During a resuscitation effort in most emergency departments, the patient is wheeled into the trauma room and the family is escorted into the family crisis room. While we work desperately to resuscitate the patient, a social worker updates the family on our progress. If the patient dies, we make him as presentable as we can, quickly put the room in order, and then invite the family in to say good-bye to their loved one. The social worker supports the family during this difficult time, and we, the code team, return to our other patients.
For decades, this approach seemed to work well. We feared that if we did let the family in during the code, they'd either get in the way or become so distraught that we'd have more patients on our hands. We felt we were doing the family a greater service by letting them see their loved one only after we'd removed tubes and lines, even though the calm scene we produced was in total contradiction to actual events.
But recently, this traditional approach has sparked controversy. Many family members want to be present during resuscitation efforts. Health care professionals are divided on whether families should be present, but most agree the issue must be addressed.
As nurses, our primary question about any policy change must be: Will this benefit the patient above all? Here, we'll discuss the pros and cons of family presence during a code and let you decide.
How family presence can help …
Hearing is the last sense to cease, and many seemingly unconscious patients may have some awareness of their surroundings. Aware of his family's presence and hearing their encouraging, loving words, a patient may find the strength to survive or take great comfort if he's dying. A family's support can help a patient feel less alone and vulnerable among strangers. If he's dying, he may well prefer to see loved ones' faces than those of the code team.
Allowing family to be present carries some obvious benefits for family members too: This may be their last chance to see their loved one and to say good-bye while he's alive. And although witnessing a failed resuscitation is a severely traumatic event for a family, seeing the extraordinary effort put forth by the code team gives real meaning to the words “We did everything we could.”
Being shut out of the resuscitation process can increase family members' feelings of helplessness, anxiety, panic, and guilt. But being able to care for a loved one during his final moments, even in small ways, and to say good-bye can reduce those feelings and help family members through the grieving process.
A family's presence can't help but increase the staff's emotional vulnerability, yet even this can benefit the family, according to research. The code team may want to be strong for the family, but families seem touched when physicians or nurses show their own grief over a patient's death.
… and how it can hinder
Family presence during resuscitation also has some serious drawbacks. Resuscitation is an intense situation; every second is critical. What if distressed family members interfere with resuscitation efforts? And how can staff continue to work effectively in the midst of a frightened, grieving family? If family members are present, will they distract attention from the patient and the care he needs?
Furthermore, resuscitation isn't pretty. How many families can handle watching someone they love undergo such aggressive measures as chest compression and intubation?
The potentially long-term mental anguish families can suffer in response to watching a resuscitation has legal as well as ethical implications. Things can go wrong during any medical procedure; the presence of family members could easily increase staff anxiety and make matters worse. Family members could sue the staff or facility for negligence or for emotional distress caused by seeing the resuscitation. However, one study points out that angry family members who are shut out of the resuscitation effort are more likely to bring a lawsuit and that providing the right kind of support may actually reduce legal risks.
And, most important, what about the patient's wishes? A patient might want his loved ones to remember him as he looked when he was alive and well, rather than during the last moments of cardiopulmonary resuscitation. He might want to face his death alone. How do we know whose wishes we're fulfilling when we allow family into the trauma room?
Weighing the pros and cons
Clearly, trying to meet all the needs of everyone involved in a resuscitation attempt would be difficult at best. We must prioritize those needs—and the patient's needs come first.
Overall, most of those who've studied this issue believe that despite the frightening and potentially traumatizing aspects of a resuscitation effort, the benefits of family presence outweigh the negatives. The patient always takes top priority, but in the broader view, the family is part of the patient. Truly holistic care takes into account not only the patient, but also his family during an event as crucial as resuscitation. Even though the patient can't be consulted during resuscitation, he's more likely to feel comforted hearing the voice of his spouse or his child than just staff members shouting to each other over his bed. And the clear benefits to family members—a chance to say good-bye, reduced guilt and anxiety, firsthand knowledge of the staff's effort to resuscitate, and possibly a more straightforward grieving process—outweigh the potential emotional trauma.
Because of the limited space and the staff's need for order and control in the resuscitation room, though, the number of family members present may need to be limited.
Nurses often take the initiative in raising the question of family presence during a code. The American Heart Association's 2001 Advanced Cardiac Life Support Provider Manual suggests we “consider the presence of the patient's family and loved ones during resuscitation attempts.” However, a recent survey found that only 5% of respondents work in units with written policies for family presence. If witnessed resuscitation is to become standard, code teams and emergency personnel together must create a clear-cut policy for their facility. This policy-making team should include nursing, medical, and risk management staff; a chaplain; and representation from social services, the ethics committee, and the volunteer department. The team must decide:
* who will be the family advocate during resuscitation efforts
* how many family members (and which ones) can be present in the room at one time
* when family will be allowed into the resuscitation room
* what the family's responsibilities will be
* where family can be in the room
* under what circumstances to make exceptions.
Educational programs for staff would be key to any new policy's success. One study recommends that educational programs teach nurses how to provide constant support for family members, helping them understand what procedures they're witnessing and how the patient is responding. Facilities may need to commit to having a trained nurse available to take this role during a resuscitation.
If the facility where you work doesn't already have a protocol in place for family-witnessed resuscitation, why not take the initiative and start the process? The Emergency Nurses Association's 2001 manual, Presenting the Option for Family Presence (2nd edition), may help guide your institution. One of the greatest gifts that we as nurses can give to families of patients we can't save is the privilege of being present during the last moments of life, to offer comfort, express love, and say good-bye.
Lauren Marrone is a staff nurse in the burn and reconstructive/plastic surgery unit at Massachusetts General Hospital in Boston. Catherine Fogg is a critical care instructor at St. Anselm College in Manchester, N.H., and a staff nurse in the emergency department at Catholic Medical Center in Manchester.