The Pause: Honoring the Dead in COVID-19 to Advance Care

The United States has been the hardest hit, by far, with more than 990,000 cases and more than 55,700 deaths.

APRIL 29, 2020 -- Could we take a moment just to Pause and honor this person in the bed. This was someone who was alive and now has passed away. They were someone who loved and was loved. They were someone's friend and family member. In our own way and in silence let us stand and take a moment to honor both this person in the bed and all the valiant efforts that were made on their behalf.

The suggested script is simple, to be followed by 15 to 45 seconds of silence after the death of a patient.

It is a moment to stop and honor a life lost and offer closure to the healthcare team that was present in the final moments of a patient's life. And, for those who engage in the practice, it has been particularly necessary in the time of COVID-19.

"In medicine, we talk about 'cases', but every case is a person," said Eileen Barrett, MD, assistant professor of medicine at the University of New Mexico in Santa Fe. "And the way things are going with the pandemic, they may have died alone and they may have died terribly," she said.

"The Pause allows us to acknowledge the person and their passing, and recognize the team that helped relieve their suffering," she added. "To me, this is a really important way to honor that life."

What is known as The Pause in many medical practices has its roots in a trauma bay more than a decade ago. A patient, whom healthcare workers had been trying to save, lost his life. As soon as he was declared dead, the atmosphere in the room shifted markedly. Seconds before, the patient lying on the bed had been the focal point of some 30 medical professionals' attention, but after his death, it was time to move on to the next patient, the next task, the next job.

That's when the chaplain spoke up.

"Before we leave," she asked, "can we just stay here and pray?"

Whether struck by her boldness or the unorthodox nature of her request at the time, everyone did, including Jonathan Bartels, RN, now a palliative care liaison nurse at the University of Virginia Medical Center in Charlottesville.

And with that, The Pause was born.

"The prayer just didn't feed me," Bartels told Medscape Medical News. "They weren't my words; I wasn't necessarily of the same belief system," he said.

"So I looked at what the chaplain was doing and thought, 'I'm going to do something, but I'm going to do it a little differently'.

The opportunity came shortly after, when a young woman struck by a vehicle was wheeled into the trauma bay. Thirty heart-wrenching minutes later, she died.

That's when Bartels saw the opportunity to speak up. "I said, 'before we leave, would you all mind if we took a moment of silence to honor this person in the bed, honor the life that's been lived, and honor our own efforts to help her?'"

It proved to be a life-changing moment for Bartels, and jump-started a movement that is now practiced around the world.

Three Million Infections

To date, there have been 3 million cases of COVID-19 around the globe, and more than 200,000 deaths. The United States has been the hardest hit, by far, with more than 990,000 cases and more than 55,700 deaths. In contrast, Spain — the country with the next-highest number of cases — has had more than 75% fewer cases and less than half the deaths.

With the death toll rising, frazzled healthcare professionals of all stripes have found themselves searching for some way to honor the dead, particularly in an age when so many people are dying alone. The Pause gives them a way to remember the sacred gift of life that has been taken from each and every victim of the pandemic.

Medscape's In Memoriam page is tracking the healthcare workers who have died from COVID-19.

Yet the profound effects of the moment of silence and reflection extend well beyond respecting the dead. For many clinicians and institutions, The Pause — and its many permutations — is a way to reconnect with their own humanity.

In fact, the practice has gone a long way toward shining a much-needed light on the mental health and well-being of healthcare workers, an aspect of professional life that is too often ignored in a world that seems focused more on throughput and profit than on people and lives.

Just ask Jeffrey Ferguson, MD, an emergency physician at Virginia Commonwealth University (VCU) in Richmond. He witnesses death on an all-too-regular basis, and also sees the insidious effect this can have on the mental health of physicians.

"As emergency providers and intensivists, our usual response to a patient's death is to clean up and move on to the next case," he told Medscape Medical News. "But taking a few moments to internalize the patient's passing has gone a long way toward recognizing our own lack of wellness. We were ignoring ourselves and skipping right over the spiritual aspect of what had just occurred," he explained.

"That's probably where many physicians' moral injury and hospital-type PTSD begins," Ferguson continued. "We're carrying these emotions around with us rather than addressing them and letting them find their rightful place."

Those sentiments were echoed by Barrett. "We're in a period where administrative burdens and workflows have led to unprecedented levels of professional burnout and disconnection from our values and sense of purpose," she said. "And I think all of this is happening against a background of professional isolation and loneliness."

This is a concern that Larry Wellikson, MD, retiring chief executive officer of the Society of Hospital Medicine, has voiced as well. With hospital mergers and new players entering the field, an altered set of values has entered healthcare, which "seem at times more like corporate America where the loyalty of employees can be torn between their employer and the patients," he wrote shortly after the society cancelled its annual meeting because of concerns about the spread of COVID-19.

"This is especially troublesome in a field traditionally based on the primacy of the doctor–patient relationship," he explained. "This can put the hospitalist right in the middle at the time when the patient can be most vulnerable."

As simple as it sounds, The Pause offers clinicians an opportunity to come to grips with their emotions. "It allows us to begin to recognize what we need for ourselves to be better doctors, better nurses, better professionals," Ferguson explained. "I've really embraced it because it's had a huge impact on me, personally."

In fact, Ferguson has been so moved by the strength of The Pause to improve clinicians' mental health that VCU — where he also serves as associate professor of medicine — has operationalized it as a standard protocol. It helped that Ferguson and Bartels are long-time friends. It was Bartels who first introduced Ferguson to The Pause; soon after, Bartels was invited to do grand rounds on the phenomenon at the institution.

