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 ARCHIVES
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Family Presence at Resuscitations
Feature article: Witnessed Trauma Resuscitation - Can relatives be present?
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From: TraumaView As a follow-up to discussions on these web sites, I give the following information. At a Mid America Trauma Conference held at Wichita Kansas, Thursday and Friday of this last week, a lively discussion occurred after a presentation from a trauma coordinator from Seattle Washington. A trauma surgeon from Houston took exception to some of the statements, but agreed with others. The issue is the need for bonding of the family during the last moments of life when a trauma resuscitation is going on in the shock room of the emergency room or a resuscitation is going on in the intensive care unit. Especially if there has been some anger and disagreement at the time of the last meeting of a family and the now dying trauma patient, it is important to have the family in the room, even if there is an open chest, to say, "I love you, I forgive you." and let the healing begin. If the family is not allowed to be in the shock room for the resuscitation, their guilt will last forever. The nurses gave information from some national nursing leadership conferences that this was a trend in the nation, for shock rooms, trauma resusciatation, birthing centers, intensive care units, even some operating rooms, and other locations. The nurses displayed a lot of empathy and identity with the families and supported their position very strongly. The surgeons were violently opposed to this concept and displayed a lot of emotion to keep the family out, including limiting their visitations in a trauma intensive care unit to "three thirty minute visiting hours a day." This position seemed overly rigid. As these web sites have an international readership and are made up of lawyers, hospital administrators, surgeons, nurses, patient advocates, social workers, and even some patients and families of patients, I felt I must share with you this information. The names of the most vocal presentors are common knowledge, but at this time, I will leave their names off this post. I personally can see the logic for communicating with the family and for the family to fully understand the seriousness and critical nature of the injury. Many of us have been patients or family members and resented being left out of the last few minutes of a loved ones life because they were in the operating room or the intensive care unit. This apparently will continue to be a widely discussed subject. ---a caring empathetic and sympathetic patient advocate
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From: Bjorn Pret Here's my question for those who would prohibit death-bed visitations in the resuscitation area (trauma, medical, whatever): how would such rules to apply to YOUR family? If my wife or kids were in that room, you couldn't keep me out with a machine gun, so the only question is whether we go by your rules or mine. Families often need, and always deserve, a presence in the room. The trick is keeping the clinical mission in focus and the resuscitation area in control. This can only be done if the numbers are very limited, and trained personnel prepare and accompany the visitors. This will have a real and heavy impact on staffing, but in the absence of thoroughly-trained chaperones, visitation is a perilous undertaking. The consequences can be unpredictable and severe. And there's this: I've actually worked with nurses and physicians who actually push visitation, as in, "You really should be with your son at this time, for your own sake, it helps YOUR healing, blahblahblah..." In my own experience, a five- or ten-minute discussion of pro's, con's, and realities of visiting the treatment area is essential. Some families DON'T need or want to secure a new and unpleasant last memory of their beloved, and they should be allowed to make an informed and unpressured decision, either way. How easy it is to forget: we're talking about what are perhaps the most emotionally painful moments of a person's life. It's sad that these policy decisions are so often driven by the comfort and convenience of the trauma room staff. |
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From: Ken Mattox Im my view, this is a sick discussion. Any one who is pushing the family members to be present at the time of a trauma resuscitation, including open chests in the shock room, either has not been there or has a special problem of their own. This is a non-subject, families simply should not be there during the heat of the battle with blood and knives are flying. They simply would not understand and it would create more hurt and confusion than it would cause understanding and healing. Lets get on to another subject.
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From: Kelly At our facility our director instituted free reign of all visitors, with no limits of visitors allowed in the rooms. This not only goes for resuscitation, but for every patient in the ED. I always try to accommodate family, but sometimes this gets to be quite a headache, due to mostly space reasons. Our trauma/resus rooms are very spacious, but the other rooms are not, and having numerous visitors makes it impossible to move at times. Also, I don't think she even thought about privacy issues of other patients. Myself, if it was me, or any of my family members receiving care, I would not appreciate numerous visitors in the next room. There is also problems with loudness from visitors too impairing other patients who may not tolerate extra noise when they aren't well. We used to have a limit of one visitor at a time, which worked really well for the staff, but didn't work well with the patients, and their families, as we received numerous complaints, bringing our patient satisfaction percentage down. Now, we receive opposite complaints that there is excess noise, no privacy, all related back to no visitor limit. Where's the happy medium?
