If They Only Knew

As a resident, part of my responsibility is to show up and help at every code blue. I’ve seen them turn out just about every way they can, from false alarms to ICU transfers, to pronunciations. However, there is one consistent theme. Unless someone steps up to prevent it, the patient is granted little modesty. Many times, the vast majority of times, a patient is centered in a room, surrounded by 10 to 15 medical professionals, laying in his/her bed, with EKG leads and pads on their chest, completely naked. Many times toward the end of a code, I’ve found myself thinking, “Would she have wanted us to do more to preserve her dignity? If she only knew how a code blue truly works, would she have chosen DNR instead?”

I am just as guilty of this as anyone who is a part of a code blue and does nothing to cover the patient when it doesn’t compromise their care to do so. Reflecting on these questions, I find myself wondering, when she chose to be “full code,” did she have any idea that during the code she would be naked, in a room full of strangers, with little concern or action made to preserve her dignity by covering her body when able? Is it truly informed consent if we do not portray the situation truthfully to the patient in regard to what we think they might care about? Should we allow ourselves as caretakers to only focus on the heart and lungs during CPR at the expense of the human that surrounds them and the dignity they would have hoped for, and deserve?

I can appreciate the argument that the purpose of CPR is to maintain and restore blood flow and a viable heart rhythm. If that comes at the expense of exposing the patient's genitalia, then it's a small price to pay. In a sense, I agree. Saving a life may be worth temporarily sacrificing a patient's dignity. And I also understand how many could argue that saving a person's life is preserving their dignity.

However, why assume respecting modesty and restoring blood flow are mutually exclusive? We can do better, and have at least 3 options concerning patient modesty, dignity, and privacy during CPR in a hospital setting.

1. We can change nothing. We can continue to expose the patient's genitalia during a code, concentrate on the ACLS protocols, and pay no mind to what many patients would consider horrifyingly embarrassing. We can continue to only talk about chest compressions and intubation, and not disclose things patients care about but don’t know to ask. However, if we don’t share information we know some would consider relevant to their decision making, we risk lying by omission. By changing nothing, we can’t pretend their consent is truly informed.

2. We can be more transparent to the patient and/or their family about what a code blue truly looks like. Of course, this would likely not need any additional work on the behalf of the care team or hospital, and this more open transparency could simply take place during the usual “code discussion” physicians should have with every patient on admission to the hospital. We can tell patients that if their heart stops or CPR/ACLS is needed, their body will likely be fully exposed in a crowded room of strangers. Many would demand to be covered. Some would consider changing their code status. This might decrease the number of lives saved. But it would increase the number of persons respected. For those who prioritize modesty, how we respond is important. Would we feign, “We will do what we can,” knowing full well their wishes will likely be ignored? Or would we force vulnerable patients into a false dilemma, pretending the only options are to either accept the anxiety of impending humiliation, or choose DNR?

3. We can make small, simple changes that could make a world of difference. We can cover the groin if possible when checking for a femoral pulse. We can cover the chest if possible while performing chest compression on females. If there comes a point when care would be compromised if we didn’t expose the patient, we could expose them as briefly as possible. We could even designate a new role: patient advocate, or something similar. As most medical providers know, there are six main roles during ACLS: the code leader, the timekeeper, the chest compressor, the medicine provider, the airway maintainer, and someone responsible for the AED/defibrillation. However, often more than 6 people respond. One-to-two wait to help with compressions, others look up patient information, call family, etc. Adding this seventh role could promote the patient's dignity while allowing the rest of the team to focus on their traditional responsibilities. This role could serve as an important source of additional care for the patient in keeping them covered when able during a code, calling or stepping outside the room with the patient's families to discuss the situation, and advocating for their dignity in the case it might be compromised. Additionally, this might be a role perfectly designed for the patient's assigned nurse or assigned medical provider with whom the patient likely has the closest relationship at that time.

This third option, either implemented by amending existing roles or by adding a seventh would allow us to provide the best all-around care for the whole patient. This new, higher level of patient care standard may best be implemented on an individual hospital or care team basis, rather than into formal national CPR/ACLS training standards. It would allow us to tell the patient with a straight face, “If you would like CPR in the case that you need it, we will do everything we can to respect your modesty.” It would allow patients who take bodily privacy seriously to accept our care without sacrificing a core value. And it would allow those we can’t save to pass with their dignity intact.

Rarely do I leave a code, regardless of the outcome, believing I did everything I could. Sometimes I don’t have the courage to try to cover the patient. Sometimes I don’t think about it until later. But by preserving their modesty without compromising the efficacy of their treatment, we can better honor the trust they place in us. Rather than wondering what they would have chosen if they only knew, we can ensure that they do know, and then treat them with the dignity they expect and deserve.