Exchanging a Blanket for a Code Blue

How some hospitals are prioritizing comfort and connection at the end of life
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In most hospitals, “crash carts” are positioned strategically. They contain a variety of tools and medications that can be used to attempt resuscitation on a patient whose heart has ceased beating normally or who has stopped breathing. 

When a physician, nurse, or other health professional calls a “code blue,” the crash cart is rushed to the patient’s room and put to work. Chest compressions can be used to try keep blood circulating, a defibrillator can deliver a shock to restart the heart, and a host of medications and other equipment can be brought to bear in an attempt to save the patient’s life.

In some cases, a rapid response can make the difference between life and death. But it is also important to know that the vast majority of patients who undergo in-hospital resuscitation do not survive to discharge. In reality, fewer than 20 percent of such patients leave the hospital alive. When a patient is suffering from a terminal illness, the probability of survival from a resuscitation attempt decreases almost to zero. 

Knowing that they are nearing the end, many patients and families opt for “Allow Natural Death” (formerly “Do Not Resuscitate”) status. That is, when their heart stops beating, resuscitation is not attempted.

The crash cart represents an important provision for patients who collapse unexpectedly, but what are hospitals doing for the many patients whose deaths are anticipated, many of whom have opted to “allow natural death?” Nearly 1.5 million patients die in hospital every year, and in many cases physicians and nurses know for days and even weeks in advance that death is imminent. It is important that they avoid letting the fact that they will not attempt to resuscitate such a patient prevent them from providing the very best care right up to and beyond the moment that the heart beats its last.

Consider the case of Tom Stephens, a man in his 50s who suffered a rupture of an aneurysm of the aorta. By the time he arrived at the hospital, Mr. Stephens had nearly bled to death. Although the physicians and nurses involved in his care did everything right, including replacing lost blood and repairing the tear in his aorta, he suffered severe brain damage. For almost two weeks, he lingered in a coma, suffering respiratory failure and other medical complications. 

During this time, his wife and two teenage sons were always at his side, eagerly anticipating any sign that he would regain consciousness. But he never improved. The time had come to make some important decisions. Would Mr. Stephens undergo placement of a tracheostomy tube, so that a machine could breathe for him long term? Would he receive a gastrostomy tube, so that he could be fed in spite of the fact that he could not swallow? The family and care team had a series of long conversations, during which they talked about his medical problems, his life, and what he would have wanted under such circumstances.

His family concluded that, in light of his severe brain injury and other serious medical problems, he would not have wanted his life prolonged and would have chosen to be taken off the machines. His comfort would become the priority.

In some cases, at such a point the healthcare team might be inclined to withdraw. Once the goal of his care had ceased being to keep the patient alive as long as possible in hopes that he would recover, what more could his physicians and nurses really do for him? 

In fact, there was still much that could be done. It required no less expertise, dedication, and effort than curative therapies. The very day the decision was made not to call for the crash cart if Mr. Stephens’ heart stopped, a different kind of cart was called for.

This was a new kind of cart that is being implemented at a number of hospitals across the country: the comfort cart.  Unlike the crash cart, it does not contain a cardiac defibrillator, endotracheal tubes, or powerful medications such as epinephrine and dopamine. Instead it contains much lower-tech but nonetheless powerful items, including music, scriptures in various faith traditions, and a variety of homemade “love” blankets. For the patient’s family, it also includes information on grief, the dying process, and lists of area support groups, funeral homes, and community assistance programs for burial. Finally, it contains a plaster kit for making a cast of the dying patient’s hand. 

The cost of all this equipment, including the cart itself, is only about $600—a pittance compared to the costs of other aspects of contemporary hospital care.

Mr. Stephens’ boys both got to pick out a blanket. Each of his sons could keep his dad warm while he was dying and also help to inject some warmth into the otherwise cold and impersonal process of dying in the hospital. After their father was gone, they could take it home with them, keeping it in their room, or perhaps even using it on their own bed.

Such blankets help to create a sense of community around dying patients and their families. They are not purchased from a store but are made by local volunteers, including senior centers, quilting clubs, churches, and Girl Scout troops. The blanket becomes what psychologists and anthropologists sometimes refer to as a “transitional object,” providing something to cling to throughout the dying process, the funeral, and after. They help to create a caring atmosphere that lives on in memory long after the patient is gone.

In addition to selecting comfort blankets, both of Mr. Stephens’ boys chose to make a plaster cast of their dad’s hand. One even made a two-person cast, combining his own hand with that of his father. Making the casts helps balance a mood of doom and gloom with something beautiful, calling to mind the many times their father played catch with them. And the casts will help each of them keep their father’s memory close by, serving as a valuable memento years hence when they recall him to their own children, helping to make a grandfather they never could never meet seem more real. 

Often family members of a dying patient feel they can do nothing but stand by helplessly and watch events unfold. The comfort cart provides them something to do, enabling them to turn a sterile hospital room into a more home-like place where they feel less like medical specimens and more like a real family who can do something to help. Its purpose is to create a meaningful, even sacred space around them. It is not intended to inject an artificial sense of happiness into the situation, but to help people grieve, as they need to, in the way that feels most authentic to them.

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Presented by

Richard Gunderman and Peg Nelson

Richard Gunderman, MD, PhD, is an Atlantic health correspondent. He is professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. His most recent book is X-Ray Vision. Peg Nelson, NP, the director of palliative and pain services at St. Joseph Mercy Oakland Hospital in Pontiac, Michigan.

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