Separation of Patient and Family

I grew up understanding the concept of separation of church and state, and as I grew up in the  medical profession I soon learned about the concept of separation of patient and family. As a  young nurse in the Emergency Department I was shocked when a full arrest came through the  ambulance doors and the wife of 60 years was rushed into a corner of the waiting room while she  

waited for someone to update her on his condition. I worked with one physician who had  absolutely no interest in talking to the family so when he was working I became the bearer of bad  news. I always felt it was so sterile and inappropriate to have the one person who cared the most  about the just another “full arrest” on the gurney in the other room, sitting in a corner, often  times, all alone. 

The general wisdom at that time was to give periodic updates where you “primed the pump” so  to speak. We learned to use phrases that were practically memorized, “We are doing everything  we can for them right now, they have the very best care and resources working on them, he  hasn’t responded to our treatments so far, but we are continuing to try, we are hoping the next  round of medications will stimulate his heart etc.” You will notice the complete and absolute  absence of the word “dead” but more importantly no mention of “what would they have wanted  in this situation, or have you talked about resuscitation efforts with your loved one?”  Sometimes, even after we had stopped resuscitative efforts, we would go out to the waiting room  and offer further information indicating we were still working on them. This was all designed to  give them time to accept what was often the inevitable. The folly in this is the actual belief that  waiting another 10 minutes to tell them their loved one is dead would ease them into this  shocking news. There we go again, thinking as medical professionals we could affect and or  control human emotions to the most devastating news they would ever receive. Eventually we  would inform them that our efforts were unsuccessful (without mentioning what those efforts  were) and inform them their loved one had _______fill in the blank with whatever word makes  you feel better. Again, we felt we could soften the blow by using more acceptable terms  including “passed away, failed to respond.” As I write this I am astounded at how inappropriate,  archaic and delusional our thought processes were. We may have tried to find a quiet place to  talk to the family but often we were forced to go through this whole dance in the corner of the  emergency room waiting room. 

What happened next was very team specific – should we let them in the room to see the body?  The prevailing thought was that it would probably be best to wait to see them in the more  controlled setting of the mortuary, especially if they were a coroner’s case and we were required  to leave all the medical devices in place, the IVs, the arterial lines, the endotracheal tubes etc.  This practice was severely challenged one night as a young adult male was brought in by  paramedics to the ER. He was sitting behind the driver of a motorcycle when a sudden stop sent  him flying onto the car in front of them and his neck was sliced open down to his sternum from  the sharp edged rain gutter that used to adorn cars. His eyes were open, his mouth was open  while his tongue had been cut in half by his teeth. It was shocking for all of us to see. 

A few hours later, a woman arrived indicating she had heard that her son may have possibly been  brought in from a motorcycle accident. We finally established that the John Doe in the back  room was in fact her son. I showed her his identification we had found in his wallet and she was  stoic. I explained there was significant trauma involved and that it would be best to see him at  the mortuary. She left. She returned. She left, and she returned three more times, always with 

essentially the same dialogue. Finally, she implored that she needed to see him, because “I just  can’t believe it’s really him and that he’s really dead.” Silence. I asked for a few moments and  did my best to cover up the gaping holes in his neck and chest. I had unsuccessfully tried to  close his eyes earlier. I prepared her for what she was about to see, and took her back to be with  her son. She wept, instinctively my arm was around her. She whispered “it really is him. Thank  you.” She survived, and had taught me, a young nurse, a most valuable lesson. I really didn’t  know what was best for her.  

Gratefully institutions began exploring the presence of family members during resuscitation and  procedures, especially in the pediatric population that eventually spread to adult patients. The  literature is replete with favorable and studied rationale behind this practice, despite some  practitioners still swimming against the tide. With this newly acquired enlightenment many  practices started going by the wayside including strict limited visiting hours, age restrictions on  visitors, allowing more than 2 people in the room at the same time and forbidding anything that  resembled or tasted like home into the hospital.  

I arrived at a small community hospital in Orange County, California to transport a 64 year-old  male patient with a dissecting thoracic aortic aneurysm. The helicopter flight was only 12  minutes, but the preparation and loading process would take significantly longer. His blood  pressure was dropping quickly as the dissection extended. Pharmacological interventions to  reduce the pressure and drop the heart rate had proven ineffective. As is often the case, the staff  had scattered, grateful for our arrival and the reprieve from caring for a patient typically out of  their comfort zone. His construction worker son was seated next to him, fresh from a muddy job  as evidenced by the mud on the floor and his boots. He appeared to have no idea how sick his  dad was. It soon became clear that he would not survive the flight. By now he was profoundly  bradycardic and hypotensive enough to require a Doppler to get the pressure. He was drifting in  and out of consciousness and his distal pulses were absent. I pulled up a stool and talked to them  both about the seriousness of his condition and the options we had before us. We could load him  and fly him to the receiving University hospital with the high probability that he would go into  full arrest and require resuscitation and likely not survive to get to the operating room. Or, we  could sit with him, and allow his son to be with him and allow him to die in as peaceful a way as  possible. His son quickly chose the latter.  

I remained with them, and encouraged the son to lean down, touch his dad and tell him those things he wanted to say. I was honored to witness a most poignant and tender scene as this burly  construction worker wept as he apologized for his teen age antics, for his absence during his  rebellious years and professed his absolute love and admiration for his dad who had provided a  safe and loving life for him. As his heart neared asystole, I asked if he wanted us to start  resuscitation efforts that would include medications and CPR. He looked up and shook his head  in the affirmative. His son kept talking into his dad’s ear, apparently there were more sentiments  he needed to express. After five minutes, I asked again and this time, he simply said “No, I am  ready to let him go now.” I was moved and as we hugged, tears flowed. I was humbled by what  had just transpired and grateful that we had moved far from the days of separation of family and  patient. 

Patients’ families relive the worst day of their life over and over. They replay our actions, our  attitudes, our facial expressions, their feelings and their feelings about us, as caregivers. They  talk about “that day” at family get togethers, and at holidays. It’s vital to continually assess  whether we are merely health care providers, or we are caregivers. For me, I want caregivers on  my family members’ team. I want caregivers who follow the theory of relativity, where they  treat patients like they are their relative, for they are indeed someone’s mother, wife, sister,  daughter… I wouldn’t want my mom to die in the presence of only strangers, or to have all  decision making left in the hands of those strangers, or to not have her pain addressed at  consistent intervals, or fail to recognize that she is and was a vital and vibrant woman who  contributed much to the world. True caregivers will do all of that and more.

Janie works as a flight nurse for the University of Utah’s AirMed program currently, and as a Hospitalist Nurse Practitioner at Tosh caring for orthopedic patients and does expert witnessing in the arena of air medical transport. She has spent 36 years as a flight nurse both in Southern California and Utah. She has a Tennessee Walker horse who does equine therapy with traumatized youth and loves him as much as her husband (Don’t worry he knows!) She has four children and 10 grandchildren whom she also adores. She loves the outdoors, American history, classic rock, anything pink, her hair-do from the 80s and most sports. She developed an interest in compassionate care-giving early in her career as she witnessed practices that literally broke her heart. She is a frequent contributor to the AirMedical Journal as she works to engender the idea that compassion is an incredible strength that will not only help keep you out of a court room, but truly change lives. Some of her greatest influences are her dad, Abraham Lincoln and the late Fred Lee, author of “If Disney Ran Your Hospital: 9 ½ things you would do differently.”

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2020 Prose, "Separation of patient and family"