Code Blues and Death: An Intern's Perspective

It’s unbelievable to think that half of my first year of residency is complete. While six months is a sizeable chunk, the time really flew by. As some work weeks near 80 hours, the days, the patients, and experiences feel heavy. As I started my two-week vacation, I reflected on what happened after July. From long morning rounds to evening sign out, a resident's routine day is full of surprises. However, one of the biggest surprises thus far has been the frequent encounters with death.

When you sign up for medicine, you realize that death is an inevitable part of the job. But as you progress through your training, you get closer and more comfortable with it. The moment that death is actualized by a lot of providers is during their first code. For my audience who is unfamiliar with the term "code", it is slang for when a patient experiences cardiopulmonary arrest. In other words, the patient stops breathing and their heart stops. If anyone has ever experienced a code, it's fair to say that they're all pretty damn chaotic.

I'll never forget the first code I ever witnessed as a medical student. The overhead announcement was made, and my resident became wide eyed as she realized it was a patient our team was caring for. She ran faster than I thought she was physically capable of, and I followed her to the second floor on the other side of the hospital. When we arrived, a crowd of providers had congregated, and I was out of breath. The patient was a man in his 70's admitted for congestive heart failure. The code leader was yelling orders as the team assumed their roles. More people threw on gloves and entered the room while others shouted that there were too many people. Clutter from the room was thrown aside. Pads for electrical cardioversion were attached to the patient. I heard ribs crack as my resident pushed on the patient's chest. Time stamps were called out and syringes of epinephrine were handed off. The anesthesiologists arrived and they inserted a breathing tube. Pure madness. Periodically, compressions were paused to check for a pulse, and after several rounds, there continued to be none. The patient's heart was still not working. After almost 30 minutes, I heard the code leader say, "we'll go two more rounds and call it if there's nothing". My resident ushered me forward to do compressions. After one round, I was covered in sweat. My resident took over. My hopeful self-imagined a miracle where somehow, they would feel a pulse. To my disappointment, after another round nothing changed. "Time of death 3:52 PM", the resident said. Silence. The chaos stopped. Slowly, the staff ushered their way out. A pale, lifeless body laid. Honestly, some traumatic shit.

I’ll never forget feeling this disdain when I learned we had failed to resuscitate the patient. Standing by the body felt genuinely painful, creepy, and humbling all at the same time. But most of all, the feeling of failure prevailed. All the medical care, interventions, and treatments suddenly felt like a waste. Hundreds of hours and thousands of dollars were spent on this patient, for what? Just to apologize to their family? I remember thinking how rare that feeling was. Boy was I wrong.

When I became a resident, a few things surprised me. First, it didn't occur to me how many times I would have to encounter this sequence. Second was how guilty I felt each time it would happen to my own patients. Third was how often I wish patients and their families had changed their code status. I'll explain.

When a patient is admitted to the hospital, they are requested to provide a code status. In the event the patient's heart stops, they can request that measures such as CPR and a breathing machine be used to keep them alive. This status is known as "full code". Conversely, a patient and their families can request that none of these measures be tried. This is known as "Do not resuscitate or DNR" status. Several times, the latter is chosen if a patient is expected to pass from a terminal illness, is very old, or recovery following a code would severely compromise quality of life. In these scenarios, measures for resuscitation would be harmful and/or uselessly prolong life. Several times, code status decisions are made and documented by the patient long before they become sick. Other times, the patient never expressed their desires and are currently too sick to make decisions. In these cases, the family must choose for them, which can be tough. Although the topic of code status is difficult, I wish more people addressed it in earlier stages of their disease. Believe it or not, more people in the hospital deserve to be DNR even before their admission. I mean this in the most respectful way, and one my first patients taught me this.

During my first week as resident, I was on the cardiology floor and one of my patients went unresponsive. My senior was attending to another sick patient and I was alone. As I was bedside, I immediately began pressing on his chest and the nurse outside called the code blue. After two rounds of compressions, we were able to revive him. He was 94 years old with multiple co-morbidities and COVID. His organs were failing, and as it stood, his status was a full code. He was an intelligent retired engineer that lived a fruitful life. However, he was now sick, confused, and unable to make decisions. Given his co-morbidities, his prognosis was poor and additional interventions would be futile. Therefore, I was instructed to call his family and inquire about switching the patient's code status. I had never done this before. I hesitantly called his son. I updated him on what happened, and I was very clear. I told him his father's condition was deteriorating rapidly and he should consider changing his code status to allow him to pass peacefully. When I answered his follow up questions, it became clear to him. I asked him what his final decision on code status was. He started to cry. I wanted to cry. At this point, the senior residents and cardiology fellows were listening in. The son was rightfully distraught and couldn't give me an answer. He knew it was his father's time to go but still felt guilty for making that decision. I allowed time for grief, but my colleagues weren't as patient. They took the phone from me and continued the discussion. They were respectful and professional, and reiterated how it would be cruel to do compressions again if we had to. The son cryingly understood, and his father's status was officially made DNR. The patient was transferred to the ICU. Because he was COVID positive, visitors were not allowed. He eventually died a few hours later. No family was by his side and the morgue took his body.

After hearing what happened the next morning, I was really sad. My senior resident supported me but we moved on after a short de-brief. I continued working as there were notes and discharges to be completed. I convinced myself I was okay and I really thought I was. But subconsciously I was disturbed by the incident. I rarely ever have dreams but the following night, I had one. I was alone, in that same patient's room. I felt nervous that he was going to crash. I didn't know what to do because I was new. Then voices of his son crying sounded off. I woke up and felt horribly guilty. Did we do something in our care for him to deteriorate? Could we have saved him? Or was it his time to go? If it was, how could we allow him to be alone? Should we have called his son earlier to communicate how sick he was? All of these questions ran through my head for the next several days. The truth was they didn't have a right answer. But one thing that was for sure was that I shouldn't have felt guilty. It was all part of the job.

In the following months, I experienced more code blues. I broke terminal diagnoses to families and legally pronounced patients’ deaths. Whether you believe in God or not, the reality is that we will all pass one day. The limitations of being a physician are frustrating but inescapable. You can't save everybody and truthfully, nor should you. I've learned that “saving” can do more harm than good sometimes. I believe that people deserve the right and dignity to pass peacefully when medical treatment is exhausted, and that quality of life is so important. We as resident physicians experience death frequently. Over time, our response to death dies down. I don't feel the same emotions I did when my first patient passed away and appropriately so. It would be difficult to do this job if that was the case. But each time it does happen, it still hurts. I don't think there's a perfect way to deal with it but like many difficult things in life, talking about it really helps. I'm grateful for my co-residents; we've been emotionally there for each other through the thick and thin. I believe reading and writing about the topic helps too. It's a familiar subject in medicine with all sorts of literature and internet pieces written on it. Not feeling like you're alone in this experience as a healthcare professional is half the battle. It seems obvious that you wouldn't feel that way while working with others. But it's surprising how busy we get and bottle up some of these experiences.

Additionally, given our busy schedules I encourage myself and my colleagues to be there for our patients during death. A lot of times, when a patient is approaching the end, families don't understand and will want more to be done. They will be frustrated and blame you for the decline of their loved ones. While these accusations hurt, you have to understand where they're coming from. I've learned thus far that spending time with families to explain the disease process really helps them understand. Having our knowledge as physicians is a privilege and sharing it with patient families can encourage appropriate decisions from their end. Communication is key and teaching patient's and their families in my experience tends to create a positive experience. Death is extremely tough. But we as providers, patients, and families are in this together and constant discussion can only make us all more comfortable with the topic.