SCCM Resource Library-Open Visitation in the ICU for All: Families, Friends, and Pets (Flipped Classroom)

Video Transcription

Good morning everyone, my name is Dr. John Whitcomb, I am the moderator for this session titled Open Visitation in the ICU for All, Families, Friends, and Pets.  This is a flipped classroom setting and we will be live and we will save time at the end for questions. There is also the chat feature that you can type in your questions as well.  We have three presenters this morning. We have our first one, Dr. McAdam, who will present on open visitation, moving from acceptance to facilitation.  Our second presenter is Dr. Wayne, allowing pet visitation in the ICU, why not? And the third presenter is Dr. Hayden and her topic is when family is not legally family.  So we'll get started here and I'll have our first speaker, Dr. McAdam, kick us off.  All right. Good morning. My name is Jennifer McAdam, and I'm a professor in the College of Nursing at Samuel Merritt University in Oakland, California.  And it's my pleasure to be here today to present on the topic, Open Visitation, Moving from Acceptance to Facilitation. I have no disclosures to report in this presentation.  So the three objectives I'd like to cover is recognizing how broad definitions of family can lead to more open visitation policies.  Then I'll discuss some ideas on how to better facilitate open visitation in the ICU. And finally, I will share some ideas for open visitation  that were used at different types of institutions. So let's start off thinking about ICU families. Some of us feel very okay with families.  Some of us may cringe and say, oh, not that family again. Some families are helpful, some are disruptive, some take a lot of energy.  But regardless, patients and their families come as a package. So we have to figure out their experience and how to incorporate them into the care.  As Jane Howard states, call it a clan, call it a network, call it a family, whatever you call it, whoever you are, you need one.  So how can a broad definition of family lead to more open visitation policies? Well, in 2014, the research project Humanization of Intensive Care Movement was developed  to focus more on the soft skills in the ICU versus the technological skills. These soft skills like kindness, concern, dignity,  or as the authors put it, humanizing the ICU are much needed. So they created this model here with eight areas that can help achieve this humanization.  I'd like to point out to number one, which is open ICU visitation policies. What we find, though, still is that most ICUs have restrictive visiting policies  that are based on custom or tradition. They don't, they lack critical reflection of the practice, and they're not evidence-based.  By redefining the definition of family can be the first step in developing a more open policy.  With this, we can allow the patient to define their family, and this allows us to get rid of that strict blood relation or marriage aspect of the family definition.  And also, we can start thinking of families as partners in care versus visitors, which will restore the role of family as a caregiver if they wish,  and it will also promote contact between the patients, their families, and the healthcare team. So what would a broad visitation definition look like?  Well, I like this one from the American Association of Critical Care Nurses. I think it works well. They say that open visitation is unrestricted access  to a hospitalized patient by a chosen support person, and this person's integral to the provision of emotional and social support 24 hours a day.  They also go on to say that that support person, if they infringe on the rights or safeties of others, or if they are medically or therapeutically contraindicated  for that patient, then it could be restricted. But I do want to point out, if we do restrict, to please make sure we're not discriminating against anybody or allowing explicit  or implicit biases as our rationale to restrict. So we redefined family. We discussed a broad or open definition of family visitation.  So now how can we facilitate open visitation in the ICU?  Well, when I, the first step is trying to think about what is stopping it in the first place. So after doing research on this topic, it seems to me the biggest barrier is us,  the ICU staff, our attitudes, culture, etc. We still remain skeptical about the benefits of open visitation, even though there's evidence to contradict this.  A recent systematic review found that benefits include reduction in delirium and anxiety for patients, as well as increased satisfaction with care and families.  And that's just to name a few.  Obviously, too, we don't want to lose control. We like to have control of our ICU room. We feel it increases our workload. We do, we are concerned about interruptions to care.  Many of us feel we lack the skills to work with families, especially, you know, these demanding, maybe unrealistic families. We feel sometimes they're time-consuming.  And also, there could be security issues, depending on where your hospital is located. And there have been reports of increased risk of burnout with open visitation.  So we have to keep that in mind. Now, this list is not insurmountable. But we do need to address these. And they have to be heard, right, before we can move forward.  So how do we overcome all these barriers? Well, I came across this very timely research article in Intensive Critical Care Nursing.  And this is a multi-centered qualitative ground theory study. They interviewed nurse leaders in adult ICUs in magnet status hospitals throughout the United States.  And I think it provides a great framework for thinking about this topic and how you can think about facilitating open visitation in your ICU.  So their model was really to think in terms of three phases, a pre-implementation phase, implementation, and then sustainment.  And in each phase, you would assess, of course, any barriers that would come about and then try to develop strategies to overcome these barriers.  In their study, they found that, you know, nursing attitudes were the biggest barriers in both the pre-implementation and the implementation phase.  And then when they got to the sustainment phase of open visitation, it became more of like clinical issues and non-clinical issues.  Let's look at each phase a little closer to give you some ideas of what went on and some strategies you might be able to use.  So in the pre-implementation phase, these were the things that came up quite a bit was loss of control, they were worried about interruptions to care,  and they felt that there was no benefit to it, so why do this? Now, here's a quote that kind of, you know, captures this.  It's once you say open, does it literally mean open the doors for people to come in? And so the initial reaction of this person was how am I going to manage  with people drifting in and out? How can I provide high-quality care if we let people in at any time? Of course, these are legitimate fears, and they need to be addressed.  