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From: Charles Krin As a small town hospital, our facility does not often have the crowding problems that some of the larger ones do. Our policy is technically to allow only two ICU visitors on even hours from 1400-2000, and only one in the room with the patient in the ED. If staffing and patient load permits, we often are able to liberalize those limits quite a bit, especially if a patient is in extremitis, and further resusitation efforts are going to be limited. (We also prehaps have a larger load of folks who come in for terminal and comfort care than some of the larger hospitals, simply because we do not have access to a good hospice program out here.) Things do occasionally start to get out of hand in the ED at busy times, but a quiet invite to the local Sheriff's office for some of their boys to come in and have coffee tends to reduce the number of folks waiting around to make trouble.
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From: Chris Hawkins How arrogance clouds the vision! Who are we to decide what a person needs to come to terms with the devastation and loss of the most impotent person in their life - potentially the reason for their existence. We all deal with loss in our own way, if this involves seeing that the health care system is doing absolutely everything possible to save their loved one without compromising the integrity of the patient then we as health professionals must learn to live with it. I have no problem with immediate relatives or significant others being present with appropriate support, as long as there is no chance of compromising patient integrity, safety or potential judicial actions i.e.. in the case of trauma. Chris Hawkins
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From: Tim Coats There is a danger of extrapolating the work done on the observation of medical resuscitation by relatives to the trauma situation. In a medical cardiac arrest (especially paediatric) there may be a benefit from allowing relatives to see part of the resuscitation and say goodbye etc, as long as there is sympathetic and expert nursing support, the medical team feel comfortable with the presence of family members, and appropriate follow-up support is available. This seems especially appropriate when relatives have already witnessed the pre-hospital part of the resuscitation attempt. Trauma resuscitation is different, and I can see that some of the things that we do may be profoundly damaging to family members. I know of no series that compares the psycological outcomes or grieving process in relatives who witnessed or did not witness trauma resuscitation. I have also come across nurses who belive that relatives should be pushed to witness resuscitation as it is 'Good for them'. This is dreadful. Advocates of relatives watching chests being opened should apply the same standards that we would before the introduction of a new medical procedure - do the research and show me the evidence that it has a benefit. As no evidence is available, there is (as k has pointed out) little point in further discussion. Tim. Timothy J Coats MD FRCS FFAEM
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From: Nick Macartney About 2 hours ago I was in the A & E, with a 9 month baby who had choked. Mother and father were there. Baby was distressed, but breathing adequately, crying etc. The presence of the parents was seriously detrimental to the care that baby got. They were ( naturally ) distressed, and took a member of staff to comfort them, and kept interfering with the care, objecting to the venous access, among other things. I am interested in the best interests of the patient. If I think the parents will interfere with this, they go at that instant. Lets stop this politically correct C***, and get real. The parents often get in the way and delay treatment. This is bad. If they have a psychological problem, see a shrink. Dr NJD Macartney MBBS FRCA
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From: Mathias Kalkum <<a caring empathetic and sympathetic patient advocate“, You are wrong! >> 1.) first of all we have to care for the patient and in the second place for his family. Care for the patient includes care for his privacy. I can imagine a lot of people who wouldn´t like someone watching them be resuscitated, operated, catheterised, and so on.No one has the right to disturb this privacy - wether he´s a family member or not. 2.) it´s hard enough to take care for a critical ill patient. I do not want to have to take care of crying relatives, collapsing friends, or to prevent anybody from bringing himself or the patient in danger by disturbing critical treatment. 3.) I can´t see why watching someone open the chest of a beloved one should do less trauma to a family member than to sit, wait, and pray that everything necessary is done. 4.)Finally if the patient is declared dead his relatives should be allowed to say goodby to him and any help should be offered to them. 5.) This is for the acute critical ill patient - not for someone in his final agony in a long known disease that is obviously leading to death. Dr. Mathias Kalkum |
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From: TraumaView What could possibly be the problems, except in the mind of a few very rigid surgeons. Families adapt better than do the trauma surgeons. We patient advocates have to live with the patient families after the surgeons go to the operating room or the conference room after a fleeting communication with the family
