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They are the words I half expect whenever the red phone rings between 6 and 7am, words which strike both fear and dread into the heart of even the most hardy PEM doctor. It is a nightmare scenario no doctor wants to face. But once the patient arrives, we know what to do – there are algorithms which we can follow like automatons – and there is never a shortage of pairs of hands; paediatric arrest calls, in particular, are usually extremely well staffed.
The resuscitation of a critically ill child in the Emergency Department is a high pressure situation. Parents tend to be present for all paediatric-related attendances to the Emergency Department, from manipulation of fracture to full cardiorespiratory arrest. The presence of a parent can provide reassurance to an anxious child and a valuable ally in clinical examination to the struggling doctor; we tend to assume that neither of these roles is necessary in adult patients. This does not always work to our advantage; I have a very clear recollection of a father fainting during reduction of an ankle fracture/dislocation (and the absence of a spare pair of hands to help him out while the three of us present were engaged in sedation (plus counter-traction), manipulation and plastering). But why do we keep parents present during cardiac arrest: is it the right thing to do?
It seems strange to think that as recently as 1996, attention had to be drawn by the Resuscitation Council to the disparity between relatives’ wishes to be present for CPR and clinicians’ unease at the suggestion. At this time, relatives’ presence at cardiorespiratory arrest was by no means the accepted norm. A review of the literature in 1998 echoed this, describing papers which felt that relatives should definitely be present if the patient was a child, and others where staff were against parental involvement. It seems likely that as we shift in clinical culture away from a paternalistic approach to medicine we also hand the responsibility for such decisions to the relatives and parents of our patients.
I wonder whether it is the challenge of staying our own emotions which makes us uncomfortable with the presence of the parents, as if any outward expression of the potential devastation when a child dies will render us unable to maintain the clinical façade we so often and so readily hide behind.
The outcomes of paediatric arrest are poorer than many staff believe, but it is thankfully an infrequent occurrence, so data on all aspects of paediatric arrest is difficult to obtain. Paediatric arrests often run for longer than adult ones and a recent study appraised here seems to suggest that some children may have a good neurological outcome even after prolonged CPR.
A survey in 1999 asked 400 parents whether they would want to be present if their child needed to undergo invasive procedures of varying seriousness and found 83.4% would want to be present at resuscitation if it was likely that their child would die, compared with 71.4% who would want to be present “if their child was unconscious during resuscitation”. It is hard to imagine a situation of resuscitation in an unconscious child where death was not a significant possibility; these findings then emphasise the importance of also communicating expectations to parents in a resuscitation situation.
A small scale study in 2008 provides some useful insight into parental perspectives; 8 interviews were conducted with 14 parents some time after the resuscitation to ascertain their feelings and thoughts. The predominant perceptions were that being present meant being there for the child, and that this took precedence over the parents’ own anxieties or concerns. There was also a feeling that witnessing events helped to “make sense of a living nightmare”, and there were connotations of guilt in the statements of parents who had been absent for one reason or another. Those healthcare professionals who feel that clinical management has prevented them from providing parents with support might be reassured; recollection of the resuscitation itself was difficult and “a bit of a blur”.
So it looks as though most parents would want to be present, especially if there is a chance the child would die. What about the staff then?
A study of staff perceptions of parental presence at cardiac arrests in a Paediatric Intensive Care Unit found that only 61% of staff who had experience of parents being present would enable parental presence in future. A survey of 158 critical care nurses found that 73.5% thought parents being present was a positive experience, although 63.4% felt that doctors did not want parents present.
I wonder whether this perception extends to the ED; now, in 2013 it seems unthinkable that we would not offer – and even encourage – parents to be present. Standard practice in EDs I have worked in is to allocate a separate member of (usually nursing) staff to the role of parental liaison, explaining procedures, treatments and actions which are being undertaken and providing a point of contact throughout the ED episode. Obviously it is essential that at some point the parents discuss the situation with a doctor or senior healthcare professional, especially when resuscitation is unlikely to be successful and the team is moving towards discontinuing CPR. One of the most challenging aspects of a paediatric arrest situation is maintaining leadership of the situation with an often overwhelming number of staff in attendance; the allocation of a doctor as well as a nurse to the important role of liaising with parents may be a valuable use of some of these personnel.
