All Eyes on PCI—Should Patients’ Family Members Watch Cases?
Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.
Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.
Colleagues,
As the world knows, Paul Teirstein is a courageous and skilled interventionist. From his Scripps meetings, there’s always so much to take away. Last week, I was really taken by the case of the 86-year-old woman with a heavily calcified and highly tortuous LAD that challenged even Paul. Equally interesting was the fact that the patient’s daughter, a scientist, was in attendance after Paul and she discussed this.
Having the family in attendance during a case, let alone during a live case with a panel at a national meeting, is courageous and something that most of us might not encourage but others may. I spoke to Paul, and both of us wanted to get some idea of how this is thought of among our peers. Eventually, we’d like to let operators of live cases know our thoughts and provide insights from the field.
Question 1: Do you let family members watch their loved one’s procedure in your lab?
Question 2: Do you think it’s a good idea to have the patient’s family in live case demonstrations at interventional meetings?
My thoughts:
1. I do not want to have family members present during the procedures. It adds one more level of stress and should a complication occur, might be highly upsetting to all. After the case, I’m happy to bring the family member into the lab, see the patient, review the angiograms, and have a brief talk.
2. Regarding family members present at national live case demonstrations, I think this cannot be avoided as the meetings are open to all who register and attend. I would not invite them but if asked if they could be there, I would agree and discuss how the live cases are performed and what they might encounter.
Some live case operators are better than others. Same for moderators and panels. I think we should conduct the lives cases as if there were family present every time. The moderator and panel should be helpful and respectful. The principle operator should be focused on the patient, and the operator/discussant should be educating and interacting with the panel and aware of the audience’s need to understand the action. The panel should, of course, be engaged and not add flippant comments or distract with too much comedy. I like to recommend to my fellows and colleagues that brevity, clarity, and wit are usually appreciated—a light comment, appropriately directed and on point when possible, but never in a negative way.
Paul S. Teirstein, MD (Scripps Clinic, La Jolla, CA):
For our entire careers, there have been some physicians who’ve believed live cases in general should be outlawed.
In fact, about 30 years ago, someone on the Scripps ethics committee raised concerns about the ethics of live cases and they investigated my live conferences. They appointed a pulmonologist to audit the 3 days of live cases at the hotel. He was impressed by the conference and reported that he thought the patients receiving live surgery got terrific care and were protected during the conference. It ended up creating a wonderful friendship between me and the pulmonologist.
And just to be clear, I did not encourage the patient’s daughter to attend. Just the opposite. I told her I wasn’t thrilled about the idea and that it would place some more pressure on me, but if she went to the hotel, she should be able to watch and I would not stop her.
Of course, she loved it and thought it was fascinating, etc. Her presence, and witnessing the discussions, turned out to be very helpful. I ultimately decided not to try rotational ablation due to excessive risk in an extremely tortuous and very calcified LAD. Explaining the nuances of that decision to her turned out to be very easy after she had witnessed the discussion. So, in the end, I was glad she was there, but I did not encourage it.
Phillip Mumford, MHA, MBA, BSHA, RCIS (Memorial Hermann Northeast Hospital, Humble, TX):
It is our policy to restrict family members from observing procedures in the cath lab. I hold the view that this approach is essential, especially considering that circumstances can change rapidly during diagnostic catheterizations. Allowing family members to be present may heighten anxiety and could inadvertently interfere with the delivery of care.
Furthermore, having family members in the room during live cases can lead to misunderstandings about the situation at hand. These misinterpretations might be perceived as neglect or a lack of communication, potentially necessitating additional educational resources. It is crucial that the physician and staff can focus entirely on the procedure without the added pressure of managing family expectations and concerns. Therefore, maintaining a controlled environment in the cath lab is vital for ensuring optimal patient care and outcomes.
Kirk Garratt, MD (ChristianaCare, Newark, DE):
What a great topic, and Mort, I agree with everything you’ve said about this. Paul’s conferences are terrific and his outcomes are great, but overall outcomes at live cases aren’t that good. An increased risk of complications is expected when you select tough cases to show, but the stress and distraction of the theater environment has to contribute, too. I agree with you that it’s not a good idea to add the tension of a family member watching.
There’s also a risk of increased legal jeopardy: live cases involve dialogue (often with lots of jokes) between the operator and the panel. If there’s an adverse event, a family member might come away with the impression that the operator wasn’t as focused on the patient’s care as she/he should have been, which could translate into powerful courtroom testimony. I don’t think you can keep families away from presentations if they’re committed to attending, but we should discourage it, as Paul did in this case.
Barry Uretsky, MD (UAMS Medical Center, Little Rock, AR):
This is good question which we all encounter. I agree with everything you and Paul have written.
Personally I am not in favor of family members watching the procedure. An exception is in the case where the patient does not speak English and the presence of a family member who can interpret is often helpful to the operators and sometimes reassuring to the patient. I try to determine if the family member is psychologically capable of observing, and this determination is, of course, quite subjective and unscientific.