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From: Frederick Foss, MD I am a trauma surgeon, and a believe myself to be a strong patient and family "advocate". First off, i am trying to save a life! I am trying to present a family member back to the family, so they can iron out whatever differences the may have had over the past several decades. When a patient is "crashing" and attempts are being made to reverse the process, it is not appropriate for the family to have a final good-bye! I resent the notion that surgeons are unfeeling and rigid boobs who do not have the family and patients best intrerest's at heart. If the family feels the need to say their final good byes, maybe the resuscitation team should leave the room and allow the family to have some privacy and as a consequence cease all resuscitative efforts. I am not sure why this needs to be completed while there still is perfusion, however inadequate. When things are looking futile and death appears immenent, the patient is as responsive as when death has actually occured. Their perception of their environment is also the same. I doubt they hear and perceive any better with inadequate perfusion as with no perfusion. I have had the unfortunate experience, of having family present in the resusc. room during a very intense and complicated resuscitation. I was worried about how the patient's family perceived my efforts and whether I measured up to the standards of care set forth by ABC's ER ( I have been actually notified by several family members and/or patients that my approach was not similar to that seen on that dreadful program.). Also the family memeber was very hysterical, rightly so, which placed the resuscitation team on edge. while I was trying to work on the patient, I had questions directed to me by the family. While the patient survived, it was a completely unsatisfactory experience for me and the team. A debriefing after this experience, resulted in heightened security and the immediate ushering of family members to a private waiting room. I believe the best approach is for the resuscitation team to work in the mileau in which they feel comfortable. Try not to add further stressors to an already stressful situation. Remeber the primary goal of the resuscitation team is to save the patient's life and not to heal any deep seated, problematic family dynamics.
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From: Traumaview Dr. Foss: You are so far behind the times. Are you married? Do you have children? If your child was in the shock room and you had said a harsh word to them the last time you saw them, dont you want to be in the shock room as they pump on his chest so that you can whisper in their ear, "I forgive you, will you forgive me?" The majority of the nursing management literature on this subject for coronary care units and for rehabilitation units strongly supports that families do better when they particapate in their love ones care and recovery or final days. Get with it, Join the 21st century. Go talk to your nurses in the ICU and emergency department and see what they say to you. Many nurses even believe that families should also be in the operating room, just as fathers now are in the birthing center. This togetherness helps bonding and begins the healing process. An empathetic health care giver
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From: Richard Steyn Let us not generalise, not all surgeons are rigid. Not all families adapt and it is exceptionally dangferous for us to assume that they will. Do you patient advocates deal with the patients long-term? I have had the experience of dealing with bereaved relatives both as a GP and as a surgeon. I have had relatives in the resuscitation room whilst I have been performing internal massage in someone's chest. There can definitely be long-term problems for relatives if they are not adequately supported both at the time and in the many months (and years) to follow during the bereavement process. This support must be continuous and adaptive to the relatives requirements and certainly not adequately provided by staff with limited experience of long-term care, possibly assisted by previous staff attendance at a "counselling course" and subsequent provision of a telephone number for the patient to call. Unfortunately this is all too often the problem in some UK A&E departments. Unless arrangements are made for the provision of care at the time of resuscitation and proper arrangements for ongoing supportive care involving the appropriate primary care resources then you may be doing the patient's relatives a great disservice and are just not aware of it. If family are present during medical or trauma resuscitation it is essential that the family GP is made aware that the relatives have been present. All too often this does not occur. Richard Steyn
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From: TraumaView I appreciate your biased and traditional trauma surgeons view Dr. Eric Frykberg, but it represents a dated and obviously rigid view. I really appreciated the speech from the nurse from Seattle at the Wichita Kansas trauma meeting. You might like to check with Dr. Steven Smith and Dr. Kenneth Mattox who were on the podium. In my view and the view of several of the nursing directors who were in attendance, these two surgeons were made to look silly and not supportive of attempts at nursing organizational advances. We have made MAJOR advances in organized nursing in allowing families into the intensive care units, the burn units, and now the emergency centers. You just do not understand the needs of families during moments of grief. You should have heard the roar of applause from the nursing leadership persons in the room at the Wichita meeting when one of the nursing questions put Dr. Mattox down. You surgeons are no longer in control of what the patient and the family want. We now hold the role of patient advocates and must defend them against historic lock outs by the surgeons, limited to but a few moments three times a day as occurs in some surgical ICUs. Believe me when I tell you that you will loose this battle. The momentum is already very strong. Legislation for patient advocacy and independent practice will prevail. Please PLEASE stick to what you do well, procedural organ injury reversal in the operating room and leave the touchy feely, family and patient interactions to us. We know what is best for the patient. We will be happy to talk with your national organizations about it, but they have not responded when we have contacted them. Science, yes, have you ever heard of Elizabeth Kubler Ross and the phases of adjustment to grief. The weight of science supports the family participate in the successes as well as the grief and yes, even death.
