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After my last post supporting the option of parent presence when a child is anesthetized for surgery, many parents and a reader with a disability shared their experiences and opinions.
Pediatric Anesthesia Forum
General Pediatric Anesthesia => General discussion => Topic started by: LouiseKinross on August 17, 2010, 06:09:31 PM
Title: Parent presence at induction
Post by: LouiseKinross on August 17, 2010, 06:09:31 PM
Given a CAPHC report showing parents overwhelmingly want to be present when their child is anesthetized in the OR, but wide variation in 16 Canadian hospitals surveyed as to when they do or don't allow parent presence, I would be grateful to hear comments from anesthetists as to whether you support, or don't support, parent presence, and why.
In addition, I am interested in knowing if any hospitals have a separate, "safe" ante-room where children are put under before being taken to the OR.
Operating rooms are horrifying places (massive lights, boxes of technology, frightening tools, people in masks). When so much effort is expended on making other experiences in the hospital child-friendly, I'm surprised that so little has been done to reduce the trauma of being taken to the OR and having a stranger put a mask over your face.
I am communications manager at Holland Bloorview Kids Rehabilitation Hospital here in Toronto, and write a blog on parenting kids with disabilities. I wrote a blog related to the new report re parent presence and my own personal experience with my son, who has had multiple surgeries. We've had a number of parent replies but I want to hear from anesthetists!
Why do you, or don't you, support parent presence? Does anyone have positive experience with a safe ante-room where kids are anesthetized before being taken to the OR? Or with other initiatives to make the operating room or induction less traumatic?
Many thanks! Louise
Title: Re: Parent presence at induction
Post by: mwkonig on August 20, 2010, 01:57:41 PM
Certainly a controversial topic and there probably isn't a single "right" answer to all aspects of this. One of the problems when discussing this topic is that we need to differentiate between what the parents want and what is beneficial for the child. It is easy to show that parental satisfaction increases when they are allowed to be present during induction of anesthesia. Despite the parental perception that they "help" their child during this phase, it is actually not at all proven that parental presence in fact benefits the child. This issue has just recently been reviewed in a Cochrane study and the author's conclusion was that parental presence is not superior to induction without parents, and likely less effective than premedication (see Yip et al.: Non-pharmacological interventions for assisting the induction of anaesthesia in children" Cochrane Database Syst Rev 2009: CD006447).
That being said, ultimately a lot of other factors come into play, many of them simply concern the logistics involved in providing the "parental presence option". Depending on OR layout, number and type of cases, available personal, additional expense, etc., bringing all parents into the actual OR for induction may be difficult and impractical and therefore parental presence may not be offered routinely at some places.
At my hospital we have induction rooms for most of our OR' so bringing parents in for induction is relatively easy since they dont have to change into a "bunny suit" or scrubs. As a consequence of this culture, parents here ususally expect to be able to accompany their child, even in cases where theit would certainly not make much sense, such as in the case of a small infant or an immature and tearful teenage parent. So many of us would like to sometimes limit this practice a bit, particularly when it seems unlikely that the child will get any benefit from it or when oral premedication with midazoloam seems more effective.
Title: Re: Parent presence at induction
Post by: LouiseKinross on August 22, 2010, 11:31:02 AM
Dear Dr. Konig: I'm immensely grateful for your message and insights.
Thank you for referring me to the Cochrane review, which I read. I was surprised that in the eight studies assessing parental presence not one showed parent presence reduced child's anxiety (vs induction without parents).
I did have a few thoughts. The review notes that most studies excluded children with a history of chronic illness or developmental delay. Some excluded children who had received previous surgery.
I think this is precisely the population in which parents are most insistent that they be present: children with chronic conditions who endure repeated surgeries (going to the OR is not a discreet/one-time, quickly forgotten event in the life of the child/family, but occurs multiple times a year, over years) and who may have developmental disability/be non-verbal (unable to advocate/parent is their only voice).
Perhaps it would be useful to study this specific population by tracking physiological indicators of anxiety at time of induction when parents are present vs. non-present. I think we also need to look at long-term impact of parental presence for this population.
The studies are telling me loud and clear that my presence is not reducing my son's fear in the moments of induction. What they are not gauging is the long-term psychological impact of him knowing that I am there. Yes, he went through hell, but mom was there. What does that mean for the level of trust between a vulnerable child and parent over time? What does it mean for the parent to be able to say: I couldn't take away the fear, but at least I was witness to it. He didn't do it alone.
(of course this may be irrelevant for the healthy, verbal child going in for the one minor surgery he'll have in his entire childhood).
The Cochrane review notes that most children find induction very stressful. My son has had more than a dozen surgeries and it was only recently that I learned he could be given a sedative in advance (and you note that premedication was shown to be superior to parent presence in one of the reviewed studies).
