The Chaplain & the Doctor: A Team to Support End of Life

This stirring documentary is a tribute to all who care for those at the end of life. And to the importance of treating the person, not just the disease.

The Medical Pause; Health Care Professionals Acknowledge Death

Health care professionals often see death as a failure. Their job is to keep people alive and well; when a patient dies, they mark the time of death, do the paperwork, and move on to try to save someone else. Jonathan Bartels is a nurse who has developed "the medical pause," a way for health care professionals to acknowledge that a life has ended in a respectful and meaningful manner.

The medical Pause is a practice implemented after the death of a patient. This practice offers closure to both the medical team and the patient. It is a means of transitioning and demarcating the brevity and importance of this moment. Through silence this shared event is able to be honored and marked by a multicultural medical staff. Silence allows individuals to personalize their practice while not imposing onto others. This act is a means of honoring a persons last rite of passage. To bring an element of the sacred back into a profane world of medicine.

Anyone can ask to do this following a code/death. At first it may feel awkward because we are standing in a vulnerable place and asking for a moment of respect. After it is done, it becomes easier to repeat because everyone involved understands how important it is.

“Could we take a moment just to Pause and honor this person in the bed. This was someone who was alive and now has passed away. They were someone who loved and was loved. They were someone’s friend and family member. In our own way and in silence let us stand and take a moment to honor both this person in the bed and all the valiant efforts that were made on their behalf.”

45 seconds to a minute of silence.

“Thank you everyone.”

A lesson on life’s end: How one college class is rethinking doctor training

"The class, called Life at the End of Life, places students with medical aspirations — before they even apply to medical school — with patients at the Terence Cardinal Cooke Health Care Center (TCC), a nursing home in Harlem. The students enter the doors of the clinic knowing that their patients will not get better, and likely never leave. In an increasingly tech-enabled medical profession, where death is postponed as long as possible, the class challenges pre-med students to confront that ultimate reality, and to learn how to guide patients and their families through it. And along the way it’s challenging their field’s hidebound distinction between medicine and palliative care — between doing everything to keep someone alive, and helping them die with dignity."

A lesson on life’s end: How one college class is rethinking doctor training:

Beth Israel Deaconess examines mistakes made after patients die

 "The hospital has created a 20-person working group to focus on the aftermath of a patient’s death. It’s part of a broader effort to reduce “insults to dignity” — mistakes that cause emotional harm, but haven’t traditionally been considered medical errors. For example, after another woman died at the hospital, her family got to the funeral home and couldn’t find her pocketbook, said Patricia Folcarelli, senior director of patient safety. It turned out the pocketbook was still in the hospital morgue. In another case, the hospital failed to complete an autopsy that a family had requested, she said. These cases happen with low frequency, but have high impact, Folcarelli said. “If something about the death doesn’t sit well with the family members, they’re at higher risk of complicated grief” — when grief gets “stuck” or turns into depression, added Kathleen Rimer, the hospital’s director of spiritual care."

Beth Israel Deaconess examines mistakes made after patients die

The Liz Army | Hacking the hospital death

A beautiful essay on helping a friend to a quiet, loving death space.

"The medical team gave Jim medication to take away any pain he may experience. They removed his breathing tube, and unhooked all machines except for the one monitoring his heart beat. Quickly, his bed was moved to the sunny room where his friends, including myself, were waiting outside by the window. As soon as the medical team cleared out we poured in. One person set up the speakers. Another friend was ready with the iPod. The door to the medical area was closed. The rest of us swarmed in around him: hands placed on his hands, his legs, his feet. The room was small, so some hovered around the perimeter and in the doorway to the open air. We fell silent and the first song began. Nearly every other song on Jim’s iPod was a Christmas song, so I wasn’t surprised when “I’ll Be Home For Christmas” started playing through the speakers. For decades, Jim gifted friends with his mix CDs of obscure Christmas songs he had spent the previous year curating. This is perfect, I thought, while I cried and laughed at the same time. Unburdened by machines his body began sinking into the bed. As the body shifted and settled I said, “This is natural,” mostly to remind myself that what I was witnessing was part of the cycle of life, much like a baby crying when born."

The Liz Army | Hacking the hospital death

Every Nurse's Nightmare: A Dying Patient With a Frantic Family and No DNR in the Emergency Room

Shared with permission: I think I would be accurate in saying this is every nurse's nightmare.

