Not long ago, when my father was about to undergo a heart procedure, I hinted to the cardiologist, a colleague, that I wanted to be there, too, not just to offer comfort but also to be present for the play-by-play that would lead to a critical decision: whether to open his blocked arteries with a stent or to perform bypass surgery. Draped in an X-ray-shielding body suit over his blue scrubs, the doctor hesitated.
I understand why.
I’ve stood in his shoes and listened to family members say they want to be present 24/7 with their loved ones, often in the most challenging of hospital environments, such as the intensive care unit.
And initially — like many of my colleagues — I was hesitant.
An ICU room is filled with lifesaving equipment — ventilators hissing, monitors beeping, red and green lights flashing — around which doctors and nurses carefully maneuver. If families are there, the nurses must keep a watchful eye to make sure that no equipment is moved. “Nurses like to be in control of their work environment,” an ICU nurse manager told me.
Moreover, in the ICU, a family member could become distressed to see their loved ones bucking the ventilator or bleeding from a fresh wound.
However reluctant we doctors may feel, “patient-centered care,” in which patients and families are involved in shared decision-making, lies in our future. It is one the six goals of the Institute of Medicine in redesigning the American health-care system, along with safety, effectiveness, efficiency, equity and timeliness. And under a new payment scheme, launching in 2013, hospital payments will be based in part on surveys that ask patients and families how well the doctors and nurses communicated and if they were responsive to patient needs.
A more open approach
Over the past year, the ICU at my hospital has been field-testing a more open approach. We are not the first to do so. Geisinger Medical Center in Danville, Pa., went to an open ICU policy nearly a decade ago, found it extremely disruptive and soon reverted to only 30 minutes of visiting six times a day. On a second attempt, however, Geisinger developed an extensive communication program for both families and staff, and open ICU visitation has been successful since 2003. A 1997 study found that open ICU visitation practices had a beneficial effect on 67 percent of patients and 88 percent of families.
I am surprised by how well the open policy at our hospital has worked over the past six months. I have become comfortable seeing family members stretched on recliners in the ICU during my early-morning visits. They update me on how the night went for the patient. One ICU specialist said, “I don’t have to chase down families to update them on what is happening.”
Some ICUs are also inviting families to participate when a team of a dozen professionals, including doctors, nurses, pharmacists and social workers, decide on the plan for the patient.
“I’m not sure that is such a good idea,” one cardiologist told me. It was 8:30 in the evening, and he still had not finished seeing his patients.
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