A parent wants full information that puts them in the best position to choose a course of action that will reduce their child's stress.
The review is positive in noting that child-focused interventions (therapeutic clowns, hypnosis, a quiet, low-sensory environment, and hand-held video games) can reduce anxiety. I hope we see more studies of these interventions with the most vulnerable children -- those who have repeated surgeries and those with delays who may not be able to speak for themselves.
How was the rationale made at your hospital for separate induction rooms that accommodate parent presence (given studies suggest it does not benefit the child)?
Again, thank you very much for taking the time to educate me about the Cochrane review and shed light from the perspective of an anesthesiologist. I will share our correspondence with the parent readers of BLOOM who I know will find it invaluable. Cheers. Louise
Sunday, August 15, 2010
Dec 20, 96: Anxious but cooperative.
April 14, 97: Teary-eyed 3-year-old (I wept when the record noted that he carried his beloved red fire hat).
May 27, 97: Cried on induction (Fire hat and butterfly net in attendance).
Dec 15, 97: Cried on induction.
Of course I didn't see these reactions because I wasn't given the option of being in the operating room while he was put to sleep.
So I was heartened to read a recent report on parent presence at surgical induction (and recovery) by a group that includes parents and professionals from the Canadian Family Advisory Network, the Canadian Association of Pediatric Health Centres and the Canadian Association of Child Life Leaders, as well as youth.
I found the report on Sasha Bella Stein Blumberg Forever -- a blog created in memory of a little girl who died from serious heart and liver problems. Her father Jonathan writes the blog and her parents started a fund to support family-centred care at SickKids hospital in Toronto.
Jonathan writes that an anesthetist describes induction without a parent like this: “A stranger picks you up and takes you away and puts a mask over your face and you wake up in pain."
The full report is posted on the Sasha Bella site and includes these findings:
97.3 per cent of 121 parents surveyed said it was very important or important for them to be present at induction, but about one-third had never been present.
Parents noted that they felt they had to "fight hard" or "battle" to be present at induction; that to be denied access made them question hospitals' stated commitment to family-centred care; that preparation for parents who attend an induction was essential; and that parent presence was particularly important when a child had developmental or other chronic conditions.
Just over half of 32 teenagers said they wanted a parent present with them at induction to make them feel safer, more comfortable and less alone.
A survey of 16 Canadian hospitals found wide variation in whether parents were allowed to be present. One hospital said it "always" gives parents the option, five said they "usually" do, eight said they "occasionally" do, and two said they "never" do.
Research suggests that being present does not necessarily reduce anxiety in patient or parent at the time of induction, but may reduce anxiety or other negative outcomes from the experience over time. Overall, the report says, there is agreement that parent presence is usually helpful when the child is undergoing repeated surgeries or has a mental health or developmental condition.
Recommendations included: that hospitals consider the benefits of parent presence and learn about the experiences of hospitals that have established programs; that CAPHC make information about member hospitals' policies available on its website: that parents be informed in advance whether they can be present, and, if they can't, why not; that where parent presence is offered, parents be educated in advance about what to expect and how to support their child.
I believe preparation is essential -- and can't be done on the fly in the OR. When I accompanied Ben for the first time more recently it wasn't till he was sitting on the table that a nurse said: "He may fight it. He may fall back, so I want you to be prepared. His eyes may fall back in his head."
In addition to preparing parents for what to expect -- and perhaps having a child life specialist present as a child/parent support -- it would be great if children could be put under in a "safe" adjoining room -- without the technology and tools visible -- or if hospitals looked at how to make the OR more child-friendly. Much effort is expended on the latter in other parts of children's hospitals, only to be negated by the frightening scene that awaits in the OR. The room Ben had his hip surgery in was massive, with imposing lights and boxes of technology and equipment that reminded me of power tools.
We've had anesthetists and nurses who took the time to explain equipment, cheer Ben on and reassure me, and others who just wanted to get the job done: they pulled the mask from behind him, so he didn't see it, then placed it on his mouth and held it while he thrashed.
It's painful to see your child's body fight, then slump, then become lifeless. Last time the anesthetist and nurses looked up at me expectantly -- as if to say: "This is your exit lady." I bent over to kiss his cheek and breathed in the foul gas still billowing from the mask. They took off his hospital gown and I left him there, unconscious and naked.
It's disturbing, but I wouldn't have it any other way. A child deserves to have a parent with them through that kind of horror.
Monday, August 9, 2010
Last year Columbia University launched the first graduate program in Narrative Medicine, noting that "our modern medical system has all but forgotten the critical importance of stories: stories of suffering, stories of healing, stories of the relationships that tie patients to their clinicians."