Finally, it is useful to hold an informal debrief after such cases although the practicalities of the Emergency Department do not often allow this to occur immediately. Paediatric arrests can be emotionally difficult for all concerned (read this blog post for a chilling account of a paediatric arrest written by a doctor/parent) and even if I personally feel that the care provided was as good as it could be, I know this does not necessarily represent the perceptions of all present parties. A difficult experience of interacting with the family of the child may occur independently of the outcomes of resuscitation and have a lasting effect on staff.
Regardless of the department workload, a brief discussion of the case at a time relatively soon after events can both address human factors and also identify valuable learning opportunities, improving future team performance and hopefully outcomes – see articles here (2008), here (2011) and here (2011).
What are your experiences of parental presence at paediatric arrest – positive, negative, useful or uncomfortable?
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A though provoking post, Natalie.
I’ve stood on both sides of the curtain. My first daughter, Elizabeth, was born by emergency caesar due to APH and unfortunately did not survive. My wife was out for the count as she had been given a true rapid sequence GA and I was made to wait out in recovery whilst I heard the overhead tannoy for a ‘Neonatal Code Blue’. I knew what was going on but I think being in the room would have made me understand it and process the sudden, life-changing experience.
My own experience made me push to have the parents of a little girl in her (eventually futile) resuscitation last month. With a caring social worker as support person the parents were able to come in and out as we intubated and carried out CPR. Did it help? I’m not sure but at least they can look back and not wonder if we did not do everything.
I am revisiting this post after some time.
I have been asked to think about whether I think parents should be present at arrests during education sessions and on the APLS course. I have read the evidence and listened to compelling speeches which actively promote parental presence at arrests. I nodded and agreed, well I am sure that is what I should be saying…. In reality, I really wasn’t sure. I am pretty junior. Even the thought of putting a cannula in or fishing a jelly bean out of a child’s nose in front of parents makes me anxious. Admittedly, this is getting easier! Arrests, even in an adult, are stressful. How could I possibly keep my my head and ‘perform’ in front of a parent. What if it goes horribly wrong?
And then I tried to put myself in a parent’s shoes. I don’t have children, so this is difficult. So how would I feel if it was a relative. I don’t think I would want to be present. But then it is all very hypothetical isn’t it? Based more on logic than emotion.
Very recently, I was involved in my first ever ‘real life’ paediatric arrest. A previously completely well child had an out of hospital arrest. It was completely unexpected by the parents. Actually, it is unexpected by medics and especially in a non-paeds specialist unit. Well kids don’t arrest do they? We had a pre-alert and had the chance to assemble the full paediatric ‘arrest team’ in preparation. As Natalie suggests we were very well staffed. A true multi-disciplinary group made up of medics who work wholly in the ED and some who very rarely do. They were all well aware of the resus algorithms and comfortable in their roles.
After a short time the team leader, an ED Consultant, felt it was appropriate to speak to the relatives. They aced the team as a group if they would be happy for the relatives to come into resus if they wished too. There were no objections. Dad wanted to be present. Mum did not and was supported by our allocated nurse. I thought it would be really nerve wracking and the parent would be scrutinising our practice. In reality, they seemed oblivious to what was going on around them. Instead they held the child’s hand and focused on their face. Perhaps this is the ‘blur’ described above. Dad left after a few minutes but returned after it was decided that continued resuscitation was futile. He was present at the time we stopped. This felt completely right.
My view now? Well I don’t think that we should compel a parent to be present at the arrest, but they should be given the choice. Our practice is exactly the same whether they are there or not. In this case, by stander CPR had been started pre-hospital in front of the parents and so it would seem odd to suddenly say it is not appropriate for them to be present.