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.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.