N V T S: Parental presence during routine intraoperative care
Myron Yaster MD, Lynne Maxwell MD, and Justin L. Lockman MD MSEd
When my sons were young, we watched Mel Brooks’ hilarious movie History of the World, Part 1 together and laughed hysterically. As many of you know the Latin alphabet does not have the letter U and uses the letter V in its place. Based on the scene below whenever we were out in public and saw something that was absolutely NUTS we would look at each other and confidentially say N V T S. Today’s PAAD by Quiñónez et al is another article from a series of articles in the October issue of Anesthesia and Analgesia based on transparency and the CURES act. I asked Justin Lockman, the PAAD’s critical care writer to review this with me and Lynne Maxwell, the PAAD’s voice of reason, because, well, I thought the article and its implications were N V T S. Send me your thoughts and I’ll post them in a future Reader’s response. Myron Yaster MD
Original article
Quiñónez ZA, Pyke-Grimm KA, Char D. Could, Should Families Watch Their Loved One's Surgeries and, If So, When? Anesth Analg. 2022 Oct 1;135(4):704-707. PMID: 36108184
Parental presence at the induction of pediatric anesthesia is common. Quiñónez et al. ask: “Could, should families be allowed to be in the OR for the entire surgery and if so when?” [1] After all, parents (and other loved ones) are already allowed to witness and be present for procedures in the ED, in diagnostic imaging studies, during the induction of anesthesia in the OR, and even during resuscitations and invasive procedures in the intensive care units. [2]
What is driving this question and movement? “Medicine continues to shift from a model of paternalism, in which the doctor decides what is in the patient’s best interests, to patient- and family-centered care (PFCC), in which decisions that support a patient and family’s needs, goals, and values are made in partnership. With this shift, there has been growing focus on efforts to restore decision making to families and on efforts to increase transparency in care decisions to better support family autonomy. PFCC encourages patients and family members to be active contributors to planning, delivering, and evaluating health care through collaboration with health care providers.”[1] We believe that the extension of this movement to environments where children are undergoing surgery or other invasive procedures under anesthesia compromises our professionalism and limits our roles as physicians (note: we are DOCTORS, not health care providers!). This movement to PFCC and its extension to the OR downplays our education, training, experience and expertise. Of what possible benefit is parental presence to an unconscious, anesthetized patient?
Indeed, when my (LM) own 12-year-old son needed an appendectomy, while I was present for the anesthesia induction (and started his IV because the anesthesiologist missed), I left the OR as soon as he lost consciousness, prior to intubation. I had no desire to watch the surgeon operate on my son. (In fact, I let the surgeon decide whether to do the surgery open or laparoscopically (it was at the dawn of laparoscopic surgery). I knew it would do neither my son nor me any good for me to be present.
What are the considerations for familial presence in the OR or any other environment?
· Does it benefit the patient’s psychological state? It’s hard to imagine how it could for an unconscious patient.
· Does it benefit the family by increasing understanding, contextualizing care, or helping process emotions around care? Perhaps, but there is ample reason to believe there may be psychological harm to parents caused by witnessing surgery on their children. We have all witnessed parents crying and even fainting upon witnessing induction of their children.
· Does it help the physicians leading care to provide more informed decisions about care? We would argue that it does NOT. Unlike in the ICU or ED setting, where parental input can help with understanding goals of care, and inform decisions about limitations of resuscitation, the OR environment does not present these opportunities – except in VERY rare, emergent situations like intraoperative arrest in which I (JLL) do support bringing families into the OR.
· Are there harms to the patient, family, or clinicians from FP? As noted above, parents may suffer from FP. We argue that patients will also suffer because of decreased sterility, decreased free communication among team members, and the possibility of distraction from care if a parent becomes a patient (e.g., through syncope). And some clinicians will likely view this as a major intrusion on their own wellness and autonomy to do what is best for their patients. In the case of ICU and ED resuscitation, this potential intrusion is considered worthwhile because of the long term benefits to the family of witnessing “everything being done” for their child as they work through the grieving process [2, 7]. But are the risks worth it without any clear benefits?
· How do we provide FP across diverse patient populations (in every sense of the diverse)? For example, how many parents would be allowed into the room? Is a child with divorced and remarried parents entitled to have 4 family observers during the surgery? Are there cultural differences in explanations of what families are witnessing? How will we prepare team members for the range of emotional expression we should anticipate seeing in the OR? Will we need interpreters in the OR for non-English speaking families?
· Would the expectation be to provide total transparency, independent of clinical benefit, so long as there are not clinical harms? Does the surgeon need to explain each step of the surgery to the family at the expense of great distraction from patient care?
We can’t answer all of these questions, but you will need to because this train is on the tracks and may be coming to your practice in the very near future if it hasn’t already!
There are some situations when familial presence makes sense. We have already mentioned PICU and ED resuscitations. It is also already established practice during labor and delivery and C-sections. How about parental presence at the induction of anesthesia? Although it is common, data does not support its superiority over oral midazolam. Indeed, as Zeev Kain and colleagues – and Cochrane reviews – have shown, oral midazolam is better at reducing stormy inductions and limiting regressive postoperative behaviors like nightmares and bedwetting than parental presence.[3-6]
With little to no evidence to support parental presence during surgery, there are, as Quiñónez et al point out, potential downsides. As we have already alluded to, clinicians may (likely will) find parental presence distracting, redirecting attention to the parents instead of the patient, and increase stress and anxiety for the anesthesia and surgical teams. Will family presence increase medico-legal risk/liability (or will it decrease it)? Many parents at anesthesia induction are fixated on looking at the monitors rather than focusing on supporting their child. Are there parents out there who really want us to worry about their thoughts/fears/questions/reactions instead of focusing on rescuing their child during surgical hemorrhage or anesthetic emergencies?
In essence, we believe that this idea is N V T S. What do you think?
References
1. Quiñónez, Z.A., K.A. Pyke-Grimm, and D. Char, Could, Should Families Watch Their Loved One's Surgeries and, If So, When? Anesth Analg, 2022. 135(4): p. 704-707.
2. Deacon, A., T.A. O'Neill, and E. Gilfoyle, A Scoping Review of the Impact of Family Presence on Pediatric Resuscitation Team Members. Pediatr Crit Care Med, 2020. 21(12): p. e1140-e1147.
3. Kain, Z.N., et al., Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg, 2004. 99(6): p. 1648-1654.
4. Kain, Z.N., et al., Parental presence during induction of anesthesia: physiological effects on parents. Anesthesiology, 2003. 98(1): p. 58-64.
5. Kain, Z.N., et al., Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology, 2000. 92(4): p. 939-46.
6. Manyande, A., et al., Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev, 2015. 2015(7): p. Cd006447.
7. Fallat, M.E., et al., Perceptions by Families of Emergency Medical Service Interventions During Imminent Pediatric Out-of-Hospital Death. Prehosp Emerg Care, 2019. 23(2): p. 241-248.
PS from Myron: There was no way that I could bring up Mel Brooks’ hilarious movie History of the World without also adding this scene with the incredible Bea Arthur