By Peter J Papadakos, MD, FCCM, FCCP, FAARC, FNIV
During the worldwide COVID-19 pandemic, critical care practitioners throughout the United States and the world were instructed by health agencies, government leaders and hospital administration to ban family members from visiting critically ill patients.
The question I ask, along with many of my critical care peers, is - did we do more harm than good to our patients and their families? How did the rush to deal with this pandemic and flatten the curve affect our bedside care? Did what these leaders suggest and mandate create a new standard of care that was followed by us, without weighing the accumulated data, variables and time honored ways we care for and deal with critical illness and recovery? Should we have stepped back and evaluated the risks and benefits of these ideas prior to following them? Should we have held our ground and supported science and humanity versus fear and panic? These, and many other questions need to be addressed.
Since the dawn of medicine, we as practitioners have understood the importance of family in the curative process of healing. Families have always provided support and comfort at the bedside to encourage recovery through all levels of illness. They have helped feed and comfort the sick, and have helped provide aid and a respite for the healers. In many ways, family has participated in the healing process through unyielding support and the projection of hope since the dawn of time. But things were changed with this pandemic. We have all been exposed to the avalanche of stories of people dying alone, with families being pushed into the vortex of depression because they were unable to see the sick and help in their care. Staff has also been affected by losing the ability to interact with families and receive support and feedback from them. The massive increase in burn out and depression in our bedside staff may in part of have been due to the loss of this important interaction with grateful families.
We recognize that as practitioners working in the ICU should base our care and practice on evidence, so I begin by reviewing the data we had available prior to this life changing pandemic. We all work in ICUs, taking care of critically ill patients with complex diseases, many of which have higher mortality indexes than COVID. I first look at what our “work home” looks like, the familiar place where we spend our days. I have practiced in the ICU since the 1980’s and I can state, along with others, we no longer have cold open cold wards. ICU design has greatly moved forward to now having spacious individual rooms with both patient privacy and family interaction as a goal. Critical Care Societies now give out awards for ICUs that provides space for families so they can have comfort as they help with the care of the patients. As I look around my newly built ICU, I see rooms built to provide comfortable couches that convert to beds and ensuite bathrooms. Many times I can remember families spending the night to reorient the head injured patient and prevent them from hurting themselves, and thus providing support to the bedside nurse so she can focus on her other patients. This is not unique to my unit as I have visited similarly designed units around the world. Since 2001, the Joint Commission and many hospital associations around globe have provided guidance on allowing family at the bedside in the ICU and protocols for visitation practices. This is an ever-growing positive trend in improving the ICU experience.
All of our professional societies - be they medical, nursing, or respiratory - educate us on the importance of family visitations and how it impacts healing. Through the Advocacy Committee of our own society many years ago, we developed educational materials in all the major languages to aid families with the ICU experience. We all use variants of these every day in are daily practice. The published evidence in hundreds of papers has shown that flexible visitation decreases anxiety, confusion and agitation, reduces cardiovascular complications, decreases length of stay, aids with vent weaning, makes patient feels more secure, aids in sleep, increases patient satisfaction and increases quality and safety. The data also supports that visitation does not increase infection with proper family education and protocols. Hospitals have developed protocols for visitation for many highly infectious diseases and also protocols to protect immune suppressed patients from family carried infections this has been pioneered by our colleagues in cancer units.
We clearly know from the care of patients how delirium impacts are patients. Over the last decade, we have made great progress in the reduction of delirium and its complications. It is common knowledge how it impacts mortality morbidity of critically ill patients. Worldwide, we now evaluate it through numerical scales on our flow sheets and act on it with carefully designed protocols. Many published studies and our daily observations have clearly shown that family visitation can diminish delirium by over 20%. Family participation has especially been shown to decrease delirium in the elderly who are hospitalized in the ICU. Prior to COVID, family was used commonly as a part of critical delirium reduction practice. Why did we suddenly believe that removing patient’s families from the bedside due to COVID, where the vast majority of patients were elderly was a good idea? Did you all observe the increase in delirium that is now being reported in facilities throughout the US?
I believe we were all affected by the rush to fight the pandemic, and were fixated by the concern to modulate the disease and decrease the spread. We all saw the ongoing tally of the number of cases shared regularly by our leaders and cable media, and issues of number of ventilators and treatment of ARDS were the primary concern. What we did not see is how inpatient care was affected by the removal of humanity on the patient as a whole.
I think we can now reflect back and view these actions as the most important learning experience by modern medicine, and use it as a call to action. We need to study how family isolation affected our patients, families and ourselves. Did we increase mortality, delirium, complications, length of stay and other variables due to the ban? Did it affect decision making such as goals of care? Was it a contributor to staff burnout?
If we rushed into this care model of isolation and did harm, we need to prepare for the future. Our society and other professional organizations must discuss this event and use it to lead in the development of practice guidelines. We must make a point to share them with our governments and hospital leadership. We must put into place more robust protocols and family education to allow for safe and supportive visits that will not affect the spread of infectious disease. Training families in proper hygiene and PPE use, testing visitors and placing them in isolation with patients in the hospital room may be an easy starting point. We need to educate governments, the media, administration and the public at large that what medicine has learned over the centuries in health care should not be suspended in the panic of the moment.
We, as humans, are a social species that needs the support, comfort, and the physical contact of loved ones to give us hope and the will to fight disease and optimize our physical and mental recovery. Google Meetings and Zoom cannot replace this core fact of humanity the interaction and support of loved ones.