Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Thursday, August 07, 2014

Finding Closure

"...So that whenever a code is called or whenever a patient gets into trouble and is going through a resuscitation, the family can remain present."
"The role of a family liaison is to assess the family -- do they want the option? Some families may say, 'No, get me out of here'. Others may say, 'Yes, I want to stay."
"You're there so patients can feel your presence, your voice, your touch."
Joanne Ganton, manager, patient and family-centred care, South Health Campus, Alberta Health Services, Calgary

"What we did here was put it into writing that this is something that we're going to try to do as often as we can."
"There are way more concerns from family members when they are not present, because they don't know what happened."
"When you walk into a room and you see there are 15 or 20 people actively working on your loved one -- they're doing chest compressions, they're potentially shocking the heart, they're giving lots of medications -- and you see that hasn't worked, then I think a lot of families do get that sense of closure."
Dr. Colin Del Castillo, emergency physician, South Health Campus, Calgary
Staff training for emergency situations in the eSIM unit at the South Health Campus in Calgary.
Leah Hennel/Postmedia News/Files    Staff training for emergency situations in the eSIM unit at the South Health Campus in Calgary.

If so, then no longer will fearfully fretting family members be sequestered in sterile hospital waiting rooms, in a suspense of uncertainty and apprehension, wondering whether their loved one will be present when next they awake in the morning to continue sharing days of family life. And then, when the attending physician finally walks through the door connecting to the corridor behind which frantic efforts were being extended in an effort to save the life of the person you are not prepared to mourn, not yet, the verdict can be seen by the expression on his face.

That was the traditional method, that family members of someone who is experiencing some manner of critical health or medical condition melt-down requiring emergency assistance to attempt to prolong life and lift them over the critical stage back into viability would have to wait long, lonely and frustrating hours while whatever procedures are required to establish stability are undertaken, until such time as they can be assured that the climax has passed, the patient will recover.

Now, a more relaxed and humane for some, option has surfaced, pioneered in Canada by Calgary's new South Health Campus of Alberta Health Services which has undertaken the implementation of a policy permitting families to choose whether to be present during resuscitations in the emergency room, the clinics, the patient-care floors, just anywhere those emergencies occur and are responded to, within the hospital.

Along with developing new associated guidelines, the hospital is increasing staff numbers trained to take on the role of "family liaison" at the drop of a hat. This is not a particularly new and different development to what already exists in children's hospitals which permit parents to be present when extraordinary medical steps must be undertaken to salvage the life of a child. According to the Canadian Association of Critical Care Nurses, and other health organizations as well, it is a timely venture to allow family members the opportunity "to face death with a loved one."

And while there may be other hospitals that have adopted a similar approach, the Calgary, Alberta hospital is the first one to formalize the new protocol, to put the steps into a written code, and to teach hospital staff how best to deal with these life-changing situations that impact so traumatically on the patients involved and their families. The very thought of concerned and fearful relatives being present in a hospital chamber where life-saving resuscitation efforts are taking place, however, is a cause of concern to other experts in the health-care field.

Their concern revolves around the very Herculean and very physical and shocking efforts that take place during those resuscitation procedures, graphic and disturbing. Leading, they fear, shocked family members to become hysterical and panic-stricken, interfering with the work of the health professionals doing their utmost to save another family member. Cardiopulmonary resuscitation taking place in an emergency room or intensive care unit is not even remotely pleasant to observe.

Family presence during hospital resuscitation a growing trend in Canada
A file photo of a CPR (cardiopulmonary resuscitation) class in Montreal.
Those resuscitation attempts can realistically become chaotic and hugely stressful, while the odds of survival are slender. Deep, rapid and forceful chest compressions bear little resemblance to the St.John Ambulance instructions on emergency responses in the public arena when training people who may be passers-by to such traumatic events to step in and help save a life. "You will almost invariably break ribs", explained Dr. James Downar, critical care and palliative care doctor at Toronto General Hospital.

The insertion of a central line -- a catheter to deliver medications and fluids -- into a major vein in the neck or the groin can cause bleeding. There may be more blood than that resulting, if the patient is in a state of cardiac arrest resulting from a major injury. While Dr. Downar is supportive of involving family members in patient care, his concern revolves around the psychological trauma to families witnessing the desperate effort of health professionals to save the life of a family member.

The risk of the health-care team being distracted by the distress of family members witnessing the ordeal is another troubling aspect of potential outcome. While, as far as he is concerned, there is a vital need to have family members present in emergency cases when the patient is rushed suddenly to hospital "and you're literally asking the family members questions while you're performing CPR, while you're administering shocks. 

"It's of vital importance to have that family member there so you get the clearest information you can get." Dr. Downar's experience when family members plead with the resuscitation team not to give up their efforts when they have determined further efforts would not succeed and that the patient had died during the process of trying to turn their condition around, also inform his skepticism. "And they ultimately ended up continuing with the resuscitation because they were concerned what the family might do if they didn't."

On the other hand, according to Dr. Christian Vaillancourt, associate professor in the department of emergency medicine, University of Ottawa, papers published on family-witnessed resuscitation are "overwhelmingly in favour of allowing this to happen, except perhaps during particularly invasive trauma care". When, for example, a thoracotomy is undertaken, with its shock effect to the onlooker witnessing the chest cut open, the ribs pried apart to gain access to the heart and lungs.

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