some dumpy sweats and an old robe in case it didn’t get any better. I put ID and insurance card in my pocket. After about 20 minutes, I told my wife to drive me to the UMMMC Hospital in Worcester about 3 miles from home. I reasoned if I had a serious problem, I’d already be at the hospital before an ambulance could even get to our house. When we arrived, I was unable to walk from the car to the ER room door, only a few yards. A nurse with a wheelchair got me inside.

    The triage nurse asked why I was there. I told her my suspicion and family history, and I was instantly whisked into one of the caridac cubbies (it wasn’t big enough to be a “room”). A youngish doc tried for a pulse, didn’t like what he found and called for back-up. By now, my wife was very upset, but I made her stay and hold my hand, partly for her benefit, but mostly for mine. I told her I loved her.

    By this time, I was the center of action for at least three doctors and one nurse. They cut off the clothes I had been wearing, started an IV, and began babbling about a clot-buster. I understood only some of what was happening by this time. I asked the babbling guy what he thought. He said “Do it.” I looked at my wife, who nodded. I scrawled something that should have been a signature on a form consenting to God knows what. I blanked out for a minute or two. My wife tells me I was defibbed the first time about now. I didn’t feel it.

    The only pain I felt the entire time occurred when someone tried to insert a Foley catheter and wasn’t very gentle about it (I have BPH). I remember trying to take a swing at him as I yelled. I know I didn’t hiit him. then, I was out again. My wife tells me they defibbed me the second time about then. I felt nothing.

    After a minute or so, I woke, told my wife to call my boss and tell him I wouldn’t be in the next day, gave her the telephone number to call, and told her where I left my keys to the shop. I was told I would have to be intubated. I asked not to be because I wanted to be able to communicate with my wife. Truthfully, at this point, I expected to die, and wanted to be able to tell her I loved her again. Oddly, I wasn’t afraid. My wife told me I should allow the intubation. I made her promise to hold my hand as long as she could. She did and I consented. And, I remember nothing for the next three weeks.

    I’ve been told I was defibbed several more times during the next 36 hours. My wife was so sure I wouldn’t be coming home she took my car off the road and cancelled my cell-phone contract at the end of the first week. But, thanks to some damned fine doctoring and a wife who didn’t fall apart on me, I resumed being human around 18 November 2000 and marvelled that we still hadn’t elected a President as it was the only election I’d missed since 1968.

    A quad-bypass and an ICD later. I recovered fully, resumed work and remained productive until last summer when i retired. I doubt I could have done it without my wife–even though I still tease her about killing my cellphone and car. I suspect it depends on the individual, but a relatively calm, loving, and trusted voice in a time of crisis is a real benefit to the person going through it. I hope I’ll have the ability to do the same for her should it ever be needed.

    Sorry to be so longwinded.
    Ron Pittenger, satisfied customer of UMMMC, Worcester

  • Chrysalis

    As an ex-EMT, we never know who is on the scene. We had one call where the person’s mate and children were witness. We gave it all we had, but we could not save him. The only thing that made me feel better about that call…was the fact that, that family knew that we had done everything in our power to save their loved one. Even with the loss, they knew we had tried.

  • JC

    Wow. Great writing, of course. But what a thoughtful, empathic, self-aware doctor. Wow. It’s hard to believe people like that are practicing emergency medicine, or any specialty period, but, great story. It really seems like you made the right choice in asking the wife if she wanted to be there, and in doing so, did well by her. You need a raise.

  • http://www.diabetesdaily.com/blogs/fadingtogray Christine

    Storytellerdoc- Thank you for your touching story. It really humanizes the arrest situation that is so easy to mechanically move through the motions in.

    Ron- thank you for sharing your experience. It’s not often we get to hear the patient’s side.

  • Molly Ciliberti, RN

    Thank you for your post and for letting that woman share the end with her husband. As an ICU/CCU nurse I am sure it helped her to see how hard the team worked to try to save his life. Letting patient’s family take part in their care as they are dying in the unit, being there during resuscitation if they want to and feeling that they are part of the efforts to care for their loved one is a blessing. Have been part of resuscitations where a family member (husband, wife, parent, sibling) was present and sometimes holding the patient’s hand asking them very calmly to fight to live. If it were my family member, yes, I would want to be there to love them through the struggle for life and to love them if they cannot keep up the good fight.

  • http://aebrain.blogspot.com Zoe Brain

    (tears)
    My father went into cardiac arrest just as I got there. I held his hand, and used my “voice of command” to get through to him in his semi-conscious state as the crash team worked. The only time I let go was when they put the paddles on.

    I had an intern come up to me and ask about the patient’s history, I had to tell her that I wasn’t part of the crash team, the patient was my father.

    He’d told me the day before to “keep a cool head” about this, you see.

    We got him back, after several arrests – but there was no salvage, 2/3 of his heart was akinetic. He was fully conscious and aware, able to communicate but too weak to write, so according to his expressed wishes I signed the consent form for withdrawal of ventilation and other heroic measures, and another one for the massive dose of morphine so he wouldn’t feel it this time. He got to say goodbye to his family, and have a last sip of a cup of tea.

    I held his hand again while my Daddy died.

    OK, I have mild PTSD from it. 17 years ago, you’d think I would have gotten over it by now. But it was worth it. It was worth it a million times over, to give him every chance, to be part of a team doing everything they could for him. And to give him time to say goodbye to those he loved, when all hope had gone.

    I encourage every hospital to allow relatives to be present, within the limits of medical feasibility.

    • Molly Ciliberti, RN

      I am so glad that you were there for your dad and that under the circumstances did the loving thing. Letting go can be the loving thing to do and it takes courage to do so.