Should hospitals allow family members to watch as medical teams work furiously to save a loved one’s life?
For years families have been shut out of the room during resuscitation attempts in adult hospitals. Real-life resuscitations can be almost violent and the thought was that it would be too psychologically harrowing to allow families to watch.
But a controversial trend known as family presence during resuscitation is growing as evidence mounts that relatives benefit by being allowed to stay during what may be the last moments of their loved one’s life.
In Calgary, the new South Health Campus of Alberta Health Services has implemented a policy giving families the option to be present during resuscitations in the emergency room, clinics, patient-care floors or wherever they occur in the hospital.
The hospital has developed guidelines and is increasing the number of staff trained to take on a “family liaison” role at a moment’s notice, “so that whenever a code is called or whenever a patient gets into a trouble and is going through a resuscitation, the family can remain present,” said Joanne Ganton, manager of patient and family centred care.
“The role of a family liaison is to assess the family — do they want the option? Some families may say, ‘no, get me out of here.’ Others may say, ‘yes I want to stay,’ ” Ganton said.
“Some families want the option to come in, see what’s going on and, if it’s too overwhelming the option to step out. But to be given that option, I think is what families really appreciate.”
Children’s hospitals have long allowed parents to be present during resuscitation attempts, and numerous organizations, including the American Heart Association and the Canadian Association of Critical Care Nurses support giving all families the option. Shutting families out of the room denies them a chance “to face death with a loved one,” the nurses’ group says, and to say goodbye.
Many hospitals have begun informally including families in resuscitations on a case-by-case basis. “What we did here was put it into writing that this is something that we’re going to try to do as often as we can,” said Dr. Colin Del Castilho, an emergency physician at Calgary’s South Health Campus.
“You’re there so patients can feel your presence, your voice, your touch,” added Ganton, who will be presenting her hospital’s experience with family witnessed resuscitation at the 6th International Conference on Patient- and Family-Centred Care in Vancouver Thursday.
“Families are provided with constant information so they know what’s going on at all time.”
But some experts in critical care worry real-world resuscitations may be too graphic for families, or that hysterical or panic-stricken relatives will try to interfere or demand the resuscitation team keeps going when any hope for survival is gone.
CPR, or cardiopulmonary resuscitation, performed in an emergency room or intensive care unit isn’t like the sanitized versions depicted on television. On TV, there’s usually no visible blood. Intubations go smoothly and most people survive after a few light compressions of the chest.
In reality, resuscitations can be chaotic and stressful, and the odds of survival are slim. Chest compressions have to be deep, rapid and forceful. “You will almost invariably break ribs,” said Dr. James Downar, a critical care and palliative care doctor at Toronto General Hospital. Inserting a central line — a catheter to deliver medications and fluids — into a major vein in the neck or groin can cause visible bleeding, he said. If the patient is in cardiac arrest because of a major injury there may be more blood.
If it’s a trauma case, such as a car crash or stabbing, the focus is on giving fluids and blood transfusions, trying to identify the source of the bleeding and stopping it.
Although not all resuscitation attempts are the same, “there are way more concerns from family members when they are not present, because they don’t know what happened,” Del Castilho said.
“When you walk into a room and you see there are 15 or 20 people actively working on your loved one — they’re doing chest compressions, they’re potentially shocking the heart, they’re giving lots of medications — and you see that hasn’t worked, then I think a lot of families do get that sense of closure,” Del Castilho said.
Downar supports involving family members in the care of patients. But he worries about the psychological trauma to the family if they aren’t provided adequate support during and after the resuscitation.
He’s also concerned that it may increase the risk to the patient if the team is distracted.
He says it can be vital to have families present in emergency cases where the patient is suddenly rushed to hospital “and you’re literally asking the family members questions while you’re performing CPR, while you’re administering shocks… It’s of vital importance to have that family member there so you get the clearest information you can get.”
But Downar has also witnessed resuscitations when family members pleaded with the team not to stop, even when it was clear that it was not going to be successful and that the person had, in fact, died. “And they ultimately ended up continuing with the resuscitation because they were concerned what the family might do if they didn’t.”
Dr. Christian Vaillancourt, an associate professor in the department of emergency medicine at the University of Ottawa, said papers have been published on family witnessed resuscitation “for at least a couple of decades.”
All or most are “overwhelmingly in favour of allowing this to happen, except perhaps during particularly invasive trauma care,” for example, a thoracotomy, where the chest is cut and the ribs pried open to gain access to the heart and lungs.
Vaillancourt wasn’t aware of a specific policy at The Ottawa Hospital supporting family witnessed resuscitation, “but I can say this is often the case in the emergency room when family members happen to be present at the time of cardiac arrest.”
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