So how do we do that? What are some strategies? So one thing we can do is redefine the terms. I think using things like guidelines versus rules can be helpful  or using the term flexible versus open. It can be more meaningful to people. Emphasize also that it's not a one-size-fits-all philosophy, that we do need to factor  in each patient's situation individually and reassure that it is not a free-for-all with visitors being on the unit as long as they want whenever they like.  Another thing we can do is training. Also know that this is not a simple intervention. We have to consider both patient and family interests.  We need to be able to support the patient, but we also have to support and prepare families physically and psychologically for their visits.  So now we do have to improve how we work with families. We need to develop communication skills, and we can do this through like maybe role-playing,  scripting, and here's an example of a script. Like shift change will begin in 15 minutes, last about 30 minutes. It's critical. We don't get interrupted during report,  so there aren't any mistakes in the information being passed on. Some other strategies you can try before in this pre-implementation phase is the use  of empathy, and this works really well for those resistant staff members, and you can ask some things like if it was your loved one, would you want to be there?  The answer is usually yes, I'd want to be there, so use that, and then also you can draw on their positive experiences with visitation  so they can remember how beneficial visitation can be. Another strategy is to really, you know, use guidelines and experts  and really advocate for evidence-based practice, and this is where a CNO of one hospital did say we challenged the nurses to go look at the evidence,  and when they found it, they said, oh, we see how beneficial it is to patients. So this can also be very successful.  So these are some of the strategies to use pre-implementation. So things that happened in their study when they actually implemented the open flexible  visitation policy were people were concerned, again, staff were concerned about demanding unrealistic families, interruptions to care, workload issues,  and then, again, still lack of skills working with families, and one nurse said there are just difficult families. They impede care. They just go in and out of the rooms.  We get interrupted numerous times, and it really slows down the nurse. Again, you know, another consideration we have to factor in.  And so what can we do with the, in this situation? Well, we can use kind of nurse-to-nurse education, and this is finding those champions  because they do exist in your ICU, finding those that are really passionate about open visitation, and helping them help the nurses who maybe aren't as passionate about it.  Another thing you can try is shared governance, and this is, I think, a really big thing to do is have it, have it, have the staff drive it.  So it's more of a ground-up versus top-down policy, and then, I think, including patients and families in the input would be very, it's very helpful as well.  Having their voice tends to be very successful.  The other, the other part would, of course, is the workload and burnout, and we can't ignore this.  This happened, you know, we don't want to provide a human-friendly environment for patients and families at the expense of our staff.  So perhaps ICUs consider having a CNS, a family care specialist, or whatever term you use, or a social worker, someone who's trained that can work with the challenging families,  or someone that the staff can go to with challenging families. And then, I think, as researchers, we can conduct studies that look at strategies  to support open visitation, but that also maintain the healthy, safe work environments for ICU staff.  And then, what came up during the sustaining considerations? So now that policy is in place, you want to just keep it going.  Things that came up here were clinical barriers, and the biggest one there was infection risk. And, of course, we see that now with COVID, where there's isolation issues,  or where there's times where you really can't let family in. What do you do in those situations?  And then, also, non-clinical barriers, the things that came up there were lack of space to have family visits, and security issues. So what are some strategies in this area?  Well, it's really important to give nurses and physicians and other ICU staff the discretion or the autonomy to restrict if they need to.  Open visitation, flexible visitation, we want that to happen. But if there's infection risk, if there's other things going on, you want to have that flexibility to restrict.  Also, with security, you have to address it in some way. You know, this particular person said if we had an aggressive visitor, we'd first call security.  If that didn't work, you could call the police. Some other hospitals said they used panic buttons.  Whatever you do, if it is a concern at your hospital, you do need to address that piece of it. And then, family spaces, we know ICUs are generally not large areas, and so it's not  as comfortable for families to visit. But one place had a clinician zone, a patient zone, and a family zone. If you have the ability to do that, you can do that  and let families know where it is safe for them to be. Also, if you can redesign your ICU, if you're lucky enough to do that,  try to make sure you're factoring in spaces for the family. And so, it's important to think about all those barriers and all of the phases before, you know,  before you try to implement an open visitation policy, because then you can create strategies to overcome them.  And so, now what I'm going to do, I would like to just highlight three ICUs that did enact open or flexible visitation policies and some of the strategies they used for success.  So, the first one was a 10-bed ICU in Connecticut. Their previous policy was pretty restrictive, only 10 minutes per hour with no visitors allowed during change-of-shift time.  The problem they were having is that some nurses followed this policy strictly, while others just allowed open visitation. But what they did is they changed their policy to 24-7,  and they allowed patients to define the family. But they also gave nurses a bit of discretion to limit based on the patient's condition.  The successful strategies they used were that they allowed the nurses to create the new policies, so ground up versus top down.  They used scripts to alleviate anxiety-producing situations around open visitation. They used small group workshops where they did role play.  Some other things that they did were creative and I didn't think about was a communication log to record visitation issues so that they could be addressed  at the current time and not allowed to fester. They created a welcome card and updated visitor policy so the families could easily see what was expected in the new policy.  And then they found it to be very effective to have an educational board with flyers posted, but also thank you notes from families.  That kept the motivation and kept the, sustained the policy. Another one was a large tertiary public safety net medical ICU in Ohio.  They had their previous policy was two family members at a time, and only like little four-hour chunks of visiting time in the morning and early afternoon.  And families also had to have a password to get in. Their new policy was just flexible visitation unrestricted unless the patient didn't want it.  