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From: Patti Okotete I can't understand why any "lay" parent would want to see their child who has been shot in the head be resuscitated in the ED. It's hard enough for the family to see their child in ICU once they've been in the hospitals care for about 3-4 hours and cleaned up. Compassion has nothing to do with the decision to keep the family out of the resusciative area. Why is it ok for a chef to work in privacy when preparing our food, and why is it ok for court rooms to be closed to the public when they are defending a menace to society, but the health care profession must be on constant display. If you are an advocate of the victim's and the family like you say, then you know that once the patient has been in the ICU for about 2 weeks the families stop coming to visit. Yes the same family that was so insistent on being in the resus area. Did you every follow the course of the patient from door to rehab to follow-up in the trauma clinic? The answer is probably no, because you would know that the majority of the families that act out in the ED and the ICU for the first week don't really care about the victim. Try getting that brother or irrate mother to bring the patient to their clinic visit in two months. Not going to happen. The push for the family in the resus area is inappropriate. If the family really cares about the person they would rather not disrupt the Trauma Team while working.
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From: Ken Mattox Excuse me for a moment please. I was at this conference, listened to the well presented lecture concerning communicating bad news to families, and was on the podium for the panel discussion when this subject came up. It almost appears that the writer and I were at two different conferences or we percieved two entirely different things. First: The applause regarding support for families in the resuscitation room of the emergency center seem to come from 4-6 loudly clapping and vocal persons, who I do not think were trauma surgeons. The Trauma Director (a surgeon) and the Trauma coordinator did seem to be at opposite ends of the discussion regarding families in the room at the time of an open chest, etc. Second: Everyone agreed that communication and empathy are extremely important and that the surgeons, emergency physicians, nurses, chaplains, etc ALL TOGETHER, participate in that continuum of communication and caring. Several optional suggestions, such as a special room outside the clinical area where families can be alone with the deceased was discussed. Third: Panel discussions often have the panelist overstating a point to make a point for an educational goal. This was the point on this particular panel. I did not get the feeling that any party was out to get or bury any one else, but to expose the audience to differing views and the reasons for those views. Fourth: This panel discussion occurred just before lunch and during lunch, interactive discussions continued at several of the lunch tables. The nurses with whom I talked (all active in the trench and busy work in the ED) were in agreement that during the heat of the battle, especially with complex procedures that the family should not be present, but when the lines have been secured, x-rays taken, and the nurses and doctors begin to fade out of the room, the family could easilly be brought in, especially in the case of injured young children. Most of the nurses also supported restricted visiting hours in a surgical intensive care unit. Fifth: All of us, especially the trauma surgeons are the epitome of patient advocates. None of us has a corner on caring, or at least, I hope not. I have seen many a trauma surgeon spend hours with the family during a dying time, leave the OR to talk to a family during difficult times, spend hours with a family and patient post op and be the leader of the entire team in being a patient, a family, societal, and even a social advocate. I have seen surgeons, nurses, chaplains, and others who were insecure with themselves and communication skills that did a terrible job of communicating. All of us have shed tears, have felt awkward, have had to search for words, and have felt inadequate in the expression of our own grief, disappointment and frustrations at not being able to reverse a bad situation. Sixth: Yes, we all read EK Ross' books and teach the stages of grief to our residents and faculty. To my knowledge, however, I do not think Ms Ross ever worked in a trauma center. Much of her early work was developed at the MD Anderson hospital in Houston where she was working with cancer patients. My wife and I got to know her very well and appreciate all she has done for our understanding of death, dying, grief, adjustments, and even understanding of self. I cannot speak for her, but what I do remember, she did NOT advocate that a family be present during a bone marrow aspiration, an endoscopy, an interventional radiologic procedure, a cardiac cath, an operation, a trauma resuscitation or an autopsy. We have a responsibility