Annals of the American Thoracic Society

Although family is an essential unit of every society, many intensive care units continue to impose limitations on families’ access to their loved ones. Unlimited family presence is backed both by data and the guidelines of multiple professional societies. We propose that the obligation to protect the integrity and needs of our patients and families extends past our immediate relationship to them at the bedside, and is also a societal imperative. In a society rife with implicit bias, restrictions on family visitation risk selective enforcement of these rules, and further propagate social injustice. Restrictions on family presence, including rigid hours, reflect an arbitrary vision based on increasingly obsolete socioeconomic realities. The time is now to open our intensive care units both on behalf of our patients and families, and for the betterment of our society as a whole.

Family is a fundamental unit of every society on Earth. Families are comprised of individuals who provide support and create important bonds, bound by blood, marriage, or other deep relationships (1). Family participation in health care serves to improve outcomes across a broad spectrum of conditions (2, 3). Therefore, current guidelines recommend open family presence in the intensive care unit (ICU) (4, 5), while citing evidence of its safety. The majority of U.S. ICUs, however, continue to have limitations on visitation (6). Data on visiting hour restrictions in other inpatient settings are fewer, but such restrictions clearly exist (7).

The importance of open visitation extends beyond being the right thing to do. The alternative to open family presence is a system of rules barring families from their loved ones. Someone in authority makes these rules, outside of published evidence. Enforcement of such rules can be arbitrary and inequitable.

Traditional adult ICU visiting hours typically limit visits to a few hours in the late morning and the afternoon. Families are often excluded during early morning hours, under the well meaning logic of giving teams time to do morning hand-offs and rounds. A variety of rationales are given, supposing that limiting access of families to their loved ones benefits both groups (see Table 1). It should be noted that the arguments used to bar families from their loved ones in adult ICUs are the same used by pediatricians to keep parents from their children not long ago (8).

Table 1. Reasons given to limit family presence

Reason Given to Limit Family PresenceActual Data
Patient will be physiologically stressedNo adverse cardiovascular or neurologic effects when family present, cardiovascular events may decrease with unlimited presence (19), intracranial pressure is unchanged or decreases with family presence (20)
Patient may become agitatedFamily presence reduces delirium (21)
Limits are needed for infection controlNo evidence exists to support this (22)
Families will be too exhaustedFamilies have decreased anxiety, improved communication, and increased satisfaction with unlimited presence (17)

Adapted by permission from the Association of Critical-Care Nurses position statement (5).

Not only are these restrictions discordant with published data and guidelines, they are poorly aligned with the growing reality of many Americans’ work situations. More than one-quarter of Americans work nights. About one-third work 45 hours or more each week; 29% work weekends (9). Nonstandard and contingent work has increased, the commitment of their employers has declined, and the U.S. worker feels this instability and insecurity (10). These increasingly variable American work hours and challenges of obtaining leave misalign with stagnant visiting hours.

For many families, restrictive visiting hours look more like another institutional wall excluding them from those they love. This exclusion from their lives comes at the moment when their family members are at their most vulnerable. These barriers are highest for those families with the fewest economic resources and the least job flexibility—for example, those without family leave or those without financial means for daycare or additional caregiving. These are the families that suffer most from rules keeping them from their loved ones’ sides.

Beyond the challenges with visiting hours themselves, we must remember that visiting hours policies are not self-enforcing. Enforcement is by individuals, and the enforcement may frequently become selective. In a medical system already besieged by inequities in care, visitation policies become another way in which the health care system creates injustice.

As an on-call resident, I (G.N.) was seated at a nursing station writing my admission note when my attention was diverted. It was approximately 2,100 hours—late, but hardly the middle of the night. Two nurses were ordering a family member out of his loved one’s room. He explained, pleadingly but appropriately, that he simply wanted to be with his loved one, and that he would not interfere with her care. I certainly had not been aware of his presence before the commotion. “No,” the nurses replied, “visiting hours are over and you must leave.” The man was an African American. The care team—both nurses and physicians—were white. Were they ordering every family member to leave at that moment? Or were some patients—patients that might look more like those clinicians—receiving other accommodations? Despite the appearance of just following the rules, both of the authors can remember many nights on that same floor when families spent the entire evening. Instead, I watched and did nothing as he was escorted away from his loved one. Whatever their intent—either strictly following the rules or selectively enforcing them—in the years following, we understand that those in authority must mitigate against even the perception of bias.

Arbitrary limitations on family presence place health systems at grave risk of differential enforcement by race. Racial disparities persist in the U.S. health care system (11). We know that racial bias persists in the way the pain of African American patients is both perceived and treated (12). The Joint Commission recognizes that bias threatens the quality of care provided, and gives recommendations for health care workers to combat it (13). This bias—nearly always implicit, not explicit—no doubt frames perception of families’ suffering as well.

