When a patient dies during resuscitative measures, clinicians don't always stop and reflect. “Generally, they walk away…. The body is left in whatever condition it was in, and the auxiliary staff is left to help clean up and prepare the body for family to come in,” said Jonathan Bartels, RN, a palliative care liaison at the University of Virginia Medical Center in Charlottesville.
There could be many reasons for leaving the room, he noted. “As a hospitalist, you've done everything you can for that patient and were unsuccessful. Often, there might be people leaving in frustration because they didn't necessarily gain the outcome that they were seeking, so they turn away from the body,” said Mr. Bartels, who worked for 11 years as an ED trauma nurse.
But there is an alternative. Mr. Bartels recently spoke with ACP Hospitalist about “the pause,” a moment of silence after a patient's death that he began initiating 2 or 3 years ago. He originally started the practice after a young woman's death in the ED, and since then, it has expanded to other units in the hospital.
Q: What is the pause?
A: The pause is simply just a means of honoring a patient after they pass away, and it's done in such a way that you can have a multicultural group of people in the same room focused on 1 point, which is the patient who's passed away. It's honoring the patient as a group, but doing it in silence as individuals in their own personalized way, whether that be in prayer or…in thinking positive thoughts or just recognizing the moment and the real importance of that particular moment.
Q: Where did this idea come from?
A: I had seen a chaplain stop a team and do a prayer. When she had done it, the stopping was the awesome part for me. The prayer part didn't necessarily [resonate] because I didn't share the same tradition that this person was coming from…. I didn't think it was a very big deal because I thought, this is what everyone does, right? We take a moment, we honor that person. But I soon found out that it's not what everyone automatically falls to, and to ask for it and call out for it gives them permission or invites them to try it out. In terms of its inception, I think we've paused as human beings for a long time. But our society, what goes on, and the speed of our medicine, the speed of technology, we don't take time to pause enough.
Q: Who is generally involved in the pause?
A: Anyone who's involved in trying to resuscitate the patient, so respiratory therapists, physicians, pharmacists, techs, family, social work. Whoever's in there and whoever's making the effort to try and bring them back. I've also used this process in ICUs after doing terminal extubations on patients, so it doesn't only have to happen after resuscitative attempts.
Q: Who initiates a pause?
A: It can happen from anyone. As this has progressed, oftentimes I've had the chief surgical physician call out for a pause. That's when I knew I had something, when the trauma surgeon looked at me and said, “Do your thing.” It's also being done by ER physicians, it's being done by nurses, and it's being done by technicians in the room. It's anyone who's emboldened enough to really take that step to ask for it.
Q: What do you say to initiate it?
A: Generally, what I say is, “Before we leave the room, could we just take a moment to stop as a group and honor this person that was in the bed? Before they came here, they had a life, and they had family. They were loved, and they loved other people. [Let's] take that time to recognize that right now, and also take the time to honor and recognize the efforts we put in to try to save them, and do that in such a way in silence so that we can each have our own voice.”
Q: How long does it last?
A: For surgeons, I can only do about 30 or 45 seconds, but hospitalists and medical doctors let me do it for a minute.
Q: When does it typically occur?
A: Ideally, I think the moment after resuscitative measures have been attempted; that's what the original practice did. I've seen it done now where sometimes they'll have family presence during resuscitations, so they'll call the family in and then call for the pause. Generally, we try to do it before we leave the room, but I have seen it done where that wasn't possible, and I actually saw it done in a hallway.
Q: What kind of reaction to the pause have you seen from clinicians and family members?
A: I think from a family standpoint, it exemplifies that we care and that we're not just treating a body in a bed. In this act, we're honoring a human. When a family member loses someone—I know this from my own experience—my world stops. And when we do this pause, what we do is actually participate in the stopping that this family is experiencing at their loss, even for a brief moment.
Staff [reactions] can be varied. You can have staff that really enjoy doing it. Oftentimes, that's what I hear about 80% to 90% [of the time]. But then, there are those individuals who, I think, may have underlying issues from years of experiencing this type of situation that may not have dealt with it as well. Even 30 seconds of stopping and honoring causes them distress, and they can't participate. That's 1 reaction, where they say, “I can't do this, or I'll break down.” Other people just deal with it differently, and it might not be the thing they want to do, or they suppress their feelings and just want to continue to move on, and that's how they cope. And by all means, they're not forced to do it.
Q: What's the difference between pausing and not pausing?
A: As a clinician, it allows me to put down the situation I was just in and put that away, so that I can step out of the room and then take care of the next person or the next situation that I'm walking into. It allows for closure.
Q: How has the pause expanded beyond your personal practice?
A: It started to take off in the emergency room, and people started to repeat it and replicate it and do it themselves…. I ended up publishing an article about it, but in the meantime, people from other units started to hear about what they do in the emergency room, and they started to replicate it across the hospital. Then other hospitals and people from other facilities read the article in the [February 2014] Critical Care Nurse journal, and they started contacting me and implementing programs similar to it. And it's something they're encouraged to do as not a policy, but just as a means of practice.
Q: What advice would you give a clinician who wants to implement a pause?
A: I always stress that you really shouldn't impose your own religious views in this practice. You should allow the silence to be what it is because everyone does things in their own way. This allows everyone to be both an individual and then practice in a group.
Q: Can this concept expand beyond the hospital?
A: My other focus is EMS and first responders, paramedics and firemen. It can be done anywhere. I think that this pause is not the end-all be-all, but it's just one means of trying to take care of ourselves. And I think that's really what we need to do as health care providers. [It adds only] a minute and a half.