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Witnessed Trauma Resuscitation - can relatives
be present?
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A man was knocked off his bicycle by a lorry
sustaining a traumatic amputation of his leg and a severely
fractured pelvis. His wife arrived in the Accident & Emergency
(A&E) department shortly after the resuscitation of her husband
had commenced. She asked to go and see her husband. The team
resuscitating her husband did not think that this was appropriate
and she was told to wait until he was "more stable". She finally
got to see her husband about an hour and a half later in the
mortuary viewing room.
A woman suffered an impalement injury after
being ejected from her car. She arrived in A&E, was resuscitated,
taken to theatre for a laparotomy and then onto ITU (after
which she made a full recovery!). Prior to this, her brother
arrived in A&E and insisted that he stay with his sister in
the department. He stayed near his sister in the resuscitation
room until she was taken to the operating theatre.
These are two examples of relatives requests
to be with their loved ones during trauma resuscitation. Whether
we agree or disagree, some relatives insist on seeing their
relatives during the early stages of their arrival to hospital.
This emotive subject provokes many arguments for and against
the practice of allowing relatives to be present during trauma
resuscitation. On the trauma-list, much discussion
has taken place from all sections of the multidisciplinary
team involved in trauma resuscitation.
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The aim of this article is not to solve any of
the complex problems encountered with witnessed resuscitation, but
simply to present some arguments for and against the practice. It
is hoped that trauma nurses (and the multidisciplinary team) can
reflect on what happens in their units and the implications for
the patient and their relatives.
The Arguments Against...
Sensory disturbance
Trauma resuscitations can be visually disturbing, even to the most
experienced clinical staff. At an olfactory level, burns, blood
and other secretions can result in unpleasant, upsetting smells
in the trauma room. Similarly, one would imagine that patients who
are crying out due to pain, hypoxic confusion or anxiety would cause
an auditory disturbance for the relatives.
Confidentiality
If the patient is unconscious, it is not possible to gain their
consent for witnessed resuscitation. Consequently, patient confidentiality
may be broken if the patient's wishes are not known. When considering
this, Fulbrook suggests that "not only would the relatives see everything
happening to the patient, they may hear information of an intensely
personal nature" (1). At a professional level, nursing and medical
governing bodies suggest recommendations for practice. The United
Kingdom Central Council for nurses states that "No one, not even
a loved one or relative is entitled to information which the patient
does not want them to have" (2).
Complaints/Litigation
Staff may fear that during a witnessed resuscitation, an observed
action or remark may offend relatives, leading to a complaint. Fear
of allowing observation of medical procedures may increase the risk
of litigation against the hospital or the practitioner.
Staff response
Nursing, medical and paramedical staff use a variety of methods
to deal with the stress of trauma resuscitations. Some bleak situations
may be peppered with a small degree of humour, which can help to
keep the team functioning under stress. The presence of a relative
may inhibit this coping mechanism, thereby affecting team performance.
"I appear to be detached about what is going on around me, even
making occasional light-hearted comments" (3).
Relatives emotional response
This is often cited as an argument against witnessed resuscitation.
Emergency room staff interviewed about this suggested that "panic
by relatives disrupts medical efforts" (4). Whilst Hanson and Strawser
(1992) reported that there is a fear that uncontrollable relative
grief would disrupt the team (5).
Clinical performance
With a relative present, there is a pressure for the trauma team
to perform well. This may be inhibited by a reluctance to discuss
the patients condition in front of the relative. "We felt unable
to voice our opinion about the patients deteriorating condition".
In addition, decision making may be delayed "the resuscitation was
kept going longer than usual" (4). Furthermore, many procedures
learned by doctors and nurses have to be done first time in vivo
during a trauma call. There is a commitment to train our junior
colleagues. A senior doctor talking a more junior doctor through
a chest drain insertion or a junior nurse taking blood from her
first trauma patient may not be viewed positively by a grief stricken
relative.
The Arguments For...
Respecting the relatives (and possibly the
patients) wishes
It is presumed that patients are resuscitated to save their lives
and return them to their family and friends. The wishes of close
relatives should be respected. Adams (1994) describes how she felt
whilst watching her brother being resuscitated post-injury: "It
seems that most professionals would prefer relatives not to be present
but I would not have been anywhere else at the time. I would've
liked to have held his hand but didn't dare ask" (6).