to not create any new scars or new pain. I would be happy to appear with you or any of your organizations on any panel at any forum at any time and discuss these issues. I think it is unfair to overstate what you thought you heard or what must represent your own personnal agenda on such a wide audience as appears on these web sites. It leaves the reader with an incomplete impression of a summary of a conference if only one side is given. Yes, I recognize that I often appear as an iconoclast and no one on these web sites appreciates a scientific questioning of dogma than do I. But........what you stated in your widely circulated post to Dr. Frykberg simply is not what I remember occurring at the Wichita Trauma Conference. Perhaps you had a tape recorder and will share with us all a verbatum recording of the panel discussion.
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From: Olu Swale while you are entitled to your views, disagreement does not make the opposing individual backward. What happens when your views are no longer popular? Do you become less intelligent? I have brought family members into resuscitation rooms multiple times: but only when i know that the patient we are managing/ resuscitating is no longer "resuscitable". It allows the team maximum efficiency, less crowding in an already crowded and noisy trauma room and the least amount of misinterpretation of procedures or actions. Chest compressions may still be in progress, but the team is well aware of the goals at the time the family is then brought into the room if they so wish.
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From: Andrew Robinson Perhaps you would like to introduce yourself, instead of hiding
behind a pseudonym, Personally, I feel that the question of relatives in resus areas should be left to the clinician who is making the decisions: if said clinician is capable of functioning to a high standard while under pressure from the clinical problem at hand, *and* from assembled relatives, then fine. If (as in my case) clinical decision making deteriorates with noises of background hysteria, then remove the distraction. The *patient* is the important one, the relatives come a long way second. Regards Andrew -- Dr. Andrew Robinson (Oz)
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From: Robert Eager <<I appreciate your biased and traditional trauma surgeons view , but it represents a dated and obviously rigid view.>> You call yourself a patient advocate to the exclusion of all other health care workers (esp it seems, doctors/surgeons etc.). However, from your numerous posts, it is rather clear that you not only have no idea of the issues involved, but are actually advocating putting family members into a situation that is a) out of their control, b) unfamiliar to them and c) traumatising to them, without any thought as to what is best for the patient! Is it really best for the patient to have the resus team distracted at best by the family members? Maybe you think that having various sundry family members in the throes of shock and grief, becoming hysterical and getting in the way of, if not actually fighting the resus team members is going to benefit the patient. If you think so, please explain how. Oh one more thing....What happens when a family member watching a resus sees more blood then they've seen in their entire life, goes into shock and exacerbates their angina leading to themselves needing resus? Hey...It's probably good for them right? As I stated at the start. I'm a nurse. I consider myself a patient advocate. I also consider myself to be part of the health care team which also includes the doctors and surgeons. Imho, being a patient advocate does NOT necessarily mean being a family advocate. Sincerely,
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From: Tim Buchman I fully agree that families/friends have no place in the trauma bay (resuscitation area) of an ED or trauma center. A major purpose of trauma resuscitation is to impose order and set priorities in what is otherwise a chaotic situation. The reason so many of us adhere to ATLS (for example) protocols is not that they are the "best" but rather that they provide a common frame of reference in which all of us in the trauma rooms can do our job. It's tough enough on all of us "objective" caregivers when an injured patient arrives with a smashed face, a lacerated torso, a severed limb etc. There is a certain automaticity to what we do that not only helps get the job done expeditiously, it allows us to distance ourselves emotionally long enough so we *can* get the jobs of evaluation, inventory of the injuries, establishing priorities and intervention done. Having a fellow injured human being stripped naked under the bright lights and taking the responsibility (rarely are they in great shape to give informed consent...) to try and make them well is daunting enough. Families do not understand what we are doing and it is rare that the trauma leader has time to give detailed explanations. Better to get the jobs done, and, once order is imposed on the chaos, involve the families. Having played all three roles (patient, family member, and trauma leader) at various times in my life, I speak from (at least limited) experience. Tim Buchman
