(Photo/The Washington Post)

By Deborah L. Shelton
Tues., Feb. 17, 1998; Page Z10

DALLAS—It happens every day in hospital emergency departments nationwide. A critically ill or injured patient is wheeled in one direction, while frightened family members are shuffled off to a separate area to wait.

But this typical scenario may be changing. Some hospital administrators are reconsidering the routine separation of relatives from patients undergoing resuscitation in the emergency room.

The most ambitious project is underway at Parkland Health and Hospital System, a 1,000-bed public hospital here, which is experimenting with allowing relatives into emergency treatment rooms during resuscitation attempts.

Through a research grant, the hospital is assessing the impact of family presence on patients, physicians, nurses and the family members themselves.

If it proves beneficial, Parkland officials plan to develop a policy offering families the option. Such a move by an institution of Parkland's stature could give major impetus to a practice now formally in place in only a handful of hospitals nationwide.

A pioneer in the practice, Foote Hospital in Jackson, Mich. -- a community 80 miles west of Detroit -- has allowed family members, including children, into the emergency department and trauma unit for the past 15 years.

"I think it's a matter of the caregivers having an open mind about it and the public having some knowledge about it," said James A. Freer, emergency department director at Foote, a 500-bed private facility.

"It's going to take time, but eventually you're going to see more of it," said John Maino, the associate medical director of Foote's emergency department.

Informally, the practice is already spreading, said Ellen Taliaferro, associate professor of emergency medicine at the University of Texas Southwestern Medical Center and an emergency physician at Parkland.

"There's probably more family presence going on than anybody really knows about," said Taliaferro, noting that colleagues in other institutions have told her it's happening.

Proponents compare the movement with the revolution in medical practice that took place when fathers were first accepted in hospital delivery rooms in the 1970s. Many of the same arguments used to exclude men -- that they might faint or become ill, for example -- are often used to keep relatives out of emergency departments, these supporters note.

Family presence also parallels the trend of giving patients and families more control over end-of-life care through such efforts as the hospice movement and advance directives that empower patients to determine when their own medical care should be terminated.

"We need to learn to honor the wishes of the patients and the families, and to prepare them for death," said Maino, who also serves as the Jackson County medical examiner.

Emergency room professionals appear to be divided on the issue. The concept was endorsed in 1993 by the Emergency Nurses Association, whose position statement said, "Ultimately the patient and the family members are the individuals who have the most vested interest in the outcome of the procedure and therefore should have the authority to make the decision regarding presence."

The American College of Emergency Physicians has not taken a position on the issue, but president Larry A. Bedard acknowledged "significant apprehension among some physicians" about the ability of relatives to handle the experience.

"As more research is published and more talks are presented, we may see [the practice] become more widespread," said Bedard, director of emergency services at Doctors Medical Center in San Pablo-Pinole, Calif. "If this proves to be beneficial for patients, then I think emergency physicians should, and will, adopt the practice."

Surveys Show Families Like the Option

Parkland's institutional interest in family presence began a few years ago, when two incidents brought the issue home for Theresa Meyers, a registered nurse who is also an emergency services unit manager.

After an 81-year-old man injured in a car crash died during emergency treatment, his wife of 47 years was full of questions: What did he look like? Did he say anything? Did he suffer? Meyers recalled the woman's words as she left the hospital: "If only I could have seen him for one minute to say goodbye."

It was a thought that lingered.

About two weeks later, Meyers was assisting in the care of a 14-year-old boy who had fallen from a tree and lacerated his liver. His parents begged to be allowed in the room, and this time Meyers relented. The couple talked to their son, urging him to live. The father apologized for an argument they had earlier that day.

"They stood there for two or three minutes. It seemed like forever," Meyers said. "The tears were flowing, mine and others'. The mom was real thankful."

The two incidents prompted Parkland staff members to take a critical look at the convention of barring families.

First they conducted a telephone survey of 25 relatives of people who had recently died in the emergency department, and 76 percent said they would have wanted to be with their loved one, and 96 percent said families should have that choice.

Those results jibed with a survey of 47 family members at Foote, published in the Annals of Emergency Medicine in 1987. The study found that 76 percent of family members felt their grieving was made easier by being present during resuscitation attempts, and 64 percent believed their presence was beneficial to the patient. About 94 percent said they would do it again if the situation arose.

Also nearly three-quarters of the Foote staff said they endorsed family presence, although they said it added stress while they worked.

Parkland's project began in January 1997. More than 60 interviews have been conducted with relatives, physicians, nurses and former emergency department patients. All were interviewed soon after the bedside visitation and again six months to a year later.

The study is the first to look at the benefits and risks to all involved, said Cathie E. Guzzetta, a registered nurse who is a consultant directing the project. The interviewing ended in December, and investigators hope to have an initial analysis of the data completed by spring.