And then they did have some restrictions around report time. And this was a part of the SCCM's Patient-Centered Outcomes Research Institute project.  And they also had some successful strategies they used. They had nurse, they found nurses willing to work on the project.  Of course, buy-in, right, from the nurses makes it more successful. They used education as their primary intervention.  They posted a lot of open visitation publications on their bulletin boards. They discussed them at meetings.  And they developed a nice brochure to guide visitors on the policy as well. And even though they didn't find an increase in satisfaction with care from the families,  they were able to sustain the flexible visiting policy. And they did notice a decrease in patient safety events as well.  And then finally, the last one is the Level 2 Trauma Center in Southern California. They already had a policy, open visitation policy enacted 24 hours a day.  But they did notice the nurses weren't very satisfied with it. And they did want to sustain the practice. So they decided to try some strategies to hopefully increase satisfaction  in the nurses and sustain the practice. And they used, again, a shared governance model to figure out what's going on and let the nurses help decide how to sustain it.  They decided to change it to visiting guidelines rather than rules. They, again, used scripts and prompts.  And I highly recommend this article if you want to see some good scripts and prompts for high-risk activities to give to your staff to talk to families about.  They provided one-on-one education for those that were still struggling with open visitation. And then they kept education going through huddles and email updates.  Those are just a few. I know there's more out there. But due to time constraints, I just wanted to highlight those three. So in conclusion, open visitation. Can we ever get there?  Well, I think we can by redefining family and redefining open visitation. By recognizing there's barriers but thinking about strategies to overcome them.  Being mindful of workload and burnout. And then sharing successful strategies with the other ICUs. And so my goal will hopefully that this is just something that we do.  It's not even, you know, an expectation anymore. It's just something we do. And that we recognize the important role families play in the healing process.  How they can advocate for their loved one. And that they truly are a part of our interdisciplinary team.  And so this is the family member I'd want involved or being able to visit me in the ICU. And we'll have a veterinarian, Dr. Wayne, talking to us.  And so she's going to hopefully let, this is my boogeyman right here. And I'm hoping he can come visit me. And at the end of the session, I'll be around to take questions.  And I do thank you for your attention.  Thank you, Dr. McAdam.  Great presentation. And a good segue into our next speaker, Dr. Wayne, who is going to speak to us about allowing pet visitation in the ICU.  Why not? And we do have a couple of questions that are coming in. So I will get those out.  And we can transition into our next presentation.  Go ahead, Dr. Wayne. All right. Hi everyone, I'm Dr. Wayne. I'm a critical care veterinarian working at Tufts. So I take care of pets coming in through the emergency room  and in our intensive care unit. And today I'm gonna be talking to you about allowing pet visitation in ICUs.  I have nothing to disclose.  So I just wanted to start with some important definitions. There's a lot about this in the news lately  because all of the regulations around this in particular in flying with animals has changed recently. So you may have seen some of this in the popular news.  A service animal, emotional animal, and a therapy animal all have distinct definitions. A service animal is an animal that is trained to help perform tasks to benefit an individual  with a disability. And this is defined and regulated by the Americans with Disabilities Act.  Emotional support and therapy animals have sort of looser definitions and regulations. So an emotional support animal is an animal that's used as part of a medical treatment plan  and it may provide support to someone with mental illness. These animals, there's no regulations requiring training or evaluation for them. And then a therapy animal,  which is really what we're talking about when we're talking about animals that are visiting ICUs primarily, are animals that provide pet interaction for people  with a goal of improving physical, social, and emotional wellbeing. And usually these are personal pets that have gone through some training.  So pet therapy in the United States, this is really, there's no national governing body, there's no nationally accepted standards. So this is really important to think about  if you're gonna implement a program locally, that there are guidelines, but they vary pretty widely. And so you really need to think about your particular ICU  and develop an interdisciplinary team that can kind of implement plans that make sense for you locally.  There are over 180 therapy dog organizations recognized by the American Kennel Club. And again, there's nothing nationally to guide  kind of what their specific guidelines and standards are.  So when we think about what the potential risks are for animal visitation, again, the lack of standardization, I think makes it more challenging  to implement these programs, but not impossible. People with allergies to pets is something you need to keep in mind. And again, I think there are ways to mitigate that.  And then the biggest one that we think about are infectious disease risks.  So we know that there's sharing of infectious organisms in both directions. So both from people to their pets or pet visitors, and then also from the pets to people.  Raw diets in pets can increase carriage of infectious agents like salmonella in particular.  And so I would recommend that animals who are visiting do not be on raw diets to reduce that risk, particularly in the ICU setting.  And then these visiting animals, if they're going from room to room, there's potential for them to be fomites.  So if you do want to implement a program like this, what can we do to mitigate the risk? Again, because there's no national guidance,  we really need to establish an interdisciplinary team to develop guidance that makes sense for your local hospital.  The pets that are visiting should be healthy, so that's kind of on a yearly process. But also each time they're coming to visit,  they should make sure that those pets haven't had diarrhea, they don't have any wounds, they don't have any skin infections,  and that they're washed and groomed on the day of visitation so they're not bringing outside things into the ICU.  And then we also want to think about the sort of health of the pet, so a pet that's not immunocompromised or going to be at increased risk for disease themselves  if they're going into this type of setting.  We typically think of dogs in these types of settings, but there are lots of pets, other types of pets that are trained. There's in a program at Tufts where I work,  we have a mini horse that's trained. We have some pocket pets like a hamster or a guinea pig that are trained.  