Keeping families out of ICUs no longer makes sense as the pandemic eases

On, December 9, 2020, my mom, brother, and I waited in a cold, wintery drizzle outside the local hospital in my hometown in southern Colorado, anxiously hoping to be allowed to see my dad for the last time. After contracting Covid-19, he had been in the intensive care unit (ICU) for nearly a month and his condition had deteriorated to the point that we were summoned to the hospital to say our goodbyes.

Until that day, my mom, brother, and I had seen my dad just once since he was admitted to the ICU, and even that “courtesy” was granted only because of my dad’s decades of service to the hospital as a gastroenterologist. We resigned ourselves to unsatisfying FaceTime interactions, unable to provide the comfort and touch my dad needed — and deserved — from his family.

Like so many other people admitted to the ICU during the pandemic, my dad was left to endure critical illness without those he loved the most.

As I look back on two-plus years of flawed Covid-19 policies, the willful decision to separate families from their dying loved ones was the most inhumane.

Before the pandemic, ICUs had made strides in delivering family-centered care. Recognizing the role of families in reducing delirium, depression, and post-traumatic stress disorder (PTSD), families were increasingly embraced in ICUs as an important part of the critical care team. Open visitation, shared decision-making, and interdisciplinary rounds became a cornerstone of critical care across the nation.

Even the ICU liberation bundle, promoted by the Society for Critical Care Medicine, which publishes one of the leading critical care journals, includes “Family Engagement and Empowerment” as a tool to improve intensive care outcomes.

In the early days of the pandemic, when little was known about the dynamics of viral transmission and personal protective equipment (PPE) was scarce, restricting visitors was a reasonable approach. But as the months wore on and death rates plummeted in the summer of 2020, restrictions separating families from their loved ones in ICUs should have been relaxed. Family members should have been equipped with the appropriate PPE, instructed on the proper use of medical-grade masks, and been allowed to spend time with their loved ones in the ICU.

The arguments supporting the involvement of families in the care of the critically ill are obvious and logical. Intensive care units are renowned for anxiety-producing alerts, disorienting medication regimens, disruptive light pollution, and the occasional codes and resulting commotion in nearby rooms, all of which degrade already fragile sleep cycles and precipitate delirium. Delirium can complicate an already tenuous situation, prolonging the time that patients need to be on ventilators, as well as their length of stay, and even increase the incidence of post-ICU trauma among survivors. Just as importantly, having family members present and able to have pivotal final conversations and perform important spiritual or religious rituals may help limit decisions that are likely to prolong the death process.

From personal experience, if my family had the opportunity to see the severity of my Dad’s clinical condition days earlier, we likely would have transitioned him to comfort care that would have spared him needless and often painful interventions toward the end of his life.

Even today, as travelers fly unmasked and public gatherings take place like they did before the pandemic emerged, some hospitals continue to restrict ICU visitation. My quick review of hospital visitation policies yielded dozens of examples of hospitals that continue to have draconian ICU visitation policies, especially for Covid-19 patients. I discovered that many hospitals prohibit ICU patients from having more than two visitors per day, with some allow only one visitor at a time. Other hospitals insist that only virtual visits be permitted if a patient is found to be Covid-19 positive. Astonishingly, in the most extreme example of these visitation policies, if a patient at the end of life is Covid-19 positive—a diagnosis now frequently found incidentally—they are only allowed a 30-minute, one-time visit with two visitors.

I worry about the long-term ramifications of these policies. Will hospitals doggedly pursue policies that ensconce patients in isolated chambers, or will they realize that at a time when communities are suffering and people are dying, families need to be part of intensive care delivery?

Misguided policies enacted by hospital administrators have conspired to make the nation’s hospitals isolated — an enclave into themselves rather than a place families can contribute to the care of their loved ones. And although many hospitals have amended their policies to welcome the communities they serve, too many continue to double down on visitation policies that serve only to aggravate the emotional distress and trauma exacted by the pandemic. Hospitals and ICUs had been making magnificent strides in incorporating families into the care of the critically ill. It’s time to push them to once again open their doors and make family-centered care a priority.

Neel Vahil is a first-year resident in internal medicine.