Family presence during resuscitations…the debate continues

For those of us involved in acute care medicine, you’ve likely faced the question

“should we invite the family to be present during the resuscitation?”

More than likely you also have an opinion on the matter. In fact, as I’ve started to look at the literature, people have very strong opinions about this subject! For those with short attention spans…check out a recent New England Journal of Medicine article for further evdience! 

I’ll be candid – I support the practice of having families present for the resuscitation, or at least inviting them to be present. I understand some families will decline which is entirely their choice but importantly other families will find this important to be present.

The last time I invited a family to observe was in an ICU setting where we were in the process of resuscitating a young person who had suffered cardiac arrest. The patient was extremely unstable with episodes of CPR and increasing pressor requirements.  I knew the family was waiting in the family room so I handed over the role of team leader to another colleague and visited with the family. Before leaving, however, the entire team was made aware of the plan to have the family present. Everyone was in agreement with the plan. I invited all family members to be present though only 3 of 5 requested to observe. Before entering, I outlined that they would see their loved one with a “breathing tube” and that “CPR” may be in process. We had our most senior ICU nurse with the family throughout the resuscitation to explain exactly what was happening. Never once were they left alone, however, we did encourage if they wished to hold their loved ones hand. We had planned our equipment prior to allow for this. Unfortunately the patient died but the family expressed their gratitude to the entire team for their efforts. Furthermore, they thanked us for allowing them to be with the patient during the final moments of her life. I can’t speak to why the family chose to be present, but they expressed nothing but gratitude for the invitation.

Detractors will say that family presence may have hindered the teams performance and perhaps led to psychological harm to the patient’s family. I also can’t speculate on the long term consequences for observing this potentially traumatic event. However, our team unanimously decided it would be appropriate and we proceeded accordingly.

Importantly, our team had a short de-brief afterwards where any concerns, comments and opinions were heard. There was no disagreement among team members that what was done was appropriate.

I recalled this story after reading this week’s NEJM which published a pre-hospital trial which randomized family members to observation of CPR compared to standard practice. The primary outcome was the proportion of relatives with PTSD related symptoms. Impressively, those family members who observed the resuscitation had significantly lower frequency of PTSD related symptoms than those who did not witness the resuscitation. There was no affect on resuscitation characteristics, patient survival and none resulted in medicolegal claims.

In conclusion, the authors stated that:

“family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team or medicolegal conflicts”

Some will argue that this study applies only to the pre-hospital setting since in-hospital situations are very different. In this study setting, many may have witnessed the actual collapse which differs from the hospital. So in the pre-hospital setting, maybe this is sufficient evidence to proceed with offering family presence? I can’t imagine there’s going to be another randomized trial any time soon. This is likely the best evidence we’ll get…at least out of hospital.

There is a vast array of highly opinionated individuals who have posted replies to this topic and I believe these warrant reading. Its amazing how strong the opinions are despite the lack of evidence. There have been several studies that have evaluated ED personnel opinion – these show equipoise…in one study it was 50.9% who supported family presence.

As many who are against the practice have pointed out, lack of support and communication during the resuscitation are detrimental and counterproductive. There must  be a designated individual who can provide perspective and explanation to the family. Furthermore that individual must recurrently reassess the emotional state of the family. While some feel this is a pandora box that should NEVER be opened, I would disagree. One of the editorialists for the NEJM article summaries the situation quite well:

“Part of our job as physicians is to help patients and families establish goals of care, process life-threatening events, and, at times, orchestrate the best death possible.”

 

What is most important as acute care clinicians is that we continue the discourse and encourage future study. There is clearly no definitive answer and to argue in one direction or the other without acknowledging the lack of evidence is ignorant. We have multiple surveys that report equipoise among clinicians followed by anecdotal reports of success with family observation.  Interestingly, several large guidelines have endorsed family presence including those from the AHA.