But that may or may not be appropriate for an ICU or your particular ICU setting, so you kind of want to think about that.  And then I would strongly recommend keeping your infection control teams as part of these planning teams  and keeping a log of who's there. So if there is an issue, you can track which pets were there and which people were there and track any potential infections.  We also want to think about the handler. Pets come with their handlers, so potential HIPAA concerns. We want to make sure the handlers are healthy  and they have appropriate vaccinations,  making sure that they're not a risk to the staff or the people in the ICU.  And then they need some training in terms of how to safely visit with their pets and to recognize stress in their animals. They need to have the autonomy to remove their pet  or remove their animal that they're visiting with if they feel like the animal is getting stressed.  We probably need to think about time limits.  Labs, for example, probably are never going to limit themselves, but may be super exhausted by the end of the visit. And so we may need to kind of put those in place  to have something that's reasonable for the pet.  And then in terms of training, we really want to have handlers who use positive reinforcement.  And then I kind of mentioned this, but thinking about the risks to the animals. And so making sure that they're not getting stressed in situations,  making sure that they have appropriate training, particularly in an ICU setting where there are a lot of machines and noises that may not be familiar to animals,  making sure that the animals that are coming to visit are desensitized to those things and that are not going to react.  And then they're exposed to potential infections from the people in the ICU. So thinking about making sure that those are healthy pets  and that we do everything to minimize those risks in the direction of human to animal.  So what are the benefits?  So I think there are huge benefits and I think that the benefits far outweigh the risks and that this can really be done well and safely. So physical health,  there are a lot of studies showing that animal visitation can produce endorphins and help stabilize blood pressure and reduce other health risks,  diminishing pain and anxiety, I think is a big one.  Mental health,  thinking about isolation and depression, creating motivation for people in ICU settings, reduction of boredom and providing comfort.  I think those of us that have pets recognize that animals are a huge part of mental health improvement and wellbeing. And I think the same is probably true for ICU patients.  Another really key important thing to think about is the benefits to staff. So in the places where I've seen visitation, sometimes the most positive effects  are actually with the staff. And actually in our hospital, we have done pet visitation through our program at Tufts. And you would think in a veterinary hospital  where we're seeing pets all the time that we wouldn't need this, but most of the animals that we see are sick and injured. And to see pets that don't require  something giving of the staff, but are instead giving back and are healthy is really helpful and beneficial even to our staff. So I would encourage that if you have programs  that you extend special time for your staff to visit with the pets and include that as part of your program.  Oh, I seem to not be able to go forward.  Can our IT people either extend me forward or hand back control?  There we go, thank you.  So additional considerations, we kind of mentioned, people in ICUs have allergies or maybe not the best people to have visitation for. Immunosuppressed people,  if there are wounds that can't be covered, behavior or psychiatric disorders that may be a risk to animal visitation.  When animals are visiting, we should make sure they avoid contact with invasive devices. Hand hygiene before and after visitation for handlers  and also for people who are being visited. And again, consider which type of pet. Typically we think of dogs, but there's a wide range of pets that are trained in visitation.  Reptiles is one in particular that are more likely to transmit salmonella and may not be appropriate for an ICU setting. And then consider which areas  are accessible to pets visiting. So again, for your particular ICU setting, it may or may not be appropriate for an animal to come into certain areas of the ICU.  And then one other thing maybe to consider personal pet visitations in ICU. In ICUs, so a person who's having an extended stay in ICU,  but lives with a pet at home and really wants to visit with them, and that may be a huge mental health boost. I think in some cases, benefits may outweigh the risks.  It's a little bit harder to regulate because those pets presumably are not going through your specific programming and checklists that you have in place for your pet visitors.  So in some cases may have more risk. But again, I think the benefits may really outweigh the risks in some circumstances.  So we've kind of mentioned some of the recommendations for implementation, establishing a local multidisciplinary team with expertise to establish unit specific guidelines  for the pets and the handlers and how they're going to interact with staff and with hospitalized patients.  You really should, there are some guidelines to follow, but really make sure that you're tailoring those guidelines specifically for your unit,  because again, there's no national approved guidelines and they vary quite a lot.  Animals should always be leashed in with their handlers. They shouldn't be left off to visit or off leash in most places, especially in an ICU setting.  Thinking about a champion, kind of going off what our previous speaker was talking about of having local champions for the project and kind of ground up is probably gonna be the way  to have the most success, having clear goals for what the program is. So again, I would encourage including staff visitation and staff wellbeing as one of those goals,  including all of the relevant stakeholders,  making sure that there are safe policies and that if some incident does happen or infection does happen, that there's an established way to report that and to handle that.  And then picking a specific ICU where you're gonna have success if you wanna grow that program in your hospital.  And then I just wanted to mention that as a veterinarian who manages an ICU, we also have these conversations about whether we should have open visitation  for owners to visit their pets when they're in the ICU. Right now with COVID, we are all curbside, so we don't have owners coming into our ICU at all,  but in non-COVID times, these are conversations that we have and we have similar barriers in terms of our nurses being the biggest barriers to wanting open visitation  for ICUs, but this is certainly being discussed in our settings as well.  I look forward to your questions and discussion and I will hand off to our next speaker.  Thank you, Dr. Wayne, fascinating.  