Dr. Jeffrey Parks, a general surgeon from Cleveland, Ohio, recently blogged movingly about trying to save a 4-year-old child hit by a speeding car:
He lost his vitals the minute he arrived. He was blond and blue eyed and there was dirt under his fingernails and we were pumping his pale, frail chest and finally the trauma attending performed an ED thoracotomy. His tiny, little pink lung erupted through the wound and his heart fluttered uselessly in its pristine diaphanous sac.
Wanting to do something, anything, the team decided to open up the child’s abdomen in search of any internal bleeding or injuries that might be fixable.
“There was nothing,” Parks writes.
There was no blood. His little liver was beautiful, I remember thinking. Nothing to fix. The vitals never came back and the kid died right there in front of us all…
The thought that this child’s parents might have been present, witnessing the whole heart-wrenching experience, is “just outlandish to me,” Parks writes.
Should family be in the room while resuscitation is taking place? It’s an issue that has been under debate for several years, with strong opinions on both sides of the fence. Many hospitals don’t allow it, viewing it either as too much of a liability or too much for most laypeople to handle.
But the evidence doesn’t really support this position, a nurse writes in a journal article that appeared in 2005 in the American Journal of Critical Care.
Current evidence indicates that most families want to be present and would make the same choice again. Fears that codes would be disrupted and families tormented by adverse psychological trauma have not been substantiated.
Granted, the data are limited. Most of the surveys that have been conducted on this issue have involved relatively small numbers of participants, and the survey designs haven’t been consistent. Even with these limitations, however, families appear to be remarkably unanimous in their preferences for being present during resuscitation.
Among some of the findings: Most families believed it was their right to be present during resuscitation and found that being there was helpful to them and to the patient, especially when the patient is a child. For many of them, it was an important step in understanding the gravity of their loved one’s condition and knowing that everything possible was being done. Additionally, it did not appear to leave them with long-lasting traumatic memories. One study, conducted among families who had experienced the death of a loved one in the emergency room, found that 80 percent would have wanted to be in the room if this had been an option.
A slightly different picture emerges from surveys of emergency-room staff. Doctors and nurses worried that having families in the room during resuscitation would be disruptive. Many of them felt it would be traumatic for families to witness the resuscitation efforts, and that families would not be able to understand what they were seeing. Many of the doctors and nurses also were concerned about the added level of stress of having family members in the room during an already high-stress situation. And in one study, a majority of the respondents said they didn’t think family members would want to be present during a code. There were practical considerations as well; sometimes the room is just too small or crowded with equipment to allow anyone else inside.
Despite these reservations, however, many of the emergency-room personnel who’ve been surveyed say they would always respect the wishes of the family to be in the room. Many also say they would consider inviting the family to the bedside, as long as the circumstances could be controlled. More recently, a number of hospitals have begun developing policies to help guide the staff when families want to be present during resuscitation.
Some of this ambivalence is reflected in the comments to Dr. Parks’s story. “Family in the trauma room is just asking for lawsuits,” one person wrote. “When chest compressions start cracking ribs, I can’t imagine wanting to be in the room if it was my family member. It was bad enough doing the chest compressions.”
Resuscitation during trauma or a code “is no place for a loved one,” someone else agreed. “I think that when people see this stuff on ‘ER’ or ‘Grey’s Anatomy’ without the blood and guts everywhere, it seems rather benign. The reality is far different.”
Another commenter had a different perspective:
I generally don’t like having the family in the room initially – particularly if a procedure needs to be done. But once the tubes and lines are in I am certainly OK calling in the family to witness what almost always amounts to the end of the CPR (as they do whether or not the family is present). Usually I bring them in towards the end so they can take it all in and say goodbye while they are technically “alive” (only because I haven’t called the code yet). No idea if it helps them, but they seem to like the opportunity.
There’s often a disconnect between what health care workers think patients and families want, and what patients and families actually do want. Under some circumstances, families might truly not belong in the room while a loved one is being resuscitated. More study is probably needed to identify when this could be the case. Does it make a difference if traumatic injuries are involved? Does the patient’s age make a difference? Does it make a difference if the patient survives? All things being equal, however, it appears that many families do indeed want the option of being present at some point during resuscitation, and the health care community would do well to figure out how to support them when this is their choice.
West Central Tribune photo by Ron Adams