Based on this emerging evidence, it certainly doesn’t discourage me from further pursuing family presence. I will continue to invite families into the resuscitation room, however, before this occurs I will ensure the following:

  1. Discuss with the team so that everyone is aware that the family will be entering 
  2. Offer to the family the opportunity to be present
  3. Prepare the family for what they may see and that the resuscitation may be stopped during their present
  4. Ensure there is a well experience clinician (either RN or MD) with the family throughout the resuscitation
  5. Debrief the resuscitation team afterwards

 

What should be encouraged is similar situations be incorporated within simulation training. Before we fully integrate family presence, just like any other high-risk procedure, we should practice it and be competent. The entire team should be aware and understand the implications.

For those wishing to read more, I highly recommend a critical review of the literature published in 2005. While it’s a bit older, it is quite helpful! At that time there was little evidence to support many of the concerns expressed by those do not support family presence…

 

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NEJM commentary on service in medical education – They got it wrong.

Last week there was a very interesting perspective/editorial published in the NEJM. But one that I thought deserves some comment because I strongly disagreed with the authors. In fact, I thought it was unfortunate to see this commentary in such a widely read journal.

The title was “Service: An Essential Component of Graduate Medical Education“. It was authored by two Boston physicians (both appear to be oncologists). The authors outline their concern that service should be seen as an educational objective that shouldn’t be minimized, instead “resident duties that confer a high degree of service may still provide high educational value, in the form of genuine experience with patient care”. In essence they argue that seeing any/all patients is a learning opportunity! We will often joke about this on a shift when there’s a patient that likely won’t be a valuable learning experience for the trainee. I would agree that learning probably can gained from most patient interactions however, the quality and the yield may very often be low. Plus rather than subscribe to these authors’ belief  any patient presents learning opportunities and service should be viewed as learning, we should recognize that different learners have different needs. I would argue that in the emergency department, a surgery intern may gain very little from seeing a patient with chronic back pain that is seeking opiates and has considerable behavior issues. Patients like this can be challenging and often provide little learning especially when there are other patients to see. For instance, it’s very possible there’s a patient that needs to be seen that will better fulfill the pre-defined objectives of the surgery intern. However, this patient may be useful for the senior emergency medicine resident to manage as such patients will be their responsibility once they’re staff.

The authors then provide several examples of “service” which I found quite interesting.  One which particularly caught my attention…”A family practice resident misses a teaching conference in order to see her last clinic patient, who arrives late because of transportation problems“. They argue that a “didactic” teaching session is not nearly as valuable as seeing that final patient in clinic! I think this sets a dangerous precedent. Residents/trainees should not be made to miss preestablished learning opportunities for service. Whatever this “teaching session” is, it’s been integrated into the curriculum such that the resident can work towards achieving competence in their field. There may be exceptions but as a rule I would advocate against this mindset.

We have begun to move towards a competency-based approach to medical education with a set of competencies laid out for residents to achieve by the end of their training. As they work towards these competencies, there’s no doubt that they’ll be doing “service” and “less valuable” tasks but to think that simply seeing patients and doing scut work is valuable because you never know when that little piece of learning may occur is wrong.

The final words of the authors addressed the aspect of competency-based education head on: “many medical educators have worked to optimize the educational value of residency and protect trainees from engaging in menial activities from which they do not learn. As such reform continues, however, it risks going too far and sacrificing certain essential educational experiences that can emerge from service activities, as well as the opportunity to teach trainees about service’s importance to the profession”

Overall  the author’s argument came across as annoyed staff physicians who were having to do their own work and no longer being able to pawn it off on their residents.

In general, I strongly disagreed with the authors’ argument. In an era in medical education when time has become a commodity and duty hour restrictions have become reality, we must continue on the path towards ensuring trainees are competent based on pre-defined learning objectives. We should seek efficient and high yield methods for trainees to learn. To continue forcing a resident to do dictations for the same thing over and over simply because they need to learn the value of service seems to go against this approach. It will not help trainees become better doctors and as a result our patients will suffer. And as most of us agree, we became physicians to become experts in patient care and help those who can’t help themselves.