So I wanna just discuss certain cases here So I wanna just discuss certain cases here that collectively open the door  to have the current policies or at least advocating for current policies. We all know like 20 years ago, the ICU patient would not get any visit or almost never,  or maybe not 20 years ago, but a little bit before that. And there were like limited time that maybe one or two hours a day,  they could have come and there were significant limitations. So nothing happens as you know, in medicine from internal change or maybe we do advocate a lot of times for changes,  but most of the time these changes in medicine is forced upon us and the movement in the society  kind of pushes us to do the right thing. And this is one of those areas.  So in February 2002, a hospital University of Maryland medical system was sued by a man named Bill Flanagan  because he was denied visiting his dying partner.  Robert Daniel. And the reason was that he was not qualified as a family.  And despite the fact that he had a healthcare power attorney  on behalf of the patients.  For four hours, personnel of the hospital kept him away from the doctors. And that is in the complaint.  Meanwhile, allowing the family of other patients to visit their loved one and comfort the doctors.  Then when this happened, the patient wish, which we did not want to be intubated put on mechanical ventilation was on it because nobody could convey that information to the family.  And by the time that the blood family of the patient  arrived, mother and sister and authorized the visitation, then the hospital allowed Flanagan to see the patient.  And at that time he was intubated on ventilator and they could not have any meaningful communications. And then a couple of days later, he passed away.  Not able to move forward. Okay. So Daniel's mother, the patient's mother said in support of the lawsuit, that Bill and Bobby were soulmates. And one of the best couples I've known,  they loved each other, took care of each other, came to family holidays as a couple. And Bill is still babysits for my grandson. If that's not family, then something's very wrong.  When someone is dying, hospitals should be bringing families together rather than keeping them apart.  I don't know why I'm having issue with moving forward. Okay. And the plaintiff in that lawsuit  said in one of the press releases that when you love someone, there is an awful feeling when you cannot follow through on your promises. I have a huge hole in my heart  because I wasn't allowed to be with Bobby when he needed me most. And I can only pray this never happens to anyone else.  I don't know what exactly happened as a result of this. Probably this lawsuit was settled. I couldn't find any ruling, but these paved the way for where we are right now, obviously.  The other case was in 2009.  And this happened in Florida.  Lisa Pond was playing with her three children, nine, 11, and 13, when she collapsed from aneurysm while they were on their cruise ship. And they were rushed to the closest hospital.  And her partner of 18 years, Janice Langbehn,  was not allowed to see her for eight hours. And they never got a chance to say goodbye.  Now, you can say here that maybe the hospital had a policy of kids under a certain age couldn't visit people in the ICU, but that was not the case.  After the Lisa's sister or the patient's sister arrived, eight hours later, Janice and their children were able to see Lisa. And by that time, she was already dead.  And Janice also had the patient's DPOA paperwork  or had the family had faxed them the paperwork, but the hospital had ignored. This case was dismissed in federal court, but that doesn't mean that it did not have a public effect  of pushing us toward where we are right now these days  and made the progress that we should have made a long time ago.  Let me see, maybe I pass one. Okay, so the attorneys in this case  said that the case could determine the way hospitals treat not only LGBT patients, but unmarried heterosexuals and single people who rely on friends.  And that was the main point of the lawsuit. Hospitals should allow patients to define their own families.  And according to the National Hospital Accreditation Standard, which that was the case in both of those cases. So this standard was in place when those cases had happened.  That definition of family is a person who plays a significant role in the individual's life who may not necessarily be legally related to the individual.  Even though hospital may have open visitation, gatekeepers can interpret those policies differently. So it's very important for us to train and teach our staff  to what degree that they have to use their discretion and to what degree they should be asking if things are not clear to them.  So in 2010, right after, I think I may have just got this wrong.  I think it was April 15, 2010. Right after ACA was passed, President Obama had issued a memorandum to Secretary of Health and Human Services.  And the subjects of the memorandum was that  the title was respecting the rights of hospital patient to receive visitors and to designate surrogate decision-makers for medical emergencies.  And in that memorandum,  three important things that was as a reason for this directive was mentioned that, a vidor or vidor with no children is denied the support or comfort of a good friend.  And that was the practice that was happening in a lot of hospitals. Members of certain religious orders  were not able a lot of times to choose someone other than the immediate family members to visit them or to make medical decisions on their behalf.  And LGBT Americans who are often brought from that sides of their partners and unable to act as legal surrogates if their parents, if their partners are incapacitated.  So those were the basis for this directive.  And the directive is specifically asked the Secretary of Health and Human Services to start working towards rulemaking  by obviously, you know, the rules that every department  and secretary can make within the confines of the law  to make some guidelines under their department. And the things that they were asked that all the hospitals that were participating in Medicare and Medicaid should respect  the rights of patients who designate visitors and the designated visitor should have the same visitation privileges as immediate family members.  And of course, the stating hospitals should not deny visitation privileges based on race, sex,  color, national origin and religion and other protected classes. And the hospital may restrict the visitation in medically appropriate circumstances  but should apply the same rule to everyone.  That obviously, you may just say that it's okay. So this should not be an issue after, you know, with the marriage equality, now it's the law of the land.  But again, a lot of these things are not things that we do because it's illegal. It's because we just use our own biases in the hospitals  and go against what they're already in place in law and policy and guidelines. So the training of their staff is the most important thing.  So somebody might ask, what about HIPAA on patient's privacy? So those laws are to protect patient, not to cause them suffering and harm.  Obviously, you know, a family who are on cruise ship and, you know, having vacation, if one of them collapses, whether they are married or unmarried or whatever,  so why should we prevent them, the rest of them to visit that family member or even the friend? Maybe they are not even in an intimate relationship,  but they are a bunch of friends, you know, going to travel and one of them collapses and we don't, you know, allow the rest of them to visit that person.  