NEJM Raises Questions About Detachment When a Patient Dies

BOSTON, Sept. 26 -- When a patient dies during a "code call" in the hospital, the residents, nurses, and technicians who responded to the emergency might stop for just a moment and pay respects to the life that was lost.

So suggested Katherine Treadway, M.D., an internist at Harvard Medical School, in a perspective in the Sept. 27 issue of New England Journal of Medicine.

She believes that a rapid exit from the "crash scene" when the resuscitation fails is somehow callous and inappropriate. A better way to concede that technological defeat might be if the physician in charge said, "The code is called, Let's have a moment of silence to honor this life."

Dr. Treadway described how she, as an intern, was introduced to code calls. She sprinted to the scene where a medical team under the charge of senior resident was rapidly assembling. Her main concern, she wrote, was "uncertainty about what to do, what drug to give, how to tell what was happening."

In the chaotic scene, the senior resident "seemed almost godlike -- leading us through our tasks in his calm, methodical way until he was convinced we had done enough."

But when the code was called, she and her more experienced colleagues all reacted the same way -- "we stopped what we doing, and then, as though the whole episode had been some minor distraction in our otherwise packed day, we filed out of the room."

It was, she wrote, an extension of the detachment she first learned during dissection of an anonymous cadaver during medical school.

But she began to reconsider her acceptance of this professional detachment when, "in the late fall of my internship year, I happened to be the last person to leave the room after a code."

Perhaps because she was alone, she found herself "struck by the reality that a person had just died. I made myself turn around and look at the body of this stranger." Staring at the body, which still had the wires, electrodes, and tubes -- all the accoutrements of resuscitation technology -- attached, Dr. Treadway began to think about the man and his family.

"Half-remembered words from the end of a requiem mass came into my head and I said aloud, "May choice of angels greet thee at thy coming" -- less a statement of faith than a simple attempt to acknowledge the passing of a life."

Dr. Treadway said that since that day "I have never had a patient die and not said those words."

NEJM editors have designated this an issue worth discussing and they are inviting readers to post comments onto a special online forum on "emotionally challenging issues of clinical care" that will be open from today through October 10 at the NEJM website. Dr. Treadway has been invited to post responses as well.