Valentina Di Bernardo
rMH 26, 2013, 11-13
A cultural change
The now extensive literature on the subject of the opening of intensive care units (ICUS) shows the benefits to patients, family members and nursing staff resulting from the adoption of a liberal visiting policy within these departments. Both from a clinical and organisational point of view, for some time now, we have been able to prove the groundlessness of the reasons put forward to justify the usual restrictions imposed on the admittance and visiting right of family members. Despite the abundant evidence to that effect, in many situations intensive care units continue to be “closed” wards at the behest of the healthcare staff, and in particular of the nursing staff. Maybe the reasons of this should be identified with an organisational and cultural structure that deserves to be studied from the point of view of the relationships and dynamics within the healthcare team. Effective exchange of information, involvement in the decision-making process and mutual trust seem to be the necessary preconditions to make a change, which only in this way can actually benefit all those who will be involved in it.
rMH 26, 2013, 14-17
From machine-patient to person-patient
In the field of resuscitation everything revolves around the patient: machines, monitors, medications, and staff. Patients are often unaware of such great care, but when they feel its weight on their own bodies they do not often experience any benefit. What is made in icus is to repair (or at least to try to) the patient’s biological part, his outer machine, which almost never coincides with his or her spiritual side, humanity. Hence the fact that critical care, invasive, advanced and border medicine should make an effort to restore the patient’s humanity in its place, i.e. at the centre of care. When biology and spirituality do not coincide, it should start from the latter to succeed in putting in place the best possible care measures for that specific patient. Disease and care should become more and more a social fact, taking into account the patient’s loved ones, their life plans and wills. Besides being an ethical and moral act, involving families in the process of care of a critical patient is also useful to the success of medicine.
rMH 26, 2013, 18-25
Open intensive care units: the case in favour
From the time of their creation less than fifty years ago and for many years thereafter, icus were “closed” wards where access for family members and visitors was looked on unfavorably and was therefore strictly limited. This strategy was frequently motivated above all by fears regarding the risk of infection, interference with patient care, increased stress for patients and family members, and the violation of confidentiality. This article deals with the issue of “open” intensive care unit (ICU), i.e. a unit oriented towards the implementation of non-restrictive visiting policies and committed to removing all barriers that have no justifiable necessity, on the level of time, on the physical level and on the level of relationships. The most common objections to opening intensive care units are examined, and the clinical and ethical reasons behind this alternative are considered. As things stand, there is no solid scientific basis for limiting visitors” access to icus and keeping icus “closed”. Numerous data suggest that the liberalization of access to icu for family members and visitors is not only in no way dangerous for patients but is on the contrary beneficial both for them and for their families. “Opening” icus should come about not so much in answer to pressure generated by a growing social awareness, or in simple recognition of a right, but because this policy addresses more comprehensively the issue of respect for the patient, as well as providing more appropriate responses to many needs of both patients and families. It is a decision which requires doctors and nurses to rethink their relationships with patients and their families, which calls for original solutions for each individual situation, and which should be subject to periodical checks.
rMH 26, 2013, 26-29
The open intensive care unit at the Regional Hospital of Mendrisio
Intensive care units (ICU) are historically regarded as closed wards governed by a very restrictive visiting policy. The maintenance of this closure is probably due to a culturalhistorical factor. In fact, current knowledge does not show cases in favour of the closed or restrictive model. We open an icu only if we remove the temporal, physical and relational barriers. In this way we break down time limits and symbolic walls. This, however, cannot be just a definition. To find out the intrinsic meaning of an Open-icu, we need to go beyond an easy definition. An Open-icu is above all a new model of care, really patient-centred, an ethical act, respectful of the principles of autonomy and beneficence, as well as a great cultural change. Opening is more: philosophy of care, narrative medicine, listening, humanisation, therapeutic relationship and, last but not least, it is a patient’s right. Furthermore, an Open-icu model is a way to find out sustainable and ethical solutions with the help of family members, in a technological context such as the critical area. Starting from these statements and reflections, we decided to implement an Open-model in our icu (September 2012): visits permitted 24 hours a day and an open-door policy. During this period we also conducted a nationwide survey in order to investigate the visiting policies implemented in the Swiss icus and compare these results with those from other European countries. What we discovered is that the Swiss icus are less restrictive than, say it, French, Italian and Belgian icus; nevertheless, in Switzerland too the Openmodel is not fully widespread and only 2 out of 73 adult icus implemented this care model.
rMH 26, 2013, 30-36
End-of-life care in the intensive care units (open)
End-of-life care in icus is an extremely challenging and complex situation. The dying person is living the most vulnerable part of his/her life, the final one, the one in which his/her dignity risks to be neglected and – consequently – should be particularly protected and promoted. The person’s family must make an effort to understand, so as to accept and to cope with such a tremendous grief. The health care team must help both the dying person and his/her family members in the most meaningful way. But this can be actually very difficult. An open icu can help very much in this sense, as it makes meaningful relationships possible, in which the human dimension of the caring profession can emerge at its best.
rMH 26, 2013, 44-58
No man's time. A glance at waiting in the intensive care unit
The article (an excerpt from a longer work, so far unpublished), which is the result of a partecipant observation in the service of intensive care at the Regional Hospital of Lugano performed a few years ago, portrays the experience of waiting in an environment of critical care medicine under its manifold aspects. Waiting, experienced by the various people involved, is considered through the theme of time and space, the themes of passivity and action, of forecasting and distraction, of journey, deception, gift and pledge, of presence and witness, absence and transcendence… Which are all components to be found in different proportions in the patient’s, relative’s and caregiver’s experiences: experiences that sometimes converge, and some other times diverge. The description of the experience of waiting is therefore proposed from a phenomenological point of view, which aims – if not to transform practices – at least to provide operators with new images so that they can see things from a different perspective when focusing their attention on such a crucial component of the experience of illness, hospitalization and care, which is rarely taken into consideration.
rMH 26, 2013, 71-74
Elder mistreatment and abuse
The World Health Organisation issued a report on elder abuse in the European countries in 2011. The report estimates that elder mistreatment (involving people aged 60 years and older) affects 4 million elderly people in Europe every year. With increasing life expectancy, this number is expected to grow unless effective prevention programmes are put in place. A systematic review from 2008 revealed that 6 percent of the elderly people surveyed in a wide range of countries (including European countries, Korea, the United States, and Canada) reported abuse. The range of abuse across cultures varied from 3 to 27 percent, with psychological abuse reported by nearly one-fourth of the elderly people surveyed who were dependent on caregivers. In 2005, 41 percent of community-residing Medicare beneficiaries aged over 65 years had difficulty performing of daily living activities (DLAS) or instrumental daily living activities (IDLAS) and potentially needed support from either paid or unpaid caregivers.
Delphine Roulet Schwab
rMH 26, 2013, 75-79
Representations of elder mistreatment
Elder abuse was recognized since 2002 as a priority public health problem for the World Health Organisation (who). In the Suisse Romande (i.e. the French-speaking districts of western Switzerland), they began to talk about elder abuse in the late 90s. Today, it is found that very few situations of elder abuse are reported to the police, justice and other competent authorities. Similarly, the performance of specific prevention services, which have been developing over the last ten years, are relatively not so much in demand. The research presented in the article aims at bringing elements of understanding for this situation. It explores the representations that the persons in charge of the institutions in the French-speaking Switzerland have of elder abuse, investigating the way in which this problem is handled by the institutions of the Suisse Romande. Finally, it suggests roadmaps aimed at optimizing prevention.