Well, if they were close enough to have a, you know, travel together, then they should be close enough for us or it should be good enough for us,  that relationship to allow them to visit them when they are in the ICU bed. So use your common sense, check your biases and put yourself in the family and the patient's shoes.  And who is the family? Whoever you decide and they can be legally married or unmarried, significant others, blood adoptive or foster relatives, friends, colleagues, neighbors,  or pets like my two dogs, Ponzi and Poo-Poo, who, you know, literally go with me anywhere that I go  because they have been trained and they are certified to do that. So these are the references that I used and I tried to keep it short. So a lot of the areas that I covered,  it was already discussed. So I think we can just spend more time with Q&A and answer the questions. Thank you for your attention.  Thank you. Great presentation. And we did have some questions that came in and we're gonna, I think they're gonna transition as to where we'll all be.  We'll be able to jump right in.  Let's just give it a minute here, a couple of seconds.  And we'll start with Dr. McAdam and the question.  One of the things I got here is can you talk  about various contributions families can make to their loved one's care?  Oh, and that is a great question. And I think families make great contributions. First off, they can be like a historian. For instance, they can tell us about the patient.  So when the patient maybe is intubated, cannot speak for themselves, the family can paint the picture for us. So we see them as a human, right? As opposed to someone in that bed,  we kind of see the meaning that that person has. And I think for ICU staff, it's really helpful to see that patient in that light.  And so I think they can be kind of that historian for us. They can advocate for that patient. They know what that patient may want  and they can help us understand what that patient may want. They can help with decision-making. They can help with communication.  I think too, they can help with symptom management. They might know if the patient's in pain or having other symptoms or trouble, maybe before we even know that they have that.  And I also think they can be very helpful in caregiving. They can do oral care. They can help us position the patient, make them more comfortable, maybe give them a massage,  whatever is feasible for that patient and comfortable. But I think there's a lot of things families can do that makes it more meaningful  for them to be at that bedside and to allow them to be at that bedside. And we know it does help, for the most part, it does help reduce delirium for patients.  It helps reduce anxiety and probably other benefits as well. So great question. Yeah, great. Another question for you, Dr. McAdam,  you stated they changed from guidelines instead of rules. Do you think this would give the nurses enough power to intercede when the family's presence is disruptive  to the patient's care or to the patient's care on the unit  or other patient's care on the unit? So I would hope so. I think some people like the idea of rules because then they can just point to it to say,  oh, these are our visiting hours, you need to leave.  But I think we have to get away from that. And I think nurses do need to have that, feel empowered to be able to say like, this is not a good time to visit,  but to explain to family why. Most people are reasonable. And if you say, this is what's going on and this is why right now,  we're going to have you just step out for a little while. We're going to keep you updated and I'll let you back in as soon as we can. I think most people would be okay with that.  And I think by saying it's like more flexible or guidelines, it allows, it gives nurses that structure or flexibility to do that, as opposed to, it allows them that ability  to kind of do what's best for the patient at that time. And so I do hope that it works. And then I think what ICs can do is even provide scripts  so that if you're a little uncomfortable talking to family, you can have a script or kind of a pre answer to them. And I think most people are reasonable and understand  as long as you tell them why, they kind of are like, okay, I can step out for a little bit and I know you're going to keep me updated and let me back in.  And so, yeah, so I would, yes, I would hope that using that terminology might make it more, help ICs or make ICs more willing to adopt this policy. Okay, great.  And one more question for you. Pediatric intensive care units have been successfully utilized open 24 seven for family visitations for years.  Why do adult units not look at the pediatric model to implement the 24 seven visitation?  Well, I think that's a great question. And we should be looking at pediatric,  we should be looking at their policies. I think it's a necessity maybe in pediatric ICUs because we're like, oh, their parents are going to make their decisions  and we need their parents' input. But I think it's a great suggestion, a great idea. I know I do a lot of work in bereavement research and we look at pediatric and neonatal ICUs  for ideas on that. And so I think it's a great idea to look at it for how to implement open visitation and they probably have great ideas on how to handle,  you know, how to work with families who are struggling and how to kind of work with families there 24 seven.  So I think it's a great idea and thanks for that suggestion. Yeah, thank you.  Next couple of questions is for Dr. Wayne.  Can you speak on visitation of personal pets to patients in the ICU setting?  Yeah, I mean, I think many of us who have pets would want if we were in an ICU setting would want our pets to be able to visit if it was safe to do that.  And I think, you know, you kind of hear stories of people allowing pets to come in kind of secretly to visit people. Again, I think that it's a little less regulated.  So, you know, they're not gonna follow whatever guidelines you have in place for that checklist for pet therapy type animals visiting.  So, you know, potentially there's more risk,  you know, those pets may not be as desensitized to ICU machines and noises, for example,  whereas an animal that's gone through specific training may get desensitized. But I think if there's a way to allow it that we should, and I think the potential benefits for people  having their pets visit is probably huge.  You know, I think, again, those of us that have pets, you know, in our daily lives, we know how much they're part of our mental wellbeing.  And I think for people in the ICU who are stressed, pets can be a huge, huge source of anxiety relief and improvement in mental wellbeing.  Okay, great. And this is one that really could go to anybody on the panel. And the comment was, we currently don't have a policy for personal pets.  However, we have looked the other way a few times for patients awake and alert and at the end of life. It made such a difference in the patient family satisfaction.  