If restrictive visiting hours rules are stringently and universally enforced, they will systematically exclude the families of those less economically advantaged. If professionals are given the opportunity to humanely adapt to some patients, then rules can be differentially applied, reflecting our unconscious biases. Creating rules that can be variably enforced empowers even a tiny minority to give action to their racialized perceptions, because, in doing so, they are simply “enforcing the rules.”

How we view the presence of families with their loved ones is not merely an issue of race, but of the many social issues on which our nation is divided—which must be considered humanely in service of providing the best care to all patients. For example, in a nation in which many individuals and states did not recognize marriage between same-sex couples—and many may still not approve of these relationships—visiting hours create an opportunity to selectively enforce the presence of these same-sex loved ones at the bedside. This adds injury to the insult of these same-sex couples, who are less likely than those in opposite-sex relationships to have health insurance, and more likely to have unmet health care needs (14). In his memoir, My Own County, Abraham Verghese (15) reminds us of our recent history: an ICU unit clerk, early during the HIV epidemic, describing a gay man’s visitors with derision, commenting, “New York attitude—know what I mean?” So, too, should we consider our practice with the growth of the transgender population.

Several professional societies already recommend open visiting hours as best practice in our patients’ interest. Unfortunately, such endorsement, in and of itself, is often insufficient to lead to widespread implementation. Open visiting hours further each hospital’s mission of fairly and equitably serving all patients. This open family presence may particularly serve to improve patient and family satisfaction and the sense of attachment among some of those populations most likely to feel unwelcome in the hospital. This approach mitigates the risk, to some degree, of the hospital’s rules being used to further discrimination.

As physicians and researchers, we advocate that open presence provides optimal care to our patients and their loved ones, backed by evidence and expert consensus. Guidelines exist to successfully implement this approach, with safeguards for exceptions as they may occur (e.g., abusive or disruptive family members, communicable infection outbreaks) (5). Similarly, with unlimited presence, safeguards are needed to ensure environmental hygiene and sleep (16). Inviting families into the place that is rightfully theirs—the care of their loved ones—improves outcomes at the patient level and supports our patients’ families. This approach works, across community, tertiary care, and academic medical center ICUs (7, 17, 18). It’s time for us all to recognize that removing barriers between our patients and their loved ones is also a moral imperative at both the individual and societal level.

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4 . Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, Cox CE, Wunsch H, Wickline MA, Nunnally ME, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103128.
5 . American Association of Critical-Care Nurses. Family presence: visitation in the adult ICU. Crit Care Nurse 2012;32:7678.
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7 . Shulkin D, O’Keefe T, Visconi D, Robinson A, Rooke AS, Neigher W. Eliminating visiting hour restrictions in hospitals. J Healthc Qual 2014;36:5457.
8 . Markel H. When hospitals kept children from parents. New York Times January 1, 2008.
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11 . Ayanian JZ, Landon BE, Newhouse JP, Zaslavsky AM. Racial and ethnic disparities among enrollees in Medicare Advantage plans. N Engl J Med 2014;371:22882297.
12 . Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA 2016;113:42964301.
13 . The Joint Commission, Division of Health Care Improvement. Implicit bias in health care. Quick Safety: An Advisory on Safety & Quality Issues 2016;23:4.
14 . Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. Am J Public Health 2010;100:489495.
15 . Verghese A. My own country. New York: Simon & Schuster; 1994.
16 . Owens RL, Huynh TG, Netzer G. Sleep in the intensive care unit in a model of family-centered care. AACN Adv Crit Care 2017;28:171178.
17 . Chapman DK, Collingridge DS, Mitchell LA, Wright ES, Hopkins RO, Butler JM, Brown SM. Satisfaction with elimination of all visitation restrictions in a mixed-profile intensive care unit. Am J Crit Care 2016;25:4650.
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19 . Fumagalli S, Boncinelli L, Lo Nostro A, Valoti P, Baldereschi G, Di Bari M, Ungar A, Baldasseroni S, Geppetti P, Masotti G, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. Circulation 2006;113:946952.
20 . Hendrickson SL. Intracranial pressure changes and family presence. J Neurosci Nurs 1987;19:1417.
21 . Rosa RG, Tonietto TF, da Silva DB, Gutierres FA, Ascoli AM, Madeira LC, Rutzen W, Falavigna M, Robinson CC, Salluh JI, et al.; ICU Visits Study Group Investigators. Effectiveness and safety of an extended ICU visitation model for delirium prevention: a before and after study. Crit Care Med 2017;45:16601667.
22 . Malacarne P, Pini S, De Feo N. Relationship between pathogenic and colonizing microorganisms detected in intensive care unit patients and in their family members and visitors. Infect Control Hosp Epidemiol 2008;29:679681.
Correspondence and requests for reprints should be addressed to Giora Netzer, M.D., M.S.C.E., Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 2nd Floor, Baltimore, MD 21201. E-mail:

This work does not necessarily represent the views of the U.S. Government or Department of Veterans Affairs.

Author disclosures are available with the text of this article at www.atsjournals.org.

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