The time for checklists in medicine…is NOW!

I have written about checklists in medicine before, but in light of a recent publication in the New England Journal of Medicine, I was inspired again to write about it.

One of the leading advocates for checklists in medicine is Atul Gawande. His book “The Checklist Manifesto” is an excellent read for anyone interested in the topic and definitely well written for the lay-person. Notably he’s also the senior author on this randomized trial just published in NEJM. And while the NEJM is often busy publishing some questionably biased and often pharma-funded studies, this one deserves attention. But before I discuss more about the trial…I digress…

Just this week, while we were flying I observed something quite interesting. Typically when we fly in the helicopters, our pilots ask our crewman for landing checks. At which point the crewman will go through the checklist with the pilot answering appropriately. We were out on a job and the crewman was busy in the back of the machine so the pilot read the checklist himself. After each item on the list, the pilot would answer himself….basically talking to himself. I remember asking a pilot about the value of a checklist for both their critical and non-critical procedures. He told me that by doing a checklist, he could concentrate on the variables that may arise and not worry about forgetting something small or routine. This is interesting…

I can’t remember the last time I’ve seen a physician read off a checklist, answering to themselves that all everything required is present and functional.  In medicine, we have this idea that if we can’t remember everything then it’s a sign of weakness. We don’t use checklists. In our minds “checklists are for losers” (not sure who I’m quoting here). But this idea that we must remember everything during a critical event is unique to medicine. Obviously I’m not advocating that we shouldn’t commit anything to memory but why bother trying to remember mundane items when we should be concentrating on “owning the resuscitation” (A term coined by Cliff Reid from resus.me).

We should instead focus on identifying why the patient is crashing or what might make this particular intubation difficult. We should NOT be trying to remember whether we’re missing anything… “ok…so I have the BVM, suction, tube…anything I’m missing? Of course! We need RSI drugs!”…this is a useless conversation and waste of time. By using a checklist the cue for RSI drugs will happen and the focus can be on more important things like ensuring the patient is well positioned, critically evaluating the cause for clinical deterioration – then the clinician can focus on real problem solving.

It’s interesting that many of the HEMS services out there are using RSI checklists and yet few are used in EDs around the world. At our HEMS service, we use it because we work in often hectic conditions that can be quickly become uncontrolled situations with unstable patients…wait a second…that sounds remarkably like an ED around the world! So why not implement a similar protocol? A recent paper in J Trauma looked at a standardized approach to RSI in trauma…seems promising!

And as I mentioned above, the NEJM recently published a large randomized trial evaluating the use of checklists for high-fidelity crisis simulation in an operating room setting. The use of checklists resulted in a 75% reduction to adhere to critical steps in management. Most impressively, the difference in missing critical steps was 6% with checklists vs. 23% without checklists. That’s an absolute reduction of 17%! And a relative risk reduction after multivariate analysis of 28%. If there was ever a drug trial that showed similar results it would likely be put in the water (maybe fluoride?). But last time I checked, no one will be making much money by producing a checklist. And yet despite our inability to show much more than non-inferiority with new oral anti-coagulants (vs. warfarin), the increase in use is HUGE!

This figure below published in the article is impressive. It demonstrates how the same team behaved completely differently depending on the use of a checklist. Some of the instances where they failed to adhere to critical processes of care is unbelievable and certainly is NOT good for patient oriented outcomes! V.fib and no defib for 1.5min? WOW!

Prime example of how checklists can help during resuscitations! Published in NEJM

Prime example of how checklists can help during resuscitations! Published in NEJM

I agree that we should probably study the implementation of a checklist into emergency medicine…but we probably shouldn’t wait longer. Recent publications show adverse event rates (or near misses) of 10% during RSI in the ED. This is NOT acceptable. We can do better and we should do better. Time for checklists to become an integral part of our critical actions. We can assign the checklist to be administered by our resuscitation room safety officer (yes, another novel concept that also deserves consideration…check out Cliff Reid’s great blog post on the topic)