It didn't catch on immediately, despite a few passionate champions in the hospital who backed the idea. Eventually, however, VCU's cardiac team incorporated The Pause into the debrief portion of its cardiac-arrest protocol.

"It was a strange thing to try to formalize," Ferguson said. "It's really not what most people would think of as a clinical procedure or documentation, but we built it into the checklist at the hospital level, and that's really when it started to gain traction.

"Once people see it and do it a few times, it really does change their mind," he added.

Built Into Clinical Protocol

Even for a convert like Ferguson, the process was uncomfortable at the beginning. "The first time I did it, it felt awkward," he remembered. "We don't like to have silence in that setting, especially after working on a code. But after you do it, there's this very calming effect, where you recognize the soul that's passed before you and start to process those feelings."

VCU is not alone in its efforts to formalize The Pause. The Cleveland Clinic has incorporated the practice into its routine care, going as far as to produce script cards in multiple languages that walk caregivers and family members through the voluntary process.

The movement is gaining administrative recognition as well. During a 5-day visit to the clinic earlier this year, officials from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognized 15 new best practices in place at the institution. Among these was use of The Pause.

Although Bartels — who consulted with the Cleveland Clinic on The Pause prior to the institution's adoption of the process — is excited that the movement he started back in 2009 is beginning to be recognized by accrediting bodies, he also questions its formalization into hospital processes.

"Making it mandatory isn't necessarily the right thing to do," he said. "In some ways, I get leery when institutions start to adopt it. I don't want them to fall into old patterns where they see that JCAHO has named something a best practice, so they just make it a protocol.

"It's like mandating compassion; you can't do that," Bartels continued. "Either you are compassionate or you're not. Either you adopt this practice, or maybe it's not for you and you don't adopt it. And that's fine."

Bartels emphasized that The Pause is not an opportunity for healthcare practitioners to proselytize or share religious beliefs. It "is an attempt to allow a group of people with diverse practices and beliefs to share an experience of honoring both the life lost and the care teams' efforts." He goes on to note that staff who are uncomfortable with the practice should be given the chance to opt out.

That hasn't stopped The Pause from gaining a foothold at hospitals throughout the world. In many cases, the people practicing it have no idea who Jonathan Bartels is. And that doesn't bother him in the least.

"My name has been disassociated with it, and that's perfectly fine with me," Bartels said. "Because I want the practice to survive on its own; whether I get acknowledged or not really doesn't matter."

Perhaps not surprisingly, some clinicians and institutions perform their own version of The Pause organically, without ever having heard of the practice. At the University of New Mexico, Barrett was honored to have led a patient memorial service for all residents and faculty that included quiet reflection and group sharing about death, loss, grief, and moving on.

Other institutions employ similar practices. In Seattle, Margaret Isaac, MD, an internist and palliative care specialist at UW Medicine, is routinely confronted with patient death, a phenomenon made even more acute during the COVID-19 pandemic.

As such, Isaac and her colleagues have gained a healthy appreciation for the importance of reflection when patients die. To that end, she and her colleagues have embraced a weekly form of structured reflection time to consider those who have died.

"In a way, we have tried to systematize our reflection to make sure that we're creating space to think about the losses we've experienced and the suffering we've seen, and really support one another," she explained.

During those sessions, Isaac and other members of the palliative care team — including an attending physician, social worker, chaplain or spiritual-care provider, and perhaps a resident or medical student — will go through the list of patients who died that week, reflecting on each individually.

"The chaplain leads us, and we share specific memories about each patient," Isaac noted. "We have LED candles that we each hold in our hands as we do this." The chaplain will often read a poem during these times; sometimes music is played. This is all followed by a moment of silence in honor of the dead. And as Isaac explained, the practice has taken on even more significance since the outbreak of the coronavirus, which has not only increased the number of deaths at the hospital, but also radically changed the way people die.

Dying Alone in Isolation

"A lot of people in healthcare are feeling the moral distress right now around this phenomenon of people dying alone," Isaac pointed out. "It's brutal. Patients are in isolation in their room, and we're trying to minimize the number of trips into the room by all members of the healthcare team because PPE is in such short supply. So save for a few medically necessary visits throughout the day, these people are alone."

That phenomenon has proven exceptionally challenging for palliative care professionals who pride themselves on being present in their patients' final days and hours. And in those cases, being able to pause, reflect, and process some of those emotions has proven invaluable.

"People are operating at a much higher level of stress these days because of COVID-19," Ferguson explained. "So doing The Pause is more important now than ever."

Yet in the face of the pandemic, some clinicians might feel that taking time to pause — no matter how intrinsically human and beneficial it can seem — is not a luxury they have. But as Barrett explained, it's in those situations that The Pause can play its biggest role.

"It's incredibly unusual not to have 30 seconds," she explained. "And if we don't have 30 seconds, then it means what we really need is 2 minutes. And it also means we need to restructure the work so no one is ever in a position where they don't have 30 seconds.

"The more impossible it feels, the more we should do it," she said.

Bartels is in full agreement. "It comes back to taking care of ourselves in difficult times," he said. "With COVID-19, you have to be completely aware of what you're doing. That same mindset should be applied to your mental health as well. So we have to be aware of how we're being affected by this, both on a personal and professional level.

"You can't walk into this work and think you're not going to be affected," he added. "Everyone is. And The Pause is just one practice. In the end, you've got to find your own way to heal yourself, whatever that is for you."

Bartels is also quick to acknowledge that The Pause does not work for everyone. "It's not a cure-all, and I want that to be understood," he said. "But it helps point out the fact that we're going through some really horrific things right now, and we've got to take the time to stop and sit with that and not just stuff it down."

"This is what we signed up for," Ferguson added. "I just didn't know it was going to be quite to this degree."

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