I think the pet was happy as well. We did have the patient position at the end of the unit where the pet could be brought up via a back door and not walk through the unit.  Can anyone speak to the barriers of putting in place a policy for visitation of pets and end of life patients?  So I'll open that up to anybody that'd like to take a-  Take a bite at that. Well, I really do believe that a lot of these things are arbitrary and the way that the society is looking at, you know, certain things.  Like for example, pets, pet law in general or animal law in general, you know, it's a little bit still need catching up because we are treating pets as properties.  And if somebody, you know, kill my dog,  then they can say, okay, how old was she or he? What breed it was? Here is like 500 bucks or, you know, $2,000 or whatever. And that's wrong because the value of those pets  in my life is way more than that. So I'm kind of like waiting for another lawsuit to come for some hospital that is preventing a pet to visit a dying patient or ICU patient.  There is no reason to do that. I mean, absolutely no reason. If these pets are vaccinated, they only stay in their, you know, patient's room.  There is somebody with that pet to hold them in control. Most of them, these pets are well-trained and they don't cause issues. So we just have these pre-conceived notion that,  oh, you know, they might just get, you know, agitated because of the ICU alarms or this and that. So therefore we just put a blanket ban on all of them. That is wrong in my mind.  And I think we should be moving forward and making these changes before a lawsuit forces to do that because I can guarantee you at some point in the future that will happen.  So, but we never learn in medicine. We always are behind. We just, we should be self-regulating profession, but we always like, you know, these movements from society push us  to move in the right direction. So that is my personal and professional belief that we should absolutely let pets to come and visit their family members who are in the ICU  for both the benefit of the pet and the benefit of the patients because they get better faster.  Great.  Another question for you, Dr. Wayne, has there been growth or national partnerships for pets being used for healthcare provider and patient therapy?  Not that I know of. So there are several groups nationally. Pet Partners is the biggest one and the one that at Tufts we use that has kind of,  you know, standards for training pets and their handlers.  So, but again, there's no regulations. So everyone can kind of, you know, have their own standards.  So I think that there's also, I think, increased regulation in terms of what the definitions of different types of pets are. And I mentioned kind of, you know,  pets flying on airplanes, whether they're service pets or therapy pets. So I think that there is sort of more conversation, but there's not specific national partnerships  that I know about.  Okay. And how can we better partner with executive leadership to partner with community pet therapy stakeholders?  I think a lot of this is, you know, again, sort of organic and kind of what our other speakers have talked about that, you know, it's a culture shift in the ICUs  to be sort of less prescriptive and have sort of policies that are more inclusive  of family and pet visitation and working with local groups to have successful programs that can be models for other programs to be built on.  You know, I think, you know, starting local and starting in a specific place where you're likely to have success is probably a way to grow this.  Okay, great. We've got a couple more minutes and just looking real quick, this may be for Dr. Hayden. A common challenge is that legal frameworks  don't necessarily align with the ethical and common sense frameworks resulting in certain tension in healthcare with regards to definition of family.  Can you suggest some proactive approaches to addressing these challenges with lawmakers and family advocates?  And it looks like we just have a few minutes left. So the question is that this, so the ethical does not meet the, can you just say it again?  Because it seemed to me that nothing in the law would prevent it. It's just, we need to do some catching up. Can you read the question again? Yep, I'll quickly read it.  Common challenge is that legal frameworks do not necessarily align with ethical and common sense frameworks resulting in certain tension in healthcare  with regards to definition of family. Can you suggest some proactive approaches to addressing these challenges with lawmakers and family advocates? Yeah, it is not very clear for me  that what exactly the question wanted to suggest that the law does not meet the ethical issue. There are a lot of times that it does not, but in this specific case,  I don't think that is the case. There is no ethical constraint for us to define the family to the broadest way and the law does not prevent us from doing that.  So I don't think it's the problem is the law or the problem is the ethics, is the problem is the administration of the hospital that needs to catch up  and the ICU leadership needs to be accommodated. I think that's the only barrier. I don't see any problem with now. We can get to the point of just saying that,  okay, so we can pass a law that all dogs, all human of no background or anything, so they can come and visit to the broadest. Then we're gonna run into problem with,  okay, so the infectious control, okay, all these dogs. So there has to be some limitation. They are trained enough. Can they, maybe they come and attack a family  of another patient or a staff or anything like that. So I think if you pass a law in a very broad way to cover the patients right in that sense of visitation,  then you are gonna run into a lot of unintended consequences. I think the law as is, is adequate. I think the policies of professional society  like Society of Critical Care Medicine, if we can have a guideline that we can recommend to the hospitals and then the hospital administration  and the local leadership needs to work on this and make something happen. But I think that I'm not sure if, I mean, obviously a lot of things at the state  and federal level can be improved, but in this specific case,  one thing I just wanna say right now, we always look for excuses to prevent people from visiting if you really think about it as a medical profession,  because it's just as Dr. McAdams said, it's just help us to keep the control or whatever the feeling of safety that we have or for the patient. One real thing that is now happening,  lawsuits are coming out, hospitals are preventing patient, families of COVID patients from visiting them. And I think that is wrong too, as long as we provide them with PPE  and we just say that these are the risks, they should be able to visit their loved ones. So if you really think about our history, we always are, as a medical profession,  we are a little bit on the conservative side. I don't think the law is preventing us from doing that, it's just us preventing us from doing that.  Okay, well, thank you for that comprehensive answer and we are over time. I just wanna thank our panelists for taking the time out and all our participants that listened in.  Thank you very much.  Thank you.

