A 92-year-old patient comes in from home for altered mental status. Their pressure is in the 220s/110s, and they have difficulty following commands and a rightward gaze. CT head shows an extensive basal ganglia hemorrhage. After CT, the patient becomes more agitated and confused and cannot follow commands. What does one do? It really comes down to a few points:
  • Try to involve the patient and their preferences as much as possible. If the patient is able to communicate, use their input to frame your discussion. Ask questions about the patient, their values, and what they considered important at the end of their life. Say the phrase “dying”, or use the word “death” (insert scrub reference).
  • Involve other people (other family members, chaplaincy) and plan for this to take time, like any other resuscitation.
  • Act like a doctor. If you’re leaving a resuscitation to talk to family, take off bloody items of PPE and have someone look at your face and hair. Identify yourself and sit down, but bring a friend (chaplain, nurse, security), and make sure you have an escape route, as different people can react differently. Know the next steps for your hospital process – are deceased patients brought to the morgue immediately? How aggressive is your medical examiner, etc.?
  • Consider bring the family into the room. This maybe a controversial point to some, but you should consider it every time. Evidence suggests decreased survivor PTSD, but need to have someone dedicated to provide background to the family (again have a team approach here). Limit observers to 1-2, give them a char (one without wheels), tissues, etc. 
  • Perform amoment of silence and debrief (suggest this prior to “calling it”). Recognize the life of the person, as patient death are difficult for the doctors, nurses, others as well. Too often the perception that we have “failed” the patient, and we need to recognize successful tactics and the efforts of others. Take space before you go back back to running your patient list. Ask someone not involved in resuscitation to let waiting patients know that you are with someone who is critically ill.

Remember, death and dying in the ED is hard, hard for you and hard for families. No one planned for this to happen and it goes against our training to let someone die. Consider breaking bad news like a “procedure.” Set up for it appropriately and make sure you have the tools to be effective. Finally, consider debriefing after resuscitations and bringing family in to witness resuscitations. Both have been shown to reduce secondary trauma.


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Resources for this episode

  1. Dainty KN, Atkins DL, Breckwoldt J, et al. Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review. Resuscitation. 2021;162:20-34. doi:10.1016/j.resuscitation.2021.01.017
  2. Goldberger ZD, Nallamothu BK, Nichol G, et al. Policies allowing family presence during resuscitation and patterns of care during in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 2015;8(3):226-234. doi:10.1161/CIRCOUTCOMES.114.001272
  3. Tennyson CD. Family presence during resuscitation: Updated review and clinical pearls. Geriatr Nurs. 2019;40(6):645-647. doi:10.1016/j.gerinurse.2019.11.004
  4. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366


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Death And Dying- Med Student Over Easy

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