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Lecturer Practitioner in Accident & Emergency
Royal London Hospital - City University
A man was knocked off his bicycle by a lorry sustaining a traumatic amputation of his leg and a severely fractured pelvis. His wife arrived in the Accident & Emergency (A&E) department shortly after the resuscitation of her husband had commenced. She asked to go and see her husband. The team resuscitating her husband did not think that this was appropriate and she was told to wait until he was "more stable". She finally got to see her husband about an hour and a half later in the mortuary viewing room.
A woman suffered an impalement injury after being ejected from her car. She arrived in A&E, was resuscitated, taken to theatre for a laparotomy and then onto ITU (after which she made a full recovery!). Prior to this, her brother arrived in A&E and insisted that he stay with his sister in the department. He stayed near his sister in the resuscitation room until she was taken to the operating theatre.
These are two examples of relatives requests to be with their loved ones during trauma resuscitation. Whether we agree or disagree, some relatives insist on seeing their relatives during the early stages of their arrival to hospital. This emotive subject provokes many arguments for and against the practice of allowing relatives to be present during trauma resuscitation. On the trauma-list, much discussion has taken place from all sections of the multidisciplinary team involved in trauma resuscitation.
The aim of this article is not to solve any of the complex problems encountered with witnessed resuscitation, but simply to present some arguments for and against the practice. It is hoped that trauma nurses (and the multidisciplinary team) can reflect on what happens in their units and the implications for the patient and their relatives.
The Arguments Against...
Sensory disturbance Trauma resuscitations can be visually disturbing, even to the most experienced clinical staff. At an olfactory level, burns, blood and other secretions can result in unpleasant, upsetting smells in the trauma room. Similarly, one would imagine that patients who are crying out due to pain, hypoxic confusion or anxiety would cause an auditory disturbance for the relatives.
Confidentiality If the patient is unconscious, it is not possible to gain their consent for witnessed resuscitation. Consequently, patient confidentiality may be broken if the patient's wishes are not known. When considering this, Fulbrook suggests that "not only would the relatives see everything happening to the patient, they may hear information of an intensely personal nature" (1). At a professional level, nursing and medical governing bodies suggest recommendations for practice. The United Kingdom Central Council for nurses states that "No one, not even a loved one or relative is entitled to information which the patient does not want them to have" (2).
Complaints/Litigation Staff may fear that during a witnessed resuscitation, an observed action or remark may offend relatives, leading to a complaint. Fear of allowing observation of medical procedures may increase the risk of litigation against the hospital or the practitioner.
Staff response Nursing, medical and paramedical staff use a variety of methods to deal with the stress of trauma resuscitations. Some bleak situations may be peppered with a small degree of humour, which can help to keep the team functioning under stress. The presence of a relative may inhibit this coping mechanism, thereby affecting team performance. "I appear to be detached about what is going on around me, even making occasional light-hearted comments" (3).
Relatives emotional response This is often cited as an argument against witnessed resuscitation. Emergency room staff interviewed about this suggested that "panic by relatives disrupts medical efforts" (4). Whilst Hanson and Strawser (1992) reported that there is a fear that uncontrollable relative grief would disrupt the team (5).
Clinical performance With a relative present, there is a pressure for the trauma team to perform well. This may be inhibited by a reluctance to discuss the patients condition in front of the relative. "We felt unable to voice our opinion about the patients deteriorating condition". In addition, decision making may be delayed "the resuscitation was kept going longer than usual" (4). Furthermore, many procedures learned by doctors and nurses have to be done first time in vivo during a trauma call. There is a commitment to train our junior colleagues. A senior doctor talking a more junior doctor through a chest drain insertion or a junior nurse taking blood from her first trauma patient may not be viewed positively by a grief stricken relative.
The Arguments For...
