Family Presence at Resuscitations
Date: 13.06.99 10.20 GMT
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
From: Bjorn Pret
Date: 13.06.98 19:11GMT
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,
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.
From: Ken Mattox
Date: 13.06.99 20:36 GMT
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.
Date: 14.06.99 08:20 GMT
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
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?
From: Charles Krin
Date: 14.06.99 12:37 GMT
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
From: Chris Hawkins
Date: 15.06.99 01:25 GMT
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.
Critical Care Nurse
From: Tim Coats
Date: 15.06.99 11:24 GMT
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
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
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.
From: Nick Macartney
Date: 15.06.99 15:47
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
ICU, Chase Farm Hospital
From: Mathias Kalkum
Date: 15.06.98 16.03 GMT
<<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
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
Department of Surgery / Abt. für Chirurgie
Tirschenreuth County Hospital , Germany
Date: 15.06.98 23:42 GMT
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
From: Frederick Foss, MD
Date: 16.06.98 00:12 GMT
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
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.
Date: 16.06.98 00:42 GMT
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
From: Richard Steyn
Date: 16.06.98 01:06 GMT
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
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
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.
Cardiothoracic Surgeon (previously rural General Practitioner,
Date: 16.06.98 02:10 GMT
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.
From: Patti Okotete
Date: 16.06.98 04:21 GMT
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
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
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.
From: Ken Mattox
Date: 16.06.98 04:48
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.
From: Olu Swale
Date: 16.06.98 05:07 GMT
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.
From: Andrew Robinson
Date: 16.06.98 05:38 GMT
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)
ICU Registrar, Royal Adelaide Hospital (UK)
Adelaide , Australia
From: Robert Eager
Date: 16.06.98 09:29 GMT
<<I appreciate your biased and traditional
trauma surgeons view , but it represents a dated and obviously
To whoever wrote the above post... Like yourself, I
am a nurse. However, I find that your above post not only abusive
towards fellow health care workers, but extraordinarily naive.
What you are proposing isn't patient advocacy but family advocacy.
Believe me, in the real world there's a big difference. What's
good for the patient IS NOT always good for the family, and
what's good for the family IS NOT always good for the patient!
Obviously, you have never had to try and resus someone while
fighting off an hysterical family member. Obviously, you have
never had to try and listen for breath sounds while a family
member babbles on in your ear. Obviously, you have never really
taken the time to actually analyze what happens during a resus
(particularly a trauma) and then thought about how a family
member (who's thinking is based on TV shows like ER etc.) must
think when they are watching the real thing.
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
R. Eager Sydney,
From: Tim Buchman
Date: 16.06.98 18:27 GMT
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
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.
From: Robbie Sepulvado
Date: 16.06.98 18:47 GMT
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
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.
From: Mikel A Rothenberg, MD
Date: 16.06.98 23:22 GMT
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.
Emergency Care Educator Medicolegal
Consultant North Olmsted, Ohio USA
Prof EMS -- American College of Prehospital Medicine
Date: 17.06.98 00:21 GMT
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.
From: W Raynor
Date: 17.06.98 02:54 GMT
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.
From: Tim Buchman
Date: 17.06.98 04:43 GMT
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.
From: Nick Macartney
Date: 17.06.98 08:48 GMT
<<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
ICU, Chase Farm Hospital
From: Robert Eager
Date: 17.06.98 11:41 GMT
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
From: Arthur Lam, MD
Date: 17.06.98 17:22 GMT
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
Arthur Lam MD
From: Mark Fitzgerald
Date: 17.06.98 10:53 GMT
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.
Date: 19.06.98 17:32 GMT
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.
S south India
From: Charles Krin
Date: 20.06.98 03:23 GMT
<< 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
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.
From: Dennis Hudson RN
Date: 18.06.98 22:32 GMT
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
ENA Position Statement
(Association Position and references excerpted) :
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
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),
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
Jefferson Regional Medical Center