Revisiting Traumatic Choices

The New Yorker has an article by Dr. Jerome Groopman on allowing families to view resuscitations. It's not offered online, though some of it is excerpted in the press release:
Groopman notes that while laypeople are now routinely involved in decisions at the National Institutes of Health and on hospital review boards, "family presence in emergency rooms, which is part of this larger trend, remains controversial. Not only does it represent an incursion by the public into medicine’s inner sanctum; more than any other recent development, it reveals the extent to which the power to decide how medicine is practiced is no longer an exclusive prerogative of doctors."

Reverend Hank Post, a former chaplain at Foote Hospital, in Jackson, Michigan, tells Groopman that he regarded his effort to open the hospital emergency room to families as a campaign for "human rights." Beginning in 1982, he encouraged doctors to allow him to stand with family members at the patient’s bedside during resuscitation attempts, and Foote became one of the first American hospitals to approve the practice. "It moved grieving along," Post says. "The families saw quickly how hopeless things were, and, by being present, the family can own part of what went on." Patricia Howard, an emergency-room nurse from Kentucky, persuaded the Emergency Nurses Association to formally endorse "family presence."

"We’ve always taken excellent clinical care, but not always excellent psychosocial care," Howard says. Groopman writes, "Like many proponents of family presence, she argues that today Americans are better prepared for the gore of resuscitations than they were ten years ago, because they’ve seen realistic imitations of such procedures on television." But those dramas, such as "ER" and "Rescue 911," Groopman reports, have highly idealized the success of resuscitations, with large majorities of patients returning to their normal lives. In reality, Groopman explains, "just fifteen per cent, at most, are successful." And, he adds, "patients who survive resuscitations often have brain damage or debilitating neurological conditions."

One group whose members have actively opposed family presence is the American Association for the Surgery of Trauma. In a 1999 study co-authored by R. Stephen Smith, a trauma surgeon in Wichita, the A.A.S.T. compared the demanding tasks involved in resuscitation to those in an airline cockpit. Groopman explains: "Like pilots, they wrote, emergency-room teams must assimilate large quantities of data in a short time and make quick decisions; potential distractions, such as the presence of a family member, could jeopardize the success of a resuscitation." Groopman writes, "Smith believes that hospitals should retain the right to invite a patient’s relative into the E.R. on a case-by-case basis. At the same time, he said, laypeople need to realize that they may not understand much of what they see there." Smith says, "It’s like me taking a tour of a nuclear power plant." Groopman concludes, "Keeping families out of the emergency room, however, ultimately may be impossible." "We are entering an era of openness in every field," Alasdair Conn, the chief of emergency services at Massachusetts General Hospital, says. "You want to know whether your stockbroker is a good broker. You want to get a second opinion on a legal decision. It’s happening in medicine, too. In many medical situations, there is no one right way to do things. There is this questioning, a search for alternative answers.... If my daughter or my wife or any of my relatives were in pain and in the emergency department, I would want to be there with them."

Groopman writes that trauma surgeons generally view families as a hindrance during resuscitation, echoing Bard-Parker's observations from his conference. It's interesting that one trauma surgeon, R. Stephen Smith, invokes the pilot analogy -- a favorite ploy of NHS Blog Doctor. I can just imagine it: "Ladies and gentleman, we're experiencing some turbulence. Who wants to cram into the cockpit and watch us navigate?"

But of course it's not the same (and in fact, passengers used to be able to listen to the "cockpit channel" with their headphones -- airlines are bucking the trend of openness that's permeating medicine and business).

When Cut-to-Cure and I blogged about letting families watch resuscitations two years ago, I wondered about the literature. Groopman's got the answer -- mostly just one oft-cited English study, involving 25 relatives of patients undergoing resuscation attempts. That's it! But surveys of the eight relatives who saw a loved one die, none said the experience was traumatic and all reported they were pleased with their decision to observe.

Groopman also talks a little about the history of emergency medicine, citing a new book by University Michigan EM attending Brian Zink. It's going on the wish list, along with the hope that my family is spared from viewing any resuscitation attempts, any time soon.