Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.
While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.
The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.
No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.
With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.
Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.
There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.
The provider’s common concerns include:
- Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
- Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
- Risk of litigation;
- Interference with resident training;
- Provider discomfort, causing suboptimal performance; and
- Patient confidentiality.1
Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2
Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.