Posted by: medicblog999 | October 16, 2009

Relatives at a Resus?

ed_resus1I have just read a really powerful moving post that has left me with some questions to think about.

Buckeye Surgeon shares his thoughts on a recent study into whether relatives should be present at an active resuscitation or if they should be in a separate relative’s room. To back up his own opinion, he recounts an experience he had as a junior doctor which still haunts him to this day.

Click here to have a read, but be warned, it is very graphic (but I guess you wouldn’t be reading this blog if that sort of thing bothered you).

You all finished? has the cold water running down your spine eased off now?

I would hate to be part of something like that. Hopefully, I will dodge such a thing during the rest of my years, but I know that it’s more than likely to happen at sometime.

So what do I think?

I`ll take this in two separate parts. Firstly I will tell you all what I think about resus on scene and in the back of the ambulance, and then we will have a chat about relatives being present in the A&E (ER) department.

On scene/In the Ambulance.

I have obviously been involved in many active resus attempts in the course of my duties, and to be honest the automatic response when transporting a cardiac arrest is to put the relative in the front of the Ambulance in the passenger seat. That way you can still transport them with the patient, but they do not have to witness everything you are trying to do. Surely that is the best thing, yes?

Reflecting on this, I have to ask myself if I do this for the benefit of the patient or the benefit of myself. Do I really want to be looking after a relative as the same time as trying to resuscitate the patient? In 99% of cases where I am transporting an active resus, I am on my own in the back. We aren’t as fortunate as some of my colleagues around the world you can just pull a Firefighter or Police officer into the back of the ambulance to assist. It’s just me…..on my tod….doing the best I can for my patient.

I can understand that some relatives may want to be present, but I have never had an objection from one yet, when I ask them to ‘jump in the front’. I suppose they are just happy that they are still ‘with’ their loved one, even though they are not right next to them.

As for parents of a child who has arrested, I have only had one experience of that so far, and that was of a ‘cot death’. In that case, mum travelled in the back and sat next to the stretcher whilst I continued with CPR. At the time, I think she was so numb, that it wouldn’t have made any difference what so ever, where I asked her to sit. I would find it hard to ask a mother or father to separate from their child during potentially, the final few minutes of their life.

What I do feel though, is that it has to be the decision of the relative if they want to be present or not. I think it is wrong to put your own opinion and beliefs onto a relative in this situation. What may seem incomprehensible to you may be just what the relative needs to deal with the current situation. But, the most important thing is that whoever it is, they need to be ‘fully informed’ of what they are about to witness. This doesn’t need to be an in-depth discussion, just a very quick and very frank account about what is happening and what is likely to happen.

The biggest difference between letting a relative witness a resus in the home or in the ambulance is the fact that there is no one whose job can solely be to support the relative and explain what is going on. I can imagine that the sight could be truly horrifying without anyone being able to explain what it is that we are actually doing and why.

Which brings us neatly on to the situation in the A&E/ER department

In the A&E/ER

I am aware that this discussion has been ongoing for years now. I can remember when I did my nurse training in 1992, that this was covered in our lectures. The fact that it is still being debated today shows that it is a circumstance that can never have a ‘prescribed’ way of dealing with it. It has to be taken on individual assessment of the case and the relative, and somewhere down the line, there may even be a decision based on the ‘best interests of the relative’.

However, I do feel that the discussion needs to happen. Instead of placing the relatives in the ubiquitous ‘relatives room’ with a cup of coffee, why not send someone down to ask the question?

“Would you like to be present whilst we continue with our efforts to help your son/daughter/husband/wife/father/mother etc”

or even

“We have tried everything that can to help your relative, however, despite our best efforts there is nothing further we can do. Would you like to be present when we stop?

” Hard questions certainly, but very valuable ones to ask, not only in the A&E department, but maybe we should be asking them as well whilst we are working on someone in the house or en route to A&E.

But again, I have to go back to the point about fully informing the relative. I am sure that in the case the Buckeye Surgeon shares with us, no parent would want to be present to witness the ‘mutilation’ of their child, even though they are the last ditch attempts of a team trying everything in their power to change an irreversible conclusion. I know I wouldn’t want to be a witness to that, but does that mean I shouldn’t give another parent the opportunity, no matter how unlikely it is that they would want to be there?

We are all only human; sometimes we shy away from the really hard and awkward questions to ask. It is to protect ourselves as much as anyone else, but we are all in this job for the same reasons, to help our patients, their families, friends and carers, whatever that may entail.

I am definitely for having relatives witness resus attempts, but only once they know what they are getting themselves in to. Is that the lasting image they want to see of their loved one?

What do you guys think?

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Responses

  1. I think it depends. On the back of an ambulance, irrespective of how many staff are working on the casualty, having a relative in there is going to hamper your efforts. As such, the relative should only be there if the chance of saving the casualty is so low as to make the potential benefit of being there for the relative outweigh the benefit of the increased chance of survival for the casualty by them not being there.Basically, if there's no chance, let the relative watch (if they want to), and be prepared to divert some of your attention to comforting them whilst resuscitating, otherwise they ride in the front.In A&E, they should be given the opportunity to watch if they so wish.