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From: Robbie Sepulvado In response to the need for the family to "bond" to their loved one during a resuscitation I have the following comments. First, if the family has not bonded by now they surely won't during a resuscitation. It has been my experience that the family is better served to be attended to by someone who is not busy trying to save their loved one's life...away from the action. Furthermore, the last thing the team needs to be worrying about is saying or doing something that might be taken the wrong way by a family member. I do believe it is important for families to be informed and made a part of the decision process and to be allowed access to their loved one. But that time is not during a critical period of resuscitation. There is a time and place for everything and I truly believe that most nurses and physicians I work with do their best to keep the family aware and allow as much visitation as possible. I was not at the trauma conference, but I think I can safely assume this idea to allow family members be witness to the resuscitation was the result of some brainstorming done by my fellow nurses. While I love my profession, I think there are too many of us who wish to fix everything around the patient and do not spend enough time caring for the patient.
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From: Mikel A Rothenberg, MD Hi, gang... Though a nice idea, in theory... this policy is an open invitation to a lawsuit for violation of a patient's confidentiality. Not a question of IF, IMHO, but WHEN! Take care. Mikel :-) Mikel A. Rothenberg, M.D.
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From: TraumaView In all due respect, I do not think those commenting really get the point of where we want to go with this issue. Parents of neonates who are in the NICU benefit from holding their children, even while they are dying. Nurses working with patients and families 24 hours a day are the patient advocates and understand the interpersonal needs. Physicians, especially surgeons are working episodically and usually come in at the middle of a situation, often leave early and even if they communicate, leave the confused family in our hands, frustrated and alone. Please try to look at this issue from our standpoint. In my managerial meetings, I am finding that nursing leadership, especially on the national level is strongly in favor of these moves.
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From: W Raynor What rubbish, as the Brits might say. Trauma resuscitation for cure requires complete and absolute attention to the patient and the situation, without distraction from other sources. When and if the situation has been deemed futile, and further efforts are worthless, then selectively family members may be at the patient's side. One must keep in mind the external physical condition of the patient when making that determination. A trauma patient is not a dying neonate, or a patinet with end stage coronary disease. To equate these clinical scenarios is to forget the lessons of ATLS and trauma surgery. And, personally, I take offense to the characterization of physicians as heartless souls. Shame on you.
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From: Tim Buchman There is a substantial difference between the scope and urgency of interventions when one is trying to preserve life and those when one revises to the priorities of comfort care measures. I do not think it is helpful for families to watch the often hurried, sometimes desperate measures involved in a major trauma resuscitation whereas I always think it is helpful for families to be present and participate in the process of dying. The perjorative comments about "physicians, especially surgeons working episodically" seem to be a crude attempt to polarize this discussion along professional lines, an attempt which I think reflects more on the author of the comment than on reality. In our units, the policy issues are openly discussed in our multiprofessional meetings. As for leaving "the confused family in our hands, frustrated and alone", families do become confused scared etc and all of us on the team count on the caregiver at the bedside to reinforce and clarify situations whether this is the nurse, the resident etc. Trauma is stressful on families and it is the rule, not the exception, that several passes at explaining what is going on are required to help the family cope. That the physician does not provide the explanation each time can hardly be held up as a dereliction of duty where a true team approach exists. I applaud efforts to involve famlies and friends in the process of care--but there is a time, a place, and an appropriate scope for involvement. Twenty minutes after the car crash, in the trauma bay watching the insertion of a chest tube somehow strikes me as less than appropriate.
