Siren and blue lights.
Team allocated and primed. Voices command, ears listen, and hands swiftly execute. Monitors beep—loops of communication.
As the second hand sweeps, loud voices grow quieter, and pulse checks fall into an unfortunate pattern.
Realisation, its time, knowing looks, a shake of the head, a pain, heaviness. Winding down….
“Time of Death 10:43”.
Oppressive quietness heavy with professionals’ suppressed emotions mixed with raw parental grief.
That piercing parental cry rips through the room. Our bodies primed for the fight. Or exhausted from it. Some feel a nothingness. A solemn swift clearing of the room.
Only another nine hours to go… time for the next triage; it is getting backed up. Short-staffed again today; get to the debrief if you can. It will be hard to sleep tonight and the next…
Unfortunately, this may feel familiar as we present the stark emotional and physical contrast of such high-intensity lifesaving situations with the low of the realisation that a life has suddenly ended too early.
In most Emergency Departments, staff are allotted little of that scarce resource, time, to begin processing what has just occurred. These unprocessed emotions can lead to vicarious trauma, especially in resuscitation providers. While debriefs are an essential tool in any Emergency Department’s handbook, allowing time for staff to be present is often a barrier.
An adrenaline kick surges through the bodies of the healthcare workers, promoting the delivery of focused tasks whilst making life-saving decisions, however…
Despite the advancements in medications, treatments, algorithms and resources…
The biopsychosocial model of modern medicine whispers a belief that death takes place because of a failure of the medical system. This gives rise to feelings of failure alongside the feelings of grief. Psychological harm occurs. Definitive emotional support is critical to our emotional and psychological well-being. To limit the psychological harm, perhaps we should implement THE PAUSE.
The Pause
Jonathon Bartels worked as an Emergency Nurse in America in 2009. After the death of a young person in the Emergency Department, he initiated ‘The Pause.’ This simple intervention aims to acknowledge the tragic and unexpected event humanely and respectfully. It recognises the deceased as an individual with family and friends who loved them. And it acknowledges the effort provided by the team.
The Pause creates an opportunity for loved ones and healthcare workers to respectfully honour the patient and the significant event they have been involved in before moving on to the next task ahead. It gives us permission to stop, breathe, recognise the enormity of what has happened, and provide a platform for acknowledgement.
Very rarely are the ED team allowed to stand, in silence, with a purpose. The Pause allows us to take the foot off the pedal briefly. It affords us a break and the chance for the brain to come back into focus. Most importantly, it allows us time to respect and honour the child that has died.
We are not often familiar with the concept of a good death in paediatric emergency medicine. We can only strive to provide the best care for all involved.
The Pause is a short reflective period. The brief script lasts just 15 seconds and is followed by 15-30 seconds of silence. Any of the team can say start the reflection and lead the initiative. This non-hierarchical grounding envelops the humane approach. It is not based on any particular religion, and nobody must be made to partake.
Rather, immediately after an unsuccessful resuscitation attempt, there should be an opportunity for those involved to partake. Staff can stand at the bedside or in a comfortable position in the room and process this event collectively.
Bartels suggests that The Pause should not be rigorously enforced but become part of the culture of Resuscitative Care.
The Pause reduces caregiver stress, encourages a supportive team-based culture and assists in our ability to process the trauma.
The Pause encapsulates a value which underpins a core value; to minimise pain and suffering for all.
Be kind and care for yourself and those around you.
Please watch this video for a beautiful explanation from Jonathan Bartels of this initiative.
Selected References
Copeland, A. & Liska, H. (2016) “Implementation of a Post-Code Pause: Extending Post-Event Debriefing to Include Silence”. Journal of Trauma Nursing. 23(2), pp. 58-64.
Cunningham T. (2018) “Benefits of using the pause after death in emergency departments: a Delphi study”. Southern Medical Journal. 112 (9),pp. 469-474.
Kapoor et al. (2018) “Sacred Pause Imitative in the ICU: A survey of ICU physicians and nurses”. Critical Care Medicine, 46(1), pp. 589.
Newell, J. & MacNeil, G. (2012) “Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue”. Best Practices in Mental Health. 2 (57-68).
O Malley P. et al. (2014) “Death of a child in the emergency department” American Academy of Pediatrics. 134 (1), pp. 313-330.
Przednowek, T. et al. (2012) “Implementation of a Rapid Post-Code Debrief Quality Improvement Project in a Community Emergency Department Setting”. Spartan Medical Research Journal. 6(1).
Spencer, S.A. et al. (2019) “The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices.” Resuscitation. 142, pp. 175-181.