The 86 year old female comes to the ED via the ambulance ...from her nursing home. She is fragile and frail and non-responsive. Her eyes have a fixed glazed stare. She is in a fetal position, brittle bones, decubitus ulcers everywhere. Her few family members come bursting through the ED doors screaming: 'DO EVERYTHING. And against our morals, against our compassion, against the need to have dignity to this little ladies' last days on earth, we present her with rapid CPR compressions, we feel her tiny ribs crunch and break, her blood pressure is 60/30 and she barely has a thready pulse. And we give her epinephrine and atropine and we continue to compress her chest deep and fast, and her heart rate speeds up to a chaotic fibrillation ... And we scream 'All Clear' as we force an electrical current through her heart..... And we watch her have seizures and loss of oxygen to her brain and leave her with a faint thready pulse and too much time for no oxygen to her brain.... And she 'survives' these insults that we force upon her, leaving an anoxic brain in her contratured body.

And the family is pleased: 'Praise God', He brought her back... It is God's will. She'll live to be 100. And we the ED nurses, we the ICU nurses bow our heads, because we know we brought pain and torment and assault to this tiny malnourished lady who once had a vibrant life.... Who once had a full life... But slipped into the tunnel of dying... Almost peacefully until her family forced us nurses and us doctors to bring her back with intense pain and torment.... And instead of going to heaven... Instead of being in heaven and resting in peace... WE condemned her to a living hell.

Prepare your moms and dads, grandmoms and grandpas and allow them to drift peacefully into that other world. It is not heaven on earth... It is a hell. A hell that is hell-bent, filled with pain and misery.

Your turn.

The I.C.U. Is Not a Pause Button - The New York Times

ICU Nurse Kristen McConnell: "I’ve often spoken with patients’ family members who seem to feel that an I.C.U. is a time-free holding zone; that intensive care functions as a pause button. Those conversations usually take place on the phone. It’s harder to believe in this pause button when you witness the constant poking and suctioning, the invasive examining and monitoring, the parade of medications and the contraptions necessary to deliver them, the lights and alarms, the coughing and grimacing and shuddering — or, in the less responsive, the bloating and stiffening or slackening and eventually the eerie dehumanization of both the patient and the caregiver. Thinking that intensive care can pause the march of time is a misunderstanding or a willful fantasy. There are always bargains to be made and discomforts to be faced in a place that is staving off death.

Time goes by quickly caring for patients like that young, scarily ill man. It goes by too quickly for nurses and doctors to eat or sit down or even go to the bathroom. It went by too quickly for the E.R. staff to clean the vomit off his face. Each minute matters, and it feels like a focused race. Caring for patients like the old man doesn’t feel like racing, it feels like waiting. In cases like his, time goes by slowly. But it definitely does not stop. These days are lived. For patients in the hospital surrounded by workers just as for patients at home or in hospice surrounded by people they love, these days at the end count.

Americans are increasingly aware that a good death rarely happens on its own; it needs to be negotiated and orchestrated. More people complete advance directives so their families are not left to make end-of-life decisions for them. But every day thousands of the patients toughing it out in intensive care are in fact in a purgatory maintained by family members who are either too intimidated by the complex medical situation to get involved (care providers who communicate poorly share the blame for this), or who don’t realize that this time is crucial. The cascade of responsibilities that occur when someone is dying has begun, even when the nurse on the telephone tells you that the patient is stable.

Families should realize that this time is the end of life, and they should pay attention to its quality just as they would if the patient were dying at home. That’s because although we can usually hold off death, we cannot pause time, and an extended stay in the I.C.U. is an ugly way to end a life. Unless the medical record contains an order limiting the measures that can be taken, originating from the patient, his next of kin or his designated proxy, interventions to keep him alive will continue indefinitely, regardless of the anticipated outcome in quality of life.

When a family member is in the I.C.U., it’s not enough to call. You need to drop what you’re doing and be at that person’s side, figuring out what is best for them. Doctors, nurses and technicians care about patients, but sometimes we cannot express our care by doing what we think is best for them. In the I.C.U., that is not our job. Our job is to preserve life. Often, when working with patients who have a quality of life it is impossible to imagine anyone wanting, we express our care by saying, “I’m sorry.”"



The I.C.U. Is Not a Pause Button - The New York Times