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From: Nick Macartney <<In my managerial meetings, I am finding that nursing leadership, especially on the national level is strongly in favor of these moves.>> Probably because the "national" nursing leadership, unlike the physicians, is NEVER at the coalface to see the results of the changes they advocate from their ivory towers. Dr NJD Macartney MBBS FRCA
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From: Robert Eager To TraumaView... With all due respect from a fellow nurse, I do not think that you get the point that a) resusitation is a team approach as is the overall care of the pt, b) the discussion is about families in resusitation (if I'm reading the subject heading correctly) and not about longer visiting hrs in general and c) that derogatory comments about other health care professionals are uncalled for and unprofessional. You state that nurses care for the pt 24/24 and that this gives us some great insight into their personal and family needs. I'm sorry, but I've never actually cared for a pt for 24/24. I usually go home at some stage and rely on the rest of the health care team to help in the management of the pt. While I agree that it is the nurse that, in most but not all situations, has the most contact with a pt, this does not make us any better at being pt advocates. It only implies a responsibility to inform the rest of the team about the pt's progress, the issues that are arising and any problems we may feel need addressing. The team cannot function when there is no communication, and the team cannot function when there is no direction. Please remember when you post that there are a number of professional health care workers, including but not limited to nurses, surgeons, paramedics etc, on this list and that your derogatory comments towards some members, only do a disservice to both you and your profession.
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From: Arthur Lam, MD With all due respect, this is one of the more entertaining posts I have ever read. Our nursing leaders are usually around between 9 and 4, which is the main reason why they become leaders, because they cannot stand working with the patients any longer. Yet they somehow become advocates, adovocating how empathy and grief should be carried out, directing from afar in an imaginary fashion. And since when have nurses acquire the monopoly to deliver empathy and effective communication? Perhaps the anti-trust division of the Department of Justice should look into this. Many physicians work 24 hours a day, and I regularly go through three shifts of nurses during one on-call duty. Yet I am told the nurses alone can provide the continuity of care. In my own experience, they are the ones who come in at all stages of the care process, and often, though not always, everything stops when it is time for coffee or lunch break. Please look at the issue from my standpoint, how can the nursing leaders know what to lead when the only place you can find them is the Board Room? Can you please try to understand why most physicians cannot possibly understand what you are tying to ADVOCATE? This proposal of having families present during resuscitation is a classic example of planning without understanding, theory without practice, and of course, nursing leadership without nursing. Arthur Lam MD
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From: Mark Fitzgerald I am suprised at the dogmatic (emotive) views expoused by some of you. Some times it is beneficial to have relatives present, sometimes it is not. It depends on the circumstances. In my experience having relatives present depends more on the confidence of the operators than on the condition of the patient. If you are uncomfortable with relatives' presence and it impedes your clinical work then have them leave. Everyone differs. You have to be flexible and yet keep asking yourself '...if it was me or my wife (etc.) lying there, what would I want..?' Once answered proceed accordingly.
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From: Ravi First it is families in the resuscitation room, then fathers in the 'birthing' room, next the older children (to better prepare them to be responsible citizens not shoot their sibling), next it is a television crew in the birthing room (one live birthing coming up on the internet -dont know the URL but dont miss it) guaranteed to be a moving experience, next lawyers in the ER so the patient's rights are not violated... Boy, we must be crazy if we have to be saying 'I love you' to someone who is being revived from a cardiac arrest and hypovolemia. Love and forgiveness are right there all the time. They dont have to wait for an accident. They can be communicated without by non verbal means. Example: being a responsible father, providing for the old age of your spouse. Really caring need not be demonstrative all the time. Moving into the 21st century does not mean doing 'in' or bizarre things. Ravi, |
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From: Charles Krin << Oh one more thing....What happens when a family member watching a resus sees more blood then they've seen in their entire life, goes into shock and exacerbates their angina leading to themselves needing resus? Hey...It's probably good for them right? >> Or even if it is a minor case, and they fall out, injuring themselves? Saw one situation several years ago, where I had to put 4 stitches in the forehead of a 9 year old girl (she had caught the end of a school yard toy the hard way!). Daddy insisted on staying with his "little baby," despite her protestations that she would be ok... sat him down on a non rolling stool in the corner... and about the time I placed the first suture, he passed slam out- took ten sutures to close the gash in his occiput, because as he slid down over the lip of the stool, he caught his head on the rung. I've got to agree with most of the folks voting against free admission on this one. "Reasonable access" to a dying patient where there are no heroics going on is one thing, but the key word remains "reasonable." How to define "reasonable?" How about "How would I want my family handled in this situation?" (AKA, Do unto others as you would have done unto you....) Incidently, this is a policy that I try to teach to my students, both medical, paramedical and nursing. In the mean time, I spent an extra hour counseling (non billable) a family (two elderly folks and their grand daughter who lives quite a ways away from here) on the various facets of living wills etc. This is something that both doctors and nurses need to be bringing up with the families "pre need" (to borrow a familiar phrase from the funeral parlor business), so that we will be able to provide more compassionate and appropriate care as the end of life approachs.
