Including families at the end of life can ease the trauma of death
ICUs find creative ways to ease mistrust, anxiety
The wife of a patient was standing in the hallway of the intensive care unit moments after her husband had coded. As clinical staff responded, she agonized: What was happening to him? What were the doctors and nurses doing to him? Would he be OK? She could hear the furor in the room, but she could not see it.One of the nurses noticed the woman and asked her if she would like to watch the resuscitation procedure from the doorway. The nurse offered to stand by her and answer any questions she had.
"The wife told me that she had been through everything else with her husband, why not this?" says Bonnie Jo Lekander RN, MSN, CS, director of nursing practice, research, and innovation at Fairview University Medical Center in Minneapolis.
The woman watched and could see that the medical staff were calm and efficient in their administration of care.
"She was most grateful to be present through the whole process and appreciated the effort of the staff. She also could come to terms with her husband’s death as it was happening," Lekander recalls. "His death wasn’t a shock for her."
Moral principle often can conflict with practice for many caregivers at the bedsides of dying patients, says John Hoyt MD, a critical care physician at St. Francis Medical Center in Pittsburgh.
Hoyt says he knows that allowing family members to be alone with a loved one who is dying is a good idea. His ICU, however, has 18 beds in one open room, spaced five feet apart. "If we allowed open visitation, it would be chaos," he says.
Modest alternatives are his answer to this dilemma. "A patient is moved, when possible, to a corner bed by the doorway with curtains drawn so that chairs may be placed at the bedside for family members to be with the patient during the dying process," he explains.
A question for intensive care managers is not whether to allow family members to be part of the dying process, but "how to make the family’s presence work for everyone involved," Lekander says. "We’ve developed an understanding of what the right thing is for the family, the staff, and the patient. Now we need to focus on how to implement the ethical standard." (For information on use of an end-of-life critical pathway, see story on p. 15.)
Open-door policy requires flexibility
The critical care unit at Fairview Medical Center has had open visitation since the 1980s. There were two opposing opinions about whether such a policy would work, Lekander says. Each participant in the discussion was encouraged to put his or her own family member at the center of the issue and ask, "What would I want if this were my family member?" Anecdotal experiences from both sides of the debate were shared. Facilitators called attention to the positive examples shared by each side that met staff needs as well as patient/family needs. The task of how to set visitation boundaries began to evolve from these examples.Research on visitation issues and other related topics also was shared with the participants to help them learn what claims were supported in the literature and which were more myth than reality. (See story on common myths, p. 14.)
One particular concern for the Fairview staff was that family members
would be intimidated if they heard detailed discussions of pathologies
related to their loved one. As a result of these discussions, the education
part of rounds in which that information is shared now is held at the patient’s
door out of earshot of the family and patient. The rounds continue at the
bedside for evaluation and closure with the family
present.
Each patient’s care plan also includes details on how to prepare each family for the rounds discussion. "The attending physician will often ask the family directly if they have any additional questions when the team is at the bedside," Lekander adds.
Many nurses do not restrict visits by family members, even though hospital ICU policies do, a recent study reported.1 Nurses make their decisions based on the needs of patients and nurses, rather than on the needs or requests of families, the study found.
This kind of independent decision making can be a source of ethical conflict between staff and families, Lekander warns. "Consistent boundaries are needed so that all nursing staff agree and support [the same] policy," she says.
What happens when one nurse on a shift allows unrestricted visitation, and a nurse on the next shift does not?
It took several years for the Fairview staff to agree on a workable, enforceable visitation policy, Lekander says, but the process of values identification and ethical decision making makes the unit "a more cohesive, cooperative place."
Reference
1. Simon SK, Phillips K, Badalamenti S, et al. Current practices regarding visitation policies in critical care units. Am J Crit Care1997; 6:210-217. nYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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