An Emotional Experience

Experts note that the presence of family members provides an emotional experience for emergency room professionals, who may for the first time witness a family's grief at the actual moment of a patient's death.

"You're so used to 'the gunshot to the chest' coming in. Or 'the respiratory arrest' or 'the drug overdose,' " said Meyers, who has provided emergency care with family members present and also has served as a family presence facilitator. "When you have a family member come in, you see that it's a person that you can identify with."

Linda Lasater, a medical auditor at Parkland, is an advocate of family presence because she experienced it firsthand. It allowed her to stay at the side of her husband, Jim, while physicians and nurses worked to restart his failed heart last Memorial Day.

"It's something that will be with us for the rest of our lives because it [turned out to be] a good experience for us," she said. "I pray that they will let me be there if it ever happens again. I needed to know I did everything I could for him."

Jim Lasater said that even though he doesn't recall anything about the experience, "it's comforting to know she was there."

But advocates warn that not everyone will share a positive experience, which is why any family presence policy must allow for case-by-case decision-making.

"We realize that [family presence] is not meant for everyone," said Vicki Patrick, a registered nurse who is also working on the Parkland study.

"It's important that we individualize our care and assess the needs of the patients and family."

A Fear of More Lawsuits

That's exactly what happens at Foote Hospital, where the first step calls for a staff member to do a "quick read" to determine if a family member is an appropriate candidate.

"If they say they want to be there, you figure out what's going on as best you can," said physician Freer, who's also director of the section of emergency medicine in the department of surgery at the University of Michigan. "There has to be a comfort level with staff and family members."

Given the urgency and timing factors, not all families arrive in time to be given the option. At Foote, family members are present in about 40 percent of the cases, accounting for about three to five cases a month.

Before family members are taken to the emergency room, a facilitator, usually a nurse or chaplain, explains what they can expect to see, hear and smell, the equipment in use and the appearance of the room. If they still want to be present, the staff is then notified. Facilitators stay with family members at all times.

Relatives are positioned where they can touch some part of the patient's body, perhaps holding the head or a hand.

"We usually can kind of wedge them in close," said Judy Weed, a nurse-clinician.

"Most family members stroke the hair," Maino added. "Many times they will kiss them on the forehead and talk to them or whisper in their ear. That's the personal contact that's needed."

Some physicians have worried family presence can lead to lawsuits, perhaps because relatives might misunderstand the procedures they see. But in 15 years that has not happened at Foote. Maino said he suspects a well-crafted family presence policy might even reduce the likelihood of lawsuits "because they see for themselves what you have done."

In fact, it's not unusual for families to suggest terminating resuscitation efforts when it's clear they're futile.

"I have brought family members in who saw what was going on and said: 'Enough,' " Weed said. "So you not only

have the medical staff saying, 'This is enough.' When you have both of them working together, there is never litigation."

The Emergency Nurses Association agrees. "Family presence during resuscitation efforts allows the patient and the family to support each other and [in the event of death] facilitates the grieving process by bringing a sense of reality to the treatment efforts and the patient's clinical status," the association said in its position statement.

Maino points out that family presence also can help counter the misconceptions about emergency care, often spawned by the media, even the so-called "realistic" medical shows on television.

"TV shows . . . only present the remarkable saves," he said. "They don't educate the public that the majority of those people end up dying."

However, Joseph P. Minei, medical director of trauma services at Parkland, notes that while family presence may be suitable for resuscitation attempts where a patient's heart has stopped, it may be less appropriate in the trauma unit, where action may be more intense. Trauma patients would include people who have been hurt in car accidents or shootings.

"It would be quite a shock for the family member to come in and see their loved one bleeding on the floor and us trying to take care of that patient, which may require doing procedures like inserting tubes and IVs," he said. "The shock to the family member could possibly impact on our ability to take care of the patient."

"Some of these issues may be insurmountable for trauma," he said. "But I think there's some merit to the idea, and it should be looked at."

Foote Hospital's Freer tends to agree, although his hospital's policy doesn't exclude family presence in cases of trauma.

"Most of us feel less comfortable with [family] being present just because [trauma care can look] pretty barbaric," he acknowledged.

Physicians, however, need to evaluate all aspects of the care they provide, and in all possible scenarios, Maino said.

"We have to be able to assess what we're doing, for what purposes and what the benefits are that are going to come out of it.

"Medicine is changing in its dynamics, so a lot of things we have done in the past, or even that we do today, are going to completely change in the future. What we have to do is look, not only at the science and medicine that we're providing, but how it affects people."

Reprinted with permission from the American Medical News, November 17, 1997. Copyright 1997, American Medical Association.