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From: Dennis Hudson RN Here is a partial list of the literature used for a paper on family presence. Hope you find it helpful:: The trauma nurse's role with families in crisis, Critical Care Nurse/April 1994 35-43 After care bereavement program, Critical Care Nursing Clinics of North America/vol 7,#3 Sept. 1995 519-527 A rural community hospital's experience with family-witnessed resuscitation, JEN/vol 23, #3, June 1997 238-239 A chance to say good-bye, AJN/May1994 42-45 Yes, much of the literature is anecdotal and "opinion" based, but there is definite support. I would suggest that, if you want resources, you contact ENA (1-800-2-GET-ENA) and request a copy of their position statement regarding family presence at resuscitation and invasive procedures. (citation excerpted & abrv) ENA Position Statement ENA supports the option of family presence during invasive procedures and/or resuscitation efforts. ENA supports further research related to the presence of family members during invasive procedures and/or resuscitation efforts and the impact it has upon family members, patients, and health care personnel. ENA supports the development and dissemination of educational resources for Emergency Department health care personnel concerning the issues related to family presence. The ENA supports collaboration with other specialty organizations (including, but not limited to nursing, social and family services, pastoral care, physicians, and prehospital care providers) to develop multidisciplinary guidelines related to family presence during invasive procedures and/or resuscitation. References Hanson, C., & Strawser, D.S. (1992). Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department's nine-year perspective. Journal of Emergency Nursing, 18(2), pp 104-106. Molter, N. (1979). Needs of relatives of critically ill patients: A descriptive study. Heart Lung, 8, pp 332-339. Osuagwu, C. (1993). More on family presence during resuscitation. Journal of Emergency Nursing, 19(4), pp 276-277. Whaley, L., & Wong, D. (1991). Nursing care of infants and children, 4th ed. St. Louis, MO: The C.V. Mosby Company. Williams, M. (1993). More on family presence during resuscitation. Journal of Emergency Nursing, 19(6), pp 478-479. Yanks, K.Y. (1993). More on family presence during resuscitation. Journal of Emergency Nursing, 19(6), pp 477-478. Thank you Coleen and Vicki for providing the above references. I have reviewed 9 of the 10 citations listed and the ENA Position statement. I was unable to locate any statistical outcome evidence supporting familial presence during traumatic resuscitation. In fact of the citations listed above, 2 concerned in-patient critical care units, 1 covered a single OR patient (non-trauma), and 1 spoke of "aftercare" or post-mortem bereavement. Of the remaining references, 3 were letters, 1 of which spoke only of cardiac arrest, one mentioned allowing visitation during a "quiet" point in the resuscitation with the expectation that family may be asked to "step out temporarily if things escalate". This leaves a single citation, the Foote Hospital study. Again it is primarily anecdotal with one follow up study of 47 family members in 1995 (unk. pool). Both cardiac and traumatic arrests were mentioned, but families were only escorted into resus when "initial procedures were completed". Initial procedures were not defined. As to the ENA position statement, one line supports the "option" of family presence. The remaining three paragraphs recommend research, education of healthcare personnel regarding "issues" of family presence, and collaboration with other specialty organizations to develop multidisciplinary guidelines RELATED to family presence. I don't think anybody can argue with research, education, and collaboration, but as for the rest of it....again I ask, "Where is the proof?" To advocate such a paradigm shift in trauma care, shouldn't we health professionals require SOME statistical evidence? All right everybody, show of hands... Dennis R Hudson RN CEN |