Respecting the relatives (and possibly the patients) wishes It is presumed that patients are resuscitated to save their lives and return them to their family and friends. The wishes of close relatives should be respected. Adams (1994) describes how she felt whilst watching her brother being resuscitated post-injury: "It seems that most professionals would prefer relatives not to be present but I would not have been anywhere else at the time. I would've liked to have held his hand but didn't dare ask" (6).
Seeing By allowing relatives to see what is happening to their loved one, even for a short period of time, may help to dispel terrible imagery or anxiety. "Relatives can see that everything possible is being done for their loved one" (7).
Media influences Whilst it would be naïve to imagine that a medical docu-drama or soap could completely prepare a relative for trauma resuscitation, the public may be more informed than we think. The media obsession with this type of programme does graphically bring to the living room the close up workings of an emergency room as never before.
Staff attitudes Some emergency personnel are accepting and comfortable with witnessed resuscitation. Results from a study into medical and nursing staff attitudes showed that the more senior and experienced the member of staff (in both resuscitation and caring for upset relatives), the more likely it was for them to agree with allowing relatives into the emergency room (8).
Empirical evidence (USA)
The widely discussed Foote Hospital study (5) was started as a result of the relatives of two patients insisting on being present during resuscitation (One of which was a trauma victim). Since this time, the emergency room staff have developed guidelines and a support structure for these interactions. Among some of the published results demonstrating the success that has been achieved in this area are:
- No evidence of relatives interfering
- Some incidence of hysteria where relatives were led away from the resuscitation
- Witnessed trauma resuscitation is now practiced
- Children are allowed to be present
- An excellent support system is available for relatives
- Staff regard patients as part of a community, not merely a clinical challenge.
Empirical evidence (UK)
Robinson et al (1998) conducted a small study into whether relatives wished to be present during resuscitation, and if so, were there adverse psychological side effects (9). The study involved relatives of 25 patients (including trauma victims) and was completed earlier than expected as the staff could see the benefits of having relatives present. Findings included:
- No relatives commented on any technical procedures - problems (including a difficult intubation)
- All relatives felt that it had been beneficial to be present
- Trends towards lower degrees of intrusive imagery, post traumatic stress disorder, and grief related symptoms
- Staff viewed the patient as a valued family member
In their conclusion, the authors noted that there was little evidence to support the exclusion of relatives who wished to be present during resuscitation.
In summary, this complex and controversial issue has many implications. It is an area that needs more research (10). Considerations of staff availability, support personnel, training costs and relative follow up all need to be addressed. Language and cultural barriers can be problematic when discussing this sensitive issue with relatives. However, one recommendation that can be made is to treat each trauma case individually, considering the patient's and relatives' wishes.
- Fullbrook S, 'Medico legal insights, legal implications of relatives witnessing resuscitation' British Journal of Theatre Nursing 7, 1998;10:33-35
- United Kingdom Central Council, 'Code of Professional Conduct for the Nurse, Midwife and Health Visitor' 3rd Ed. London, June 1992
- Schilling R 'No room for spectators' (letter) BMJ 309 406,1994
- Redley B, Hood K, 'Staff attitudes towards family presence during resuscitation' Accident & Emergency Nursing 1996;4:145-151
- Hanson C, Strawser D, 'Family presence during cardio-pulmonary resuscitation: Foote Hospital ED nine year perspective' Journal of Emergency Nursing 1992;18:104-106
- Adams S, Whitlock M, Bloomfield P, Baskett P, 'Should relatives be allowed to watch resuscitation?' BMJ 1994;308:1687-1689
- Martin J, 'Rethinking traditional thoughts' Journal of Emergency Nursing 1991;17:67-68
- Mitchell M, Lynch M, 'Should relatives be allowed in the resuscitation room?' Journal of Accident & Emergency Medicine 1997;14:366-369
- Robinson SM, Mackenzie-oss S, et al, 'Psychological effect of witnessed resuscitation on bereaved relatives' The Lancet 1998;352:614-617
- Small G and Pryse B, 'Witnessed resuscitation and bereavement services' 3M A & E Focus 3M Health Care 1999;10:19-21