A52-year-old man was brought to the emergency department after a motorcycle crash. On arrival, his abdomen was firm and distended. Abdominal and pelvic computed tomography scans showed free fluid throughout his belly. The trauma surgeon explained the patient’s condition and treatment recommendations to the patient’s wife and 7-year-old daughter before taking him to the operating room for emergent laparotomy. During surgery, the patient was hypotensive and hypoxic. Postoperatively, the patient was admitted to the surgical intensive care unit. Multiple blood products and fluid boluses were given for resuscitation. His family remained at his bedside throughout the postoperative period, although nurses were dismayed by the child’s presence. The patient’s wife, however, insisted her young daughter stay in the room. When the patient became increasingly hypoxic and difficult to ventilate, the attending surgeon was called to the bedside. Abdominal compartment syndrome was diagnosed, requiring emergent bedside laparotomy. The patient’s wife wished to remain in the room for the procedure and was adamant the little girl stay as well. Despite nurses’ offers to have someone sit with the child in the waiting room, the mother refused to allow her daughter out of sight. During the laparotomy, the visitors were directed to a corner of the room away from the sterile field. A nurse remained with the family to explain what was happening, yet large amounts of blood flowed from the initial incision and the odor in the room was quite unpleasant. The patient’s wife was gasping; his daughter stared quietly and hugged her doll. A chaplain approached the woman, but she did not want to talk. He asked if he could take the child to the waiting room just 2 doors down the hall; the woman refused. As the procedure continued, visibly edematous intestines popped through the incision. The surgeon explored the abdomen and identified a large tear deep in the colon. While the bowel was being sutured, the patient had runs of ventricular tachycardia. Despite administration of blood products and vasopressors, his blood pressure began to plummet. At this point, the nursing supervisor arrived, introduced herself to the patient’s wife, and asked whether she could take the child to the cafeteria. Again, the woman refused. The little girl looked worried and cried at times but did not ask to leave. The nursing supervisor remained with the child as the patient became bradycardiac and then asystolic. CPR was performed for 35 minutes and finally stopped at the wife’s request. The woman then wanted to be present during postmortem care. Again, a nurse attempted to remove the little girl from the room, but her mother demanded the child remain. The patient’s wife stood at the foot of the bed as nurses performed postmortem care; her daughter sat quietly on the windowsill playing with a doll. This case was quite upsetting to staff members. Although they fully support the philosophy of family-centered care, the nurses felt it was inappropriate for a young child to remain in the room to witness the horrific demise of her father. In most cases staff members try to honor family wishes, being careful not to project their values onto the situation. Yet, as this case unfolded, staff members became progressively more uncomfortable and worried about the psychological stress the scene presented to a child. We want to assume that parents will act in the best interests of their children, but was this mother too distressed to make good decisions? The literature is rich with discussions of the benefits of family presence and many nursing organizations, including the ENA, have guidelines supporting family presence during CPR and invasive procedures. However, this case represents a substantively different scenario from those provided in the literature because it involved an extraordinarily graphic procedure, performed emergently, in the presence of a young child. How should this situation have been managed? Was it handled appropriately? Should staff members have insisted the child be removed? Does having a familyfriendly hospital philosophy entitle any family member to dictate the terms of family presence? Hopefully, this case Barbara B. Ott is Associate Professor, College of Nursing, Villanova University, Villanova, PA.
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Jan 1, 2014
Debra Rodgers + 2
Open Access