Physical distancing measures during the COVID-19 pandemic have hindered communication between hospitalised patients and their family members. Sasangohar and colleagues[i] provide insight into use of an existing virtual intensive care unit (ICU) to facilitate online family visits amid Covid-19 visiting restrictions at a large, tertiary hospital in the United States. The paper raises some fascinating issues.
At one level, the authors simply describe the strategic adoption of a telemedicine platform that enables doctors to interact with patients using dedicated technologies, with the assistance of a bedside nurse. The platform was originally designed to allow healthcare systems to cope with the growing number of ICU patients over recent years. But, during the pandemic, the hospital site introduced the opportunity for family members to make use of the system in order to see and, if possible, talk to, a patient in ICU whilst keeping physically isolated. Drawing on pragmatically collected qualitative data, the authors outline the clear value these encounters offered and describe how grateful family members were for such opportunities at a time when visiting face-to-face was largely impossible.
On another level, the authors provide a view of the additional efforts required to make such a platform work for visitors as well as for healthcare professionals. To arrange a virtual visit, family members had to contact the ICU or the system’s operational centre; they then would receive a text or e-mail from a staff member that provided a weblink to enter the system. Even during a virtual visit, a bedside nurse was usually present. The implicit point is that such visits are normally referred to as ‘patient visits’, and in the article as ‘virtual patient visits’, but this belies the fact that there is much more to them than a person outside the hospital simply seeing and making contact with the patient.
So whilst the authors focus on facilitating virtual connections between family members and patients, we want to draw on data from our ethnography of palliative and end-of-life care in the UK[ii] to highlight the additional value of communication between families and staff that the article only mentions in passing. Indeed, the actual content of what is said in these encounters is often not the primary concern; what is significant is that the communication itself occurs. Family members gain a great deal from interactions with staff members that occur alongside seeing their loved ones – whether this takes the form of formal meetings and discussions, or more casual and momentary interactions with staff performing their standard work.
Our research shows that the desire to see a loved one who is critically ill in an ICU is also about seeing that they are being cared for, and making – albeit very fleetingly – relationships with those who are providing the care. It provides a way to develop a sense of trust, so that relatives can gain the sense that the healthcare team is striving to make the very best decisions for those close to them, even in situations that are uncertain, such as during the Covid-19 pandemic.
Relationships are not just sought by family members – they are just as important for clinical staff, especially in situations which are uncertain and perilous. In a virtual interview with us in May 2020, one ICU Consultant, Dr. Braun[iii], recounted that the absence of family members in the initial weeks of the COVID-19 pandemic brought into sharp relief the importance of communication with those close to the patient.[iv] Dr Braun and his team became increasingly aware that uncertainties about the disease were often exacerbated by the inability of patients, families and staff to meet together, face-to-face. Such conversations not only offer a means to glean more personal insight about who their patients are, especially if they are sedated and unconscious, but also allow staff themselves to expand their role from solely technical management to being part of a relationship based on human empathy and care. Not only did Dr Braun’s clinical team begin to proactively call family members, but they came to do this on a regular basis, even if the only update was that the condition of the patient had not changed.[v] Dr Braun saw this increased contact with family members as one of the few gains of the pandemic, and something they were hoping to continue in the future – for the sake of relatives and clinical staff.
The development of a relationship between staff and family members also shapes how relatives then relate to their ill loved ones. Even before the COVID-19 pandemic, we often observed ways in which staff encourage relatives to engage with the patient in specific ways. In one example, Annelieke accompanied Specialist Palliative Care consultant Dr. Clarke on a visit to Francesca, a comatose patient on a neurological ward, who was also being visited by her sister Marie at the time. Dr Clarke invited Marie into the nursing station for a longer chat. Towards the end of the conversation, Dr Clarke suggested to Marie that it was not certain if comatose patients can hear anything, but, “just in case. . .you could perhaps play some music to her that she liked, or you could read to her, if that is something you would imagine doing?” Afterward, Dr Clarke shared, “I am just thinking about the legacy: the way family members are going to look back after the patient has passed away”. In creating an opportunity for Marie to be more actively involved in Francesca’s care, Dr Clarke hoped she might one day look back on this distressing time a little more positively.
Through this lens, the organisation of virtual patient visits as described by Sasangohar and colleagues can also be understood as an opportunity to shape a better legacy. Encounters that are mediated through technology unfortunately cannot enable physical co-presence and touch. Other benefits to patient visits such as learning from patient-family interactions and creating trust will require additional investments into establishing contact with family members. But the visits potentially offer family members more than the memory of seeing their loved one while they were very sick, and in some cases in their last days of life. Through the brief but significant relationships they make with the staff in creating these virtual visits, family members may well also be able to feel that they were actively taking part in providing care for their loved one.
–Annelieke Driessen, Simon Cohn and Erica Borgstrom are researchers in the Forms of Care study.
Dr. Annelieke Driessen (@Annelie3ssen) is an Assistant Professor of Medical Anthropology at the London School of Hygiene and Tropical medicine. As Research Fellow at THIS Institute (The Health Improvement Studies Institute) she studies the experiences of patients who have been critically ill with COVID-19, and family members of COVID-19 ICU patients, and how their stories may be used in health service improvement.
Dr. Simon Cohn (@simoncohn) is Professor of Medical Anthropology at the London School of Hygiene and Tropical medicine (LSHTM). He is interested in the construction of biomedical knowledge, its everyday practice, and how non-experts make sense of it.
Dr. Erica Borgstrom (@EricaBorgstrom) is a lecturer at the Open University specialising in medical anthropology and end-of-life care. She is co-editor of Mortality, an interdisciplinary journal focusing on death and dying.
[i] Sasangohar F. et al. Use of Tele-Critical Care for Family Visitation to ICU During the COVID-19 Pandemic: An Interview Study and Sentiment Analysis. BMJ Qual Saf. 2020 Feb 28 [Epub ahead of print]. https://qualitysafety.bmj.com/content/early/2020/10/11/bmjqs-2020-011604.info.
[ii] See for the central premise of the project, Borgstrom, E., Cohn, S., & Driessen, A. (2020). ‘We come in as “the nothing”’. Medicine Anthropology Theory, 7(2). https://doi.org/10.17157/mat.7.2.769
[iii] All personal names have been replaced by pseudonyms to ensure confidentiality.
[iv] Driessen, A; Borgstrom, E; Cohn, S. “Ways of ‘being with’: caring for dying patients at the height of the COVID pandemic.” (Forthcoming). Anthropology in Action. 28 (1) xx
[v] For similar and additional interventions to support family members of ICU patients with COVID-19, see Lissoni, B., Del Negro, S., Brioschi, P., Casella, G., Fontana, I., Bruni, C., Lamiani, G., 2020. Promoting Resilience in the Acute Phase of the COVID-19 Pandemic: Psychological Interventions for Intensive Care Unit (ICU) Clinicians and Family Members. Psychological Trauma: Theory, Research, Practice, and Policy12, S105–S107. https://doi.org/10.1037/tra0000802