Should Family Members See Patients Die in the I.C.U.?

On one recent intensive care unit shift, I admitted a man whose heart had stopped earlier that day. By the time I met him, it seemed clear that he wasn’t going to live. So when he went into cardiac arrest for what I suspected would be the last time, I headed out of the unit to find his wife.

The nurses had told her to wait in the family room and though we hadn’t met, I instantly knew who she was. Leaning against a wall, eyes bleary and absent. I introduced myself and explained that my team had started CPR again. I was worried that it wouldn’t bring him back.

Then I asked her what might seem like strange question: “Do you want to be there while we do CPR?”

She hesitated and then nodded. “Come with me,” I said. We moved quickly. Inside the room it was chaos, an intern in the midst of chest compressions while another drilled into her husband’s shin for emergent IV access. For a moment I wished that I could take the question back and purge the image from her memory.

“Are you sure you want to stay?” I asked. “You don’t have to.”

She wiped her eyes on her sleeve. She was wearing a bright pink sweatshirt with a happy slogan on it. When she had put it on that morning, her 50-year-old husband just had a cold that wouldn’t go away. Now she had learned that he actually had leukemia that had caused his heart to fail. It was too fast, she told me. She needed to see it all for herself so that she could believe it was true.

I offered her a tissue box and found a chair from an empty patient room to place in a corner of the hallway. That way she could watch what was going on without seeing too much or getting in the way. She sat. I looked down at her and realized I wasn’t sure what to say. Of all the protocols in critical care, there was none that might have prepared me for this.

When I was in residency, the standard response to a code being called in the I.C.U. was to send the relatives out. Ribs break. Limbs flail. Blood sprays. Dignity fades. This is not a spectator sport — or so the thinking went. As a doctor in training, I might have found the presence of a patient’s relative to be a distraction.

A well-run code is like a dance, where any new member can threaten to disrupt the balance. So we would ask families to leave, banishing them to the waiting room until we could offer a verdict, alive or dead. It seemed safer that way.

But a growing body of research argues that we might have been wrong. Studies suggest that relatives don’t distract the medical team or interfere with decision-making in a code. Doctors don’t feel pushed to continue CPR longer than we would otherwise or to stop sooner. Nor are there increases in legal ramifications.

Perhaps more important, allowing relatives to be present for CPR doesn’t leave them with higher rates of anxiety, depression or post-traumatic stress disorder (PTSD). To the contrary, some studies suggest that when family members watch the medical team attempt to bring a loved one back from the brink, they’re actually less likely to suffer PTSD in the months that follow. Maybe there is value in knowing that we tried, and in seeing our efforts, in all their devastating detail. Maybe there is some reassurance in that reality.

It’s not only about the codes. The move to allow relatives to observe CPR comes along with broader efforts to bring families into critical care. At my hospital, we even invite family members to join us on morning rounds — an innovation I find surprisingly valuable. There is nothing like a tearful relative to keep us accountable and to remind us daily that this “great case of respiratory failure” is in fact a person. And for better or worse, that relative often provides the best continuity in a fractured medical system.

Of course we fumble from time to time. I remember an overly enthusiastic intern who once added “cancer” to a patient’s broad list of possible problems, leaving the patient’s sister panicked. Sometimes we feel the need to mince words, particularly about prognosis. Yet more often, as the days become weeks, the relatives on rounds transform into a part of our team. We greet them in the morning. We wait for them if they’re running late. But then when their loved one dies, that’s it. They disappear from our orbit — leaving me to wonder what they return to after, and whether we can support them better.

I wondered the same thing that evening, as I stood next to my patient’s wife. In the room, chest compressions were still going. The overnight attending had come in early, leaving me free to spend a few more minutes outside the room. But I wasn’t sure what to do.

“Do you want some juice?” I finally asked. She did.

“Cranberry or orange?” Inside, they paused again to check for a pulse. The next round would be the last.

She shrugged. “Cranberry.”

I grabbed the juice from the nurse’s station and brought it back to her. She took a sip. The juice was tart and her lips puckered in surprise.

“He’s not going to be O.K., is he?” she asked.

I shook my head.

“Then they should stop,” she said. “I know you tried. Let them stop.”

In the room, my patient’s body was splayed out on the bed, one arm dangled off. I hoped that his wife couldn’t see him like this. I wondered if he would have even wanted her here, if he could know. “That’s enough,” I told the resident. “You did great. But his wife asked us to stop. She’s here. Outside the room.”

He turned around, locked eyes with the wife. “I’m sorry,” he mouthed. Then he turned back to the team. “We’re calling it,” he announced.

From outside the room on the little chair I had set up for her, my patient’s wife began to sob. Her breaths came ragged and gasping, the tears leaving splotches on that pink sweatshirt. I had never seen grief so naked, and I wondered whether I had made the wrong choice. Perhaps I shouldn’t have given her the chance to see this. Perhaps I should have made her leave earlier.

Then she looked at me. And said, “Thank you.”

Daniela Lamas is a doctor at Brigham and Women’s Hospital in Boston, a staff writer for the Fox medical TV drama “The Resident” and a New America national fellow.

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