As Teresa Ciappa neared her death in an ICU last year, her family was barred from visiting due to restrictions meant to contain Covid-19. Her daughter now wonders whether in-person visits might have improved Ciappa's care, or even saved her life, Marion Renault writes for STAT News.

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Covid-19 hit, and hospitals locked down

According to Renault, ICUs have not traditionally been welcoming to visitors, as many clinicians believed their patients were too ill—and their treatments too severe—to be disturbed. But before the pandemic, some hospitals were starting to shift their policies, broadening their limited visiting hours so that loved ones could visit at their discretion.

Then, Renault writes, Covid-19 hit. Hospitals locked down to prevent the spread of a deadly disease, and loved ones were barred from visiting patients in-person.

In the case of Teresa Ciappa, her daughter, Michelle Ciappa, could communicate with Teresa only through a virtual portal until she was near death. At that point, the family was permitted to say their final goodbyes in person.

"She was alone in a room. That's the opposite of who she was," Michelle Ciappa said, adding that she believes if she had been able to be there for her mother in person, "maybe the outcome would've been different."

'There is a real cost'

According to Renault, a growing body of research seems to support the belief that in-person visitation provides a clinical benefit. Studies have shown that visitation results in:

• Shorter ICU stays;
• Patients being less likely to suffer from delirium or anxiety, which in turn curbs the risk of PTSD, long-term cognitive decline, and functional disability;
• Patients having lower levels of stress-related hormones;
• Coronary patients having lower heart rates after bedside visits; and
• Patients with brain conditions showing a decrease in intracranial pressure during their bedside visits.

Not only can visitors physically comfort their loved ones, but they also may improve care by identifying issues that might otherwise have been overlooked. Visitors can provide details that may be missing from patients' health records, notice subtle changes in behavior, and raise "red flags" as they stay with their loved ones, Renault writes.

Research has also highlighted benefits of visitation for the visitors themselves, Renault writes, including lower rates of depression, PTSD, and anxiety. And, inversely, isolation can make patients sicker; for example, research suggests that loneliness in older adults is linked to increased risk of disease and substance use, and that less socially active people are more susceptible to cold viruses.

Overall, according to a 2017 systemic review, 78% of studies on ICU care interventions focused on the patient or family identified at least one positive outcome.

Nonetheless, according to Renault, some clinicians have remained hesitant of embracing visitation, in part because many of the studies have significant limitations (such as small sample sizes) and because the results typically involved measures of family satisfaction or mental health, rather than "'harder' metrics" involving mortality or similar measures. Concerns also remain about containing Covid-19 at a time when cases are surging nationwide.

But several clinicians said they were convinced of the benefits of visitations after witnessing the effect of extreme isolation on their patients amid the pandemic.

"When you've lived without it, you recognize how much that connection matters," Rachel Sackrowitz, a critical care medicine doctor at the University of Pittsburgh Medical Center, said. "It's just more evident in ways that it hadn't been before."

"There seems to be this feeling that family is nice-to-have, not essential," Daniela Lamas, a pulmonary and critical care physician at Brigham & Women's Hospital, added. But when family isn't with patients, "there is a real cost," she said.

'There is still a very large gap that needs to be bridged with future studies'

Now, some experts are worried that the movement to allow—or even encourage—visitation has lost its pre-pandemic momentum, Renault writes.

"It took time to get those family-centered policies into the fabric of hospitals," said Traci Snedden, a critical care nurse and assistant professor of nursing at the University of Wisconsin-Madison. "Will Covid give clinicians permission to pull back again, or will it propel us forward like, 'I can't believe we went without family at the bedside'?"

While many hospitals have kept visiting restrictions in place, Akin Demehin, director of policy at the American Hospital Association, said others are "embracing the role of caregiver or the loved one as being really instrumental to the patient's recovery"—although decisions about whether and how to adopt outside support will vary from hospital to hospital.

And though many health care workers have observed "the brutal impacts of isolation on patients during the pandemic," Renault writes, experts said more evidence likely will be needed before health systems alter their pandemic-era policies—research that can be challenging to conduct on a large scale and in an ethical manner.

"There's more appreciation, but I'm not so convinced things will change," said Michael Goldfarb, a cardiac intensivist at McGill University. "There is still a very large gap that needs to be bridged with future studies."

Nonetheless, according to Renault, patients' family members, such as Michelle Ciappa, hope that the anecdotal experiences of ICU specialists and patient families could encourage future studies and reconsideration of these policies. "I'd hope they can figure out a way for someone to always be there," Michelle Ciappa said. (Renault, STAT, 7/28)