As for family members watching live cases, I agree you can’t stop them, but I am not in favor of it for all the same reasons as a local case, as well as the possibility of an errant comment by a panelist, moderator, or operator that can be misinterpreted by the family member.
Zoltan Turi, MD (Hackensack University Medical Center, NJ):
Mort, both you and Paul make excellent points. If I recall correctly, one of the pioneers of our field did an early balloon angioplasty on a patient whose physician son watched the case and as I recall the patient died on the table, though whether it had anything to do with the son being present I have no idea. But it engendered much debate about this topic some 40 years ago. Some of our colleagues, especially those with wide experience at live cases, I am sure can handle this well. For my part, I strongly discouraged the practice because I felt it changed the rhythm of the case and had the potential to affect our decision tree. We acquire finely tuned instincts that are potentially disrupted. A saying at the institution where you and I worked and that had its share of VIP patients was that “special care is bad care.” That is ancient history, but the principles would be the same. Great subject for debate.
David Cohen, MD (St. Francis Hospital, Roslyn, NY):
I am in agreement with everyone who has weighed in so far—a patient’s family members should not be allowed in the cath lab to watch their procedure. This should be a matter of lab policy so that there is no pressure on the IC to accommodate such a request. There is little upside that I can perceive and a great deal of potential downside related to differences in workflow and communication, not to mention the additional emotional burden if anything happens to go wrong. Has anyone ever heard of a family member observing surgery from the OR? When I have a patient whose family is particularly interested in understanding the procedure (such as a physician relative), I always try to bring them to a workstation and show them the entirety of the procedure after it’s completed. In that setting, communication and education are enhanced and there are no issues with emotional overtones.
Spencer King III, MD (Emory University, Atlanta, GA):
Forty-three years ago, Andreas Gruentzig proposed bringing the family in to the auditorium to watch our demonstration cases. I told him we were not going to do that, and we never did. I think he eventually agreed that it was a bad idea.
Carl Tommaso, MD (Retired, Dallas, TX):
Whenever I was asked if a family member could watch their relative’s procedure, I always said they were welcome to watch a procedure of a non-family member but not family. Never got taken up on the offer.
Arnold Seto, MD (Long Beach VA Medical Center, CA):
I agree with all of the thoughts that have been shared. Having a family member in the audience during a live case creates risk for everyone involved, including the patient (for getting different care than they might otherwise) and the operator (for having different pressures), but also the panelists (for whatever comments they might make).
Along those lines, I would suggest that if for some reason there is a family member in the audience, it would be best if all the operators and panelists were informed of their presence before the case begins, so that they might limit the scope/candor/humor of their remarks.
To be clear, though, we should preferably treat live case presentations as the equivalent of our safe space as operators to share thoughts openly, ideally with the protections similar to a case or morbidity and mortality conference.
Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY):
Couple of thoughts—fully agree with not having family in the lab there, because it is just an unpredictable X factor that is not needed (if there are issues).
For live cases, it is certainly more tricky. I have actually done two live transmissions with the family watching (both times these were physicians). One was a cardiologist who could have attended TCT in person—I’m not sure how I could have said no to that one. The other was interestingly not a cardiologist but wanted to observe along with her friend who is a cardiologist, and she knew that anyone registering could watch.
A few things about live cases—first, the data actually show that there are LESS adverse outcomes in these cases despite the increased case complexity. Maybe this is due to the detailed preplanning, the input of the panel, or fluke (although the n is not small). Second, I frankly believe that whether families are there or not, respect is critical and some of the more irreverent things that may have been more common when I was a fellow really shouldn’t/can’t happen anymore: first because they can be perceived as disrespectful, and second because in the current environment, we as a field are quite literally always a single tweet away from a major news story. Context is always important, but in our current world, perception (even out of context) becomes reality.
To this end, while we should always be on our best behavior, in retrospect I do think it’s important to notify the panelists/moderators in advance of the family member’s presence. In the more-recent case Margaret McEntegart and I did with the noncardiology family member in the audience, we were treating a chronic total occlusion through a CoreValve frame for the CTO Plus meeting. I didn’t mention the family’s presence online. Unfortunately, one of the more disinhibited panelists said aloud in discussing the case, “Why would anyone ever use that valve,” etc. I tried to be respectful and said, “There are always reasons that lead to the choice of valves, and the valve was done here at Columbia by our structural heart team, who do have a little bit of experience in the field.” I then later said that the patient’s family was watching. The panelist came up to me afterwards and feeling badly said, “Wow, I didn’t realize that.”
Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC):
Overall I agree and like the approaches articulated in most of this chain, from Paul and Mort through all to Ajay.
Two not-quite-random additional thoughts:
1. Performing or participating in (as panel members) a live procedure is a privilege. Whether family is present or not, all considerations should be on the patient. Docs who earn this privilege should never have to change what is done or what is said out loud by anyone—if they are inclined to do extra or cowboy things for an audience, or to be thoughtless or disrespectful in what they say out loud, they do not deserve this privilege.