Seeing
By allowing relatives to see what is happening to their loved one,
even for a short period of time, may help to dispel terrible imagery
or anxiety. "Relatives can see that everything possible is being
done for their loved one" (7).
Media influences
Whilst it would be naïve to imagine that a medical docu-drama or
soap could completely prepare a relative for trauma resuscitation,
the public may be more informed than we think. The media obsession
with this type of programme does graphically bring to the living
room the close up workings of an emergency room as never before.
Staff attitudes
Some emergency personnel are accepting and comfortable with witnessed
resuscitation. Results from a study into medical and nursing staff
attitudes showed that the more senior and experienced the member
of staff (in both resuscitation and caring for upset relatives),
the more likely it was for them to agree with allowing relatives
into the emergency room (8).
Empirical evidence (USA)
The widely discussed Foote Hospital study (5) was started as a result
of the relatives of two patients insisting on being present during
resuscitation (One of which was a trauma victim). Since this time,
the emergency room staff have developed guidelines and a support
structure for these interactions. Among some of the published results
demonstrating the success that has been achieved in this area are:
- No evidence of relatives interfering
- Some incidence of hysteria where relatives
were led away from the resuscitation
- Witnessed trauma resuscitation is now
practiced
- Children are allowed to be present
- An excellent support system is available
for relatives
- Staff regard patients as part of a community,
not merely a clinical challenge.
Empirical evidence (UK)
Robinson et al (1998) conducted a small study
into whether relatives wished to be present during resuscitation,
and if so, were there adverse psychological side effects (9). The
study involved relatives of 25 patients (including trauma victims)
and was completed earlier than expected as the staff could see the
benefits of having relatives present. Findings included:
- No relatives commented on any technical
procedures - problems (including a difficult intubation)
- All relatives felt that it had been beneficial
to be present
- Trends towards lower degrees of intrusive
imagery, post traumatic stress disorder, and grief related symptoms
- Staff viewed the patient as a valued
family member
In their conclusion, the authors noted that
there was little evidence to support the exclusion of relatives
who wished to be present during resuscitation.
In summary, this complex and controversial
issue has many implications. It is an area that needs more research
(10). Considerations of staff availability, support personnel, training
costs and relative follow up all need to be addressed. Language
and cultural barriers can be problematic when discussing this sensitive
issue with relatives. However, one recommendation that can be made
is to treat each trauma case
individually, considering the patient's and relatives' wishes.
trauma.org 5:8 - August
2000
References
- Fullbrook S, 'Medico legal insights, legal
implications of relatives witnessing resuscitation' British
Journal of Theatre Nursing 7, 1998;10:33-35
- United Kingdom Central Council, 'Code of
Professional Conduct for the Nurse, Midwife and Health Visitor'
3rd Ed. London, June 1992
- Schilling R 'No room for spectators'
(letter) BMJ 309 406,1994
- Redley B, Hood K, 'Staff attitudes towards
family presence during resuscitation' Accident & Emergency
Nursing 1996;4:145-151
- Hanson C, Strawser D, 'Family presence during
cardio-pulmonary resuscitation: Foote Hospital ED nine year perspective'
Journal of Emergency Nursing 1992;18:104-106
- Adams S, Whitlock M, Bloomfield P, Baskett
P, 'Should relatives be allowed to watch resuscitation?'
BMJ 1994;308:1687-1689
- Martin J, 'Rethinking traditional thoughts'
Journal of Emergency Nursing 1991;17:67-68
- Mitchell M, Lynch M, 'Should relatives be
allowed in the resuscitation room?' Journal of Accident &
Emergency Medicine 1997;14:366-369
- Robinson SM, Mackenzie-oss S, et al, 'Psychological
effect of witnessed resuscitation on bereaved relatives' The
Lancet 1998;352:614-617
- Small G and Pryse B, 'Witnessed resuscitation
and bereavement services' 3M A & E Focus 3M Health Care 1999;10:19-21
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