A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.