  2. Having just recently witnessed the (unsuccessful) resuscitation of my dad in his house, I am kind of glad that I witnessed what happened, although I was on auto pilot and nothing seemed real. I also think that it helped Lauren to witness everything as it has helped her come to terms with her beloved Grandad's death. It honestly never crossed our minds to ask to travel in the ambulance – we just jumped in the car and traveled to the hospital (I still have no recollection of the journey).We were placed in the good old relatives room at the hospital, however we all knew in our heart of hearts that he had gone. In this instance I don't think it would have been of any benefit to any of us to have been allowed into Resusc. If the situation had been different however, I do feel that I / we would have welcomed the opportunity to be present in Resusc.Great post Mark, although I had to read it in two bits as was starting to get upset. Sorry to ramble on !!!

  3. Wow Fiona, thanks for sharing that with us. Im sorry the story upset you, I know everything is still very raw.

  4. I can't say about A&E, but in general I don't really want the rellies present when attempting CPR in the patient's home.I mostly need to perfom CPR on older people. You can hear the ribs crack. One poor old boy was pigeon chested when we started. By the time we'd finished, his chest was concave. Can a relative really be prepared for that?In other cases there just isn't room. In one incident, we were trying to resuscitate a bloke in the cabin of a narrowboat. By the time we'd got him on the floor between the bunks either side, there was hardly any room for us, never mind his wife. I was bagging him from about 4 feet away.As a CFR, I don't deal with kids under 12, and I don't go to trauma. I can't really comment on these situations. However, from my experience with older people I would say that relatives should be kept away from the resuscitation.Let's face it, it's bloody undignified.

  5. I'm a former US Air Force respiratory therapist that has moved over to civilian respiratory therapy. Many of our patients that came into our ED at the military medical center were veterans that could be quite frail. We did have family members sometimes insist on being in the treatment room, but it had little effect on me personally. I was usually too busy intubating, manually ventilating, drawing a blood gas, and trading off with chest compressions. It did temper what I may have said out loud about the patient's prognosis or treatment plan, but the family members were more distant shadows at the periphery of my awareness. Yes, I know, that's cold hearted, but it's true.I personally wouldn't want to be in the treatment room if it was my family member, unless maybe it was my daughter (she's 6 years old). I know what happens and I have no desire to remember my family member's last moments like that.If a family member wants to be in the treatment room, by all means, let them. Just make sure they are aware that what they will see is graphic and can be traumatic and make sure they know to stay out of the way.That's my $.02

  6. I have seen it done both ways, depending on the situation. I think it's OK to have them present in the hospital, provided someone can be dedicated to shepherd them, explain the sights, and try to mitigate the trauma for them. I sometimes end up in that role as a paramedic after I've transferred care to the team.In the field, it's more of a practical matter. I simply don't have room for extra people in the back of the ambulance during a resuscitation.On my fire department, we are very fortunate that our chaplain is an active volunteer firefighter and medically trained. When we have enough hands, we dedicate him to dealing with the family members.

  7. I have seen it done both ways, depending on the situation. I think it's OK to have them present in the hospital, provided someone can be dedicated to shepherd them, explain the sights, and try to mitigate the trauma for them. I sometimes end up in that role as a paramedic after I've transferred care to the team.In the field, it's more of a practical matter. I simply don't have room for extra people in the back of the ambulance during a resuscitation.On my fire department, we are very fortunate that our chaplain is an active volunteer firefighter and medically trained. When we have enough hands, we dedicate him to dealing with the family members.

  8. Like many things that might, I say again, might be good in the ED/A&E I think it's generally bad in the field. The big reason is that the hospital has a lot more in the way of resources to control the situation. In the field we are on the patient (and family's) home ground. Things can go bad in a hurry if there aren't enough people on scene, including police and fire. Maybe in your system, that's not an issue, but it certainly can be in mine. If we have a field termination, we clean up the patient as best we can within our protocols and generally we'll allow the family to come in and say good bye. We also consult with the family, when possible, to let them know what has happened.It's certainly not an easy situation.

  9. My personal view is yes, but I'm biased as a volunteer with a VAS with advanced first aid training. I'd even go as far as if it was my loved one and I was present at the incident and otherwise unharmed, I may even offer to assist. My reasoning here is I would have started the resus and thus the adrenaline would be flowing and I would want the best care for them. If this means I join the paramedic in the back of the ambulance and manage the airway and bvm while they get on with the rest then I'm quite prepared to do that.Having seen such things for real, I understand them and understand their necessity, messy and undignified or not.I think one thing that would help is better first aid education for the public. Too often even tv shows such as casualty are sanitised and the public are presented with a loved one going through some pretty scary medical procedures to try and get them back to life. At least if they know about cpr and aeds then they have some preparation for the sights should they occur