Video Summary

In this video, Dr. John Whitcomb introduces a session titled "Open Visitation in the ICU for All: Families, Friends, and Pets." The session features three presenters who discuss different aspects of open visitation in the ICU. Dr. McAdam discusses redefining the concept of family and viewing them as partners in care. She presents the American Association of Critical Care Nurses' definition of open visitation and discusses barriers and strategies to overcome them. Dr. Wayne focuses on allowing pet visitation in the ICU and suggests establishing guidelines specific to each hospital. She emphasizes the importance of minimizing risks and maximizing the benefits of pet visitation. The panel discussion revolves around visitation policies in ICUs and the role of pets in patient care. The panelists highlight the importance of allowing families and pets to visit patients and discuss the need for specific guidelines. They address the challenges and barriers in implementing visitation policies and emphasize the need for cultural shifts in ICU settings. The panelists mention the successful implementation of 24/7 visitation policies in pediatric ICUs and discuss the potential benefits of personal pet visitation. They also touch upon legal and ethical issues and recommend proactive approaches. The video concludes with the emphasis on the need for hospitals to establish patient-centered guidelines and policies.

Asset Subtitle

Patient and Family Support, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Recognize how broad definitions of family members can lead to more open visitation policies
Discuss and share ideas on how to better facilitate open visitation in the ICU
Share ideas for open visitation at different types of institutions

Open Visitation: Moving From Acceptance to Facilitation
Jennifer L. McAdam

Allowing Pet Visitation in the ICU: Why Not?
Annie Wayne

When "Family" Is Not Legally Family
Mehrnaz Hadian

Meta Tag

Content Type Presentation

Knowledge Area Patient and Family Support

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Communication

Tag Rehabilitation Medicine

Year 2021

Keywords

Open Visitation

ICU

Families

Friends

Pets

Redefining Family

Barriers and Strategies

Pet Visitation

Guidelines

Patient-Centered Guidelines

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