Case:  A 28-year-old man is transported by ambulance to a hospital after an anaphylactic reaction. Soon after he arrives in the emergency department (ED), he sustains cardio-pulmonary arrest. A prolonged cardio-pulmonary resuscitation (CPR) effort ensues, involving clinicians of multiple disciplines. Unfortunately, he never recovers a rhythm and death is pronounced. Distressed clinicians disperse to attend promptly to the other pressing needs in the ED. 

Background:  While patients commonly die under the care of clinicians in EDs, intensive care units (ICUs), or inpatient wards, timely and attentive processing of the death is not. “The Pause” is a ritual practice codified by Jonathan Bartles RN (an ED nurse) to describe a short period of silence intended to honor the person, care efforts, and family after a CPR attempt is unsuccessful (1). This Fast Fact describes “The Pause” and offers implementation suggestions for a care unit or health system.  

Who?   All individuals involved with the patient’s care and all those in the immediate vicinity upon the patient’s death may benefit from participating in “The Pause”. This includes not just physicians, nurses, and the family, but also volunteers, technicians, respiratory therapists, pharmacists, chaplains, social workers, and other visitors, particularly if they were present during a CPR attempt. It is important to inform invited participants of what is about to take place and ask if they would like to participate. Allow those who are not comfortable participating to opt out.

What?  While there are no formal rules for how “The Pause” should be conducted, typically, it involves an introduction by the clinician either in charge of the code or pronouncing the death followed by 15-45 seconds of silence.  A pause should not be used to insert one’s own religious or spiritual beliefs nor should it be laden with medicalized jargon. The following script has been recommended in the published medical literature: “Let us take a moment to pause and honor (patient’s name). They were someone who loved and was loved; was someone’s family member and friend.  In our own way, let us take a moment in silence to honor (patient’s name). Let us also honor and recognize the care provided by our team” (1). After the pause, a statement of gratitude is recommended: “Thank you everyone” (1). 

Why?  The time preceding a patient’s death often is wrought with strong and complex emotions. Pausing to acknowledge these responses is vital for mental processing and meaning making. Rituals are a well-known adaptation for accomplishing this during new or stressful situations (2). “The Pause” creates an opportunity for loved ones and clinicians to honor the patient and the significance of what has occurred prior to moving onto the next, perhaps equally intense, tasks ahead. This is particularly relevant in a hospital setting where the frenetic pace can deny loved ones and clinicians from processing grief in real time; vicarious trauma can subsequently emerge among those chronically exposed to unprocessed traumatic stimuli (3-5). For clinicians, rituals such as “The Pause”, may reduce moral distress and burnout symptoms while increasing job satisfaction and bereaved care satisfaction scores (6-8).

When and where?   Many units perform “The Pause” immediately after the pronouncement of death at the bedside so that as many friends, family, and clinicians who cared for the patient and are within proximity can participate if they so choose.  If this is not possible, alternatives include setting a specific time, such as during shift change or care rounds, to honor those who died or having participants gather in the hallway as the body of the deceased is transported out of the room. When Bartels first described “The Pause,” he emphasized the importance of an organic integration model that individualizes the practice based upon the unique ritualistic needs of the care unit over a standardized implementation policy (9).

Adjacent Ritualized Memorialization Practices:  Ritualization of death is important outside of just those that are unexpected. Even in instances where the death is expected, such as on a hospice unit or while on comfort care, finding a time to honor those whom the team has lost can help make the work more meaningful and less traumatic. Potential strategies include including a moment during interdisciplinary team rounds to honor patients who have recently died; offering a “Final Salute” to deceased veterans when their body is transported off the unit; or performing a pause prior to harvesting organs from a donor or when a recipient receives an organ transplant (9,10).

Reference:

1. Protto SP.  Why the pause is important for healthcare providers caring for patients at the end of life: period of silence honors life, caregivers’ efforts.  Consult QD, Cleveland Clinic; September 7, 2017. Available at: https://consultqd.clevelandclinic.org/why-the-pause-is-important-for-patients-at-the-end-of-life/ Last accessed February 17, 2020.
2. Kehoe N. The role of ritual.  National Alliance on Mental Illness Blog. June 1, 2016. Available at: https://www.nami.org/Blogs/NAMI-Blog/June-2016/The-Role-of-Ritual. Last accessed 2/17/20.
3. Caringi, James, and L. Pearlman. Living and working self-reflectively to address vicarious trauma. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide; Guilford Press: New York City, NY, USA (2009): 202-222.
4. Newell JM, MacNeil GA.  Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue.  Best Practices in Mental Health 2010; 2:57-68.
5. Morgan, D.J.R. ‘The pause’: honouring the passing of a patient or a collective countertransference for healthcare providers?. Intensive Care Med 2019; 45:1493. 
6. Stehman CR, Testo Z, et al.  Burnout, drop out, suicide: physician loss in emergency medicine, part 1.  West J Emerg Med 2019; 20(3):485-494.
7. Kapoor S, et al.  Sacred pause in the ICU: evaluation of a ritual and intervention to lower distress and burnout.  American Journal of Hospice and Palliative Care 2018; 35(10):1337-1341.
8. Copeland D, Liska H.  Implementation of a post-code pause: extending post-event debriefing to include silence. Journal of Trauma Nursing 2016; 23(2):58-64.
9. Bartels JB (2014) The Pause. Crit Care Nurse, 34(1):74-5.  Also available at https://thepause.me/2015/10/01/about-the-medical-pause/ Last accessed October 14, 2021.
10. Nathan S, Dunn KM.  Gone but not forgotten: how VA remembers.  Fed Pract 2019; 36(6):254-256.

Author Affiliations: University of Utah, Salt Lake City, UT

Conflicts of Interest: None to report

Version History: first electronically published in October 2021; originally edited by Sean Marks MD