2. While I agree with all and do not allow family in the lab during procedure, and in addition I do not seek to legislate who joins the audience in a live procedure broadcast, my starting point is to ask: why are they asking for this? What are they seeking?
If it is a family member who is just curious or even downright voyeuristic, or is a medical professional with truly educational interest, discussing the option to observe this type of procedure, but not on your family member, makes sense to me. On the other hand, if it is a family member who feels their presence, their love, and their prayers being present in the cath lab might provide support for both their loved one and for the cath lab staff, I will spend a moment with them to discuss how both love and prayer have powerful nonlocal presence in a cath lab, whether its source is sitting in the control room or sitting in the waiting room, as a way to make sure they are comfortable sitting in the waiting room.
Stephen Ramee, MD (LSU Health Sciences Center, New Orleans, LA):
I agree with my colleagues. Live cases are a very important teaching tool, and I’ve done hundreds of them with my friends and colleagues at Ochsner. I also think it is a bad idea to have family members in the cath lab or audience, but I wouldn’t tell Paul or the others what to do.
John A. Bittl, MD (formerly of AdventHealth Ocala, FL):
Good for Paul! Personally I would never impose a policy of having families present during PCI on any operator who was insecure or in a lab where privacy was not ensured. Given the right physical layout, however, any team could consider the advantage of family presence during diagnostic and PCI procedures. Having families watch procedures was the default approach in our institution in Ocala, Florida. This was achieved from the inception of the program in 1988 by attaching separate viewing galleries for each of our four catheterization laboratories. Having families present fostered shared decision-making, allowed heart team discussions to take place on an ad hoc basis at the point of care in a private setting, and was probably a major reason for our universally successful track record of risk management (ie, not a single legal action). Our patients and families loved it. It saved time explaining what we did and what the outcomes were. I wouldn’t have had it any other way.
Cohen:
That’s fascinating, John. I have never heard of a system like this at any other hospitals. I’m curious as to what the plan of action was if there was a major complication during a procedure (eg, perforation, cardiac arrest, etc)? I imagine that might be fairly upsetting for a family member to watch.
James Blankenship, MD (University of New Mexico, Albuquerque):
The last patient I sent to emergency surgery was 9 years ago after a Rotablator perforation unreachable by a covered stent. It was one of a few cases, and the last, where I allowed a family member to watch.
Bittl:
Although our policy of having families present during invasive and PCI procedures might seem unusual, that was our normal everyday practice at Munroe Regional Medical Center in Ocala, Florida. When our not-for-profit hospital was sold to AdventHealth several years ago, the new administrators did not cancel the program but simply instituted a policy of having no more than two family members at a time—usually a spouse and another first-degree relative—to prevent our nurse or tech recorder from getting overwhelmed by questions, but sometimes we made exceptions and let in three people at a time.
I am sorry to hear about Jim Blankenship's experience, but fortunately mishaps were very rare. When they occurred, family members witnessed the efforts made by the operator, team, and partners who were called in. We had the advantage of working in a small town where almost everyone knew us. If I was called by Bob Feldman into his lab for a procedural consultation, or vice versa, the families always seemed to know who we were. To answer your question, David, I would say that the type of mishap that would be apparent and upsetting to family members rarely occurred, but we always gave family members the option of being escorted from the cath lab viewing area to go sit in the waiting room during challenging situations. Given the choice, almost every family preferred to stay. I remember that when we had to cardiovert patients with STEMI who had reperfusion arrhythmias, the cath lab team worked so fast and quietly that family members missed most of the action but appreciated being there and getting a firsthand explanation of what went on.
One way to view family presence during invasive cardiac procedures is to recall how transformative it has been in obstetrics to have fathers in the delivery room during childbirth, through thick and thin. Additionally, there has been an important trend in critical care medicine since 2005 to have families present during codes of loved ones in the ICU.
In our experience, one irony of family presence was that if a case was completed so quickly before family members could be escorted into the viewing area, everyone was disappointed, but no one ever seemed to be disappointed by watching. They felt that they were part of our team.
The Bottom Line From Mort Kern
Most operators agreed that having a patient’s family member in the procedure room is not a good idea. It increases team stress and presents a problem for the operators to manage complications and potential medical-legal implications. Most operators were favorably inclined to show procedures to the family after the fact and discuss the important findings with all concerned.
As for family presence at live demonstration cases of their loved one, most operators would discourage this practice, but no one can prohibit their attendance. Should the family wish to observe in a live case at a meeting, the operating physician should explain to them what they will see, inform the audience and panelists of their presence, and remind the panel of the need for a very thoughtful discussion and commentary, as was the case for Paul Teirstein’s annual meeting.
Conversations in Cardiology is a collection of first-person perspectives from leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.
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