COMMENTARY

How Family in the Room Affects Patient Care

Andrew N. Wilner, MD

Disclosures

February 24, 2020

Until recently, seriously ill people were often treated at home, surrounded by friends and family. As scientific advances have shifted medical care to the hospital, patients now rely on family visits for emotional support, and also for assisting with practical matters: helping with basic care, accessing old medical records, keeping track of medications. In my role as neurohospitalist at a county hospital, I have noticed another vital function of hospital visitors that is perhaps underappreciated: improving patient care.

I make daily hospital rounds with a neurology resident and occasionally medical students. Rounds are always hurried; we must examine every patient, review neuroimaging and laboratory results, discuss cases with consultants, and document everything in the cumbersome electronic medical record. We explain as much as we can to patients and their families.

However, many patients are alone with minimal, if any, ability to communicate. Often, neurology patients are encephalopathic or comatose, limiting our interaction. Some are homeless or have poorly controlled mental illness. The patient may be a "John Doe" whose true name is unknown. No visitors will arrive until administrators identify the patient. Demented elderly patients, many of whom have lost a lifelong partner, may also endure hospitalizations alone. In all these situations, without family to communicate with, my time in the room may be brief. Sometimes patients remain alone and incommunicado for days.

A concerned family also holds me to account.

The persistent absence of visitors seems to convey a silent message: "In the outside world, no one cares about me." Although visitors may not be in attendance for many reasons—work obligations, distance, lack of knowledge of the hospitalization, or even an independent patient's wishes—an empty room advocates poorly for the patient.

Face-to-face time with each patient varies depending upon many factors, especially the complexity of the case and the clarity of the diagnosis. When family members are present, I take additional time to explain the diagnosis, prognosis, and therapeutic plan.

Sometimes that extra time improves the patient's care. It provides space for a more thorough exploration of the case and for consideration of fresh diagnostic and therapeutic options. Extra minutes may solidify a nascent therapeutic alliance. A concerned family also holds me to account, elevating the patient's importance in my mind.

Of course, longer patient visits aren't necessarily better visits. Families can be distracting when their needs and behavior pull focus from the patient.

But I often thank visitors for their presence and assistance. Many must sacrifice much needed income by taking leave from work, cope with unexpected travel expenses, or otherwise place their lives on hold. I have walked in those shoes and it is not easy.

Lately, after examining a patient alone in his or her room, I pause for a few seconds. I methodically wash my hands and thoroughly dry them with a paper towel. I scan the monitors. I watch the patient breathe. I let my thoughts settle.

Then I mentally explain the case to a nonexistent family member. Although patients cannot participate, they bear witness to these silent conversations. It's my hope that this additional attention improves their care. Maybe someday one of my patients will tell me.

Andrew Wilner is a professor of neurology at the University of Tennessee Health Science Center in Memphis, a health journalist, and an avid SCUBA diver. His latest book is The Locum Life: A Physician's Guide to Locum Tenens.

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