Family Seeing Codes

Cut To Cure has an interesting after-action on his CME trip to Vegas. The part that caught my attention was:

On the last day, half of the morning was spent on discussions of “ethical issues” the most interesting one was related to the presence of family members in the trauma bay during resuscitation. Objections included the lack of space in the ED, having family members “fall out” during a resuscitation, family member interference and criticism (that’s not how Dr. Carter did it on ER last night!) and of course, fear of litigation if things don’t go well. Those that support the presence of family members during resuscitation cite reports (mainly related to ICU codes) that state the emotional benefits and “closure” that having family members present provides. The speaker polled the audience asking who would want their family member to see them with all of the accessories that go along with a complicated trauma resuscitation, very few said yes. I think that the presence of families in the trauma bay can only be a hindrance.

I do resuscitations for a living, and can say that only in VERY limited circumstances would I NOT allow a family into the room. (One or two, not the extended family).

There is, when present, no doubt in their mind that everyone is doing everything to “save” their loved one. I would say that the family of the chronically ill “do the best”, as they’ve been around medicine and hospitals for a long time, and the environment isn’t overwhelming. Those who aren’t hospital aware are frequently comforted by the fact that all those people are working so, hard, which is the absolute truth.

I support letting the family in. If they’re disruptive, let them go (with the Chaplain, or your equivalent), but most will understand. It’s what I’d want. I wouldn’t insist reluctant observers be forced to attend, but were it me, and my family is on the table, I want to be there.

I’m a control freak, and it’s very hard for me to let go, but this is one time when letting go of control, and letting in the family, is the best for all concerned.


Comments

  1. I’m in complete agreement with you. Not only is it a
    good idea to have them in the room to witness us “doing everything,” it’s also good to have them in the room so that they can fully experience the decisions they’ve made on behalf of their loved one.

    More than a few times, families have witnessed us doing CPR and intubating and have (appropriately, in my opinion) stopped us when they realize how barbaric the whole thing is. Especially on an elderly chronically ill patient.

    In ICU, we just keep piling on the interventions until it’s impossible for any of us to step back and say, “Ya know, this isn’t working.” Or, “it’s working right now, but if this guy codes, there’s no way he’s coming back.”

    But that there is a different rant altogether :-)

  2. I can see your point. One of the main points of the lecture was that in many ways the trauma resuscitation is different from a medical one. Do you allow families in when you are placing chest tubes, doing a DPL or during an ED thoracotomy? As you know they can get really messy. Would you want your family to see you like that ? Would they want to see you like that?

  3. I really feel obliged to weigh in here. It is said amongst the ER community that, when performing procedures (i.e. DPL or ED thoracotomy) it is crucial to make sure the family is not witness to this. There is actually a healing-oriented explanation for this. It is often the family who can bring hope to the patient, and it is often witnessing these procedures which can have detrimental effects to the _hope giving_ potential within each family member. As the wholistic view of the patient becomes more the norm, this is a consideration we must all take into account.

  4. I have let family stay during chest tubes. I suppose that the majority of the patients I have families with during procedures are medical cases, or atraumatic surgical ones, but not the bloody trauma resus.

    I suppose whether I’d want my family to see those procedures should be, within limits, up to the family. I’m all for paternalism in medicine when it’s warranted, but this is an area where we’ve been doing what’s more comfortable for us. It’s emotionally painful to see these scenes, but it’s more human than the family room.

    Thanks for bringing this up!

  5. I would absolutely want to be there to see the effort made to save my loved one; I would also want my family there, when that effort is made for me.

    I suppose that other people are not like me, and may feel differently about it. Perhaps their “hope giving potential” would be diminished by this, but mine certainly would not. The thought of being seperated from my loved one at a critical time, so that they might die, isolated from those who know them, would be a much harsher thing to face.

    I’m a former EMT and RN. I know that these proceedures can be ugly and hard to watch. Maybe regular people would have a harder time of it, I don’t know.

  6. Over in Singapore, from what I’ve observed in my rotations so far, families are very rarely allowed in to even peep at a resuscitation. Standard protocol: shoo relatives out, pull the curtains or close the door, don’t let them back in till we get the patient back or resus efforts are stopped.
    It’s tough for me to take sides. Relatives have told me to “keep trying” even after almost an hour post-collapse, despite the lack of any return of spontaneous circulation. Having them present in the resus room would probably result in fisticuffs if we even considered calling it.
    I think the most appropriate moment would be after the decision is made to stop resuscitating. Go outside and explain the situation, then bring them in to say goodbye before shutting the ventilator off.
    As for performing chest tube insertions with relatives present, errr, highly unlikely here! Singaporeans tend to be very suspicious of doctors. Any bleeding would probably trigger a complaint, even if the patient is SUPPOSED to bleed ( ie. during a skin incision ). :(

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    Traumatic choices

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