  10. I think it's a good idea in an A&E/ER setting, provided there is a qualified nurse or doctor that is able to talk the relatives through the procedure. The good thing about resuscitation in hospital is that it is in a controlled environment with enough staff (hopefully!) to take care of both the patient and relatives. They generally don't have the relatives present in resus in 'my' A&E, unless it is a child they are resuscitating and the parents are there. I got talking to one of our nurses who worked in Australia for a short while and he said they usually had the relatives present, unless of course they didn't want to see it. He also said that nothing really went wrong when they did that, the only bad thing to happen was that a few relatives would leave after a short while if they couldn't bear it. But if they are given the option and they want to witness it, it could be benificial. It's one thing to be told 'we did everything we could', but if you can see for yourself that they did everything they could it would answer some of those initial questions.This might not be appropriate for trauma calls, given the graphic nature of the injuries and procedures, but I don't think it's such a bad idea for a respiratory/cardiac arrest.Just some of my random thoughts on the subject.

  11. I will disagree here. The times when I have performed CPR with family present, we make an effort to explain what is going on, step by step. I honestly think it provides a level of closure to people that is otherwise not obtained by just being told we did all we could. When family sees everything that was done, they understand the reality of the situation. There are obvious times when the family needs to be removed, but most of the time I really think that it is better for them to stay and see it. In the end, they most likely will not remember the details, but if you are being professional and doing your job, their is nothing to hide. I often think we rush them out of the room because we're afraid they'll see us do something wrong. Dying is a process which the family needs to understand. In all of the rescusitations I've performed with family present, I've never had a family member say anything to make me feel they were disgusted or couldn't handle it. More often it seems family members that are rushed out end up presenting as patients at the same time, because they don't know what is happening. People aren't the weaklings we presume they are. Even is cases of trauma, pediatric instances, or untimely deaths, it is IMHO better to allow family to come to grips. This might at times require assistance from Fire or Police on scene, but hiding reality isn't going to do anything for the grieving process.After all, in death, we have two groups of patients–they deceased and the grieving. We often forget the living when all hell hits the fan.

  12. It is easy to think you'd assist with your own family, but having been in this situation before, it isn't so simple. What we are trained to do professionally and what our emotions do to control us changes very quickly. When it comes to our family, we typically become just like any other civilian.

  13. The last Resus I had was a guy in his early fifties, lived right out in the sticks. A good 40 minutes away from the nearest A&E by road which is why we were backed up by air ambulance. As a crew we were backing up responder in a car, he had already commenced BLS when we arrived. We were 12 minutes away, the car was 9 minutes away and the helicopter was about 15 minutes away. The family had commenced CPR as instructed by the call taker, unfortunately the CPR they were performing was very poor. It basically involved just rubbing the patients chest and blowing very gently into his almost closed mouth, the responder said it was probably the worst CPR he had seen in his career. We now had 5 pairs of hands on scene and as the junior person I got to do the chest compressions, the look on the patients wifes face as I took over was very telling. She had no idea of what 'proper' CPR is, she genuinely thought what she sees on TV, a couple of half hearted presses on the chest and a few gentle puffs into the mouth will bring a person back. She really had no understanding that her husband was dead. Should the public have a better idea of what happens in a cardiac arrest and what we do? And just as importantly what they should do if the situation arises? I think so, but how do we educate them? Does watching a resus help or not? If the public were better educated in what we do and were prepared for what is going to happen then perhaps it would be beneficial. It's such a difficult question to answer because every case is different as are the relatives involved. Mind you, a relative always makes a handy drip stand!

  14. I'm not sure how we'd ever do it successfully in an ambulance (especially if you're accustomed to working a resus alone in the back of the unit – egads!), but I do think that there is a place for family presence in hospital settings – if we're smart about it.Once in the NICU, I thought family presence helped us out. Now I'm not so sure. I was faced with a premature, septic infant who was extremely critical. At delivery, mom implored the neonatologist to do everything possible to save the child. Ultimately, that involved six episodes of CPR, multiple fluid boluses and numerous doses of epi in the child's few hours of life. It was only when mom was allowed into the NICU and witnessed the reality of chest compressions on a neonate that she agreed to stopping resuscitation.Letting a parent into the unit was what finally facilitated a peaceful death, but I do have to wonder what images remain in the mother's mind, likely to this day.

  15. I'm not sure how we'd ever do it successfully in an ambulance (especially if you're accustomed to working a resus alone in the back of the unit – egads!), but I do think that there is a place for family presence in hospital settings – if we're smart about it.Once in the NICU, I thought family presence helped us out. Now I'm not so sure. I was faced with a premature, septic infant who was extremely critical. At delivery, mom implored the neonatologist to do everything possible to save the child. Ultimately, that involved six episodes of CPR, multiple fluid boluses and numerous doses of epi in the child's few hours of life. It was only when mom was allowed into the NICU and witnessed the reality of chest compressions on a neonate that she agreed to stopping resuscitation.Letting a parent into the unit was what finally facilitated a peaceful death, but I do have to wonder what images remain in the mother's mind, likely to this day.


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