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Family presence: To stay or not to stay?

Thomas, Tamekia L. RN, BSN

doi: 10.1097/01.NURSE.0000314638.49473.91

Tamekia L. Thomas is a critical care education coordinator at Christiana Care Health System in Wilmington, Del.

Adapted from Thomas TL, Family presence: To stay or not to stay? Nursing2007 Critical Care, March 2007.

Over the past decade, the controversy of family presence during cardiopulmonary resuscitation (CPR) and invasive procedures has increased. Many professional organizations have supported the notion of family presence and have developed position statements concerning this topic.l Yet the controversy continues, mainly due to lack of policy changes and adaptation of written policies into practice.

The topic of family presence during resuscitation (FPDR) has gained the attention of the media, professional organizations, patients, and family members. Many research studies have been conducted to look at the benefits of family presence, family member perceptions and preferences related to being present during resuscitation, and health care providers' attitudes about family presence.2 However, several aspects related to this topic still need to be studied. For example, no study has compared the views of nurses at hospitals with formal policies on family presence to nurses at facilities that lack such policies. Studies also are needed on the factors affecting a health care provider's opinion about the presence of family members at resuscitation attempts.3

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Associations weigh in

In 1993, the Emergency Nurses Association (ENA) adopted a resolution to support family presence, and developed a position statement supporting it in 1994.4 Generally, the statement advocates for family presence during invasive procedures and CPR, and calls for the implementation of formal written policies and procedures. The ENA statement also encourages active research related to family presence and invasive procedures.4

In 2005, the American Heart Association (AHA) reinforced its recommendation to offer the option of FPDR to families in its guidelines on cardiopulmonary resuscitation.3 The guidelines suggest that offering select family members the opportunity to be present during resuscitation seems reasonable and desirable.3 It also suggests that the resuscitation team should be sensitive to the presence of family members during resuscitative efforts, assigning a team member to the family to answer questions, clarify information, and offer comfort.

Despite the acceptance of family presence by several professional organizations, this topic has created heightened awareness and debates among health care providers and consumers. Both research studies and public opinion polls suggest that most consumers think that patients' family members would want—and should be allowed—to be present at the time of death.1

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Supporting family presence

The perceptions of patients, families, and health care providers must be examined when determining the best path for family presence during resuscitation and invasive procedures. Several small studies have examined the benefits of family presence during resuscitative efforts and invasive procedures. Studies involving stressful medical procedures indicate that almost all children preferred to have their parents present.1 Being present during this time isn't only beneficial to patients, but also to their families.

Many families have been exposed to the idea of family presence through popular television shows (such as ER and Grey's Anatomy) and the media (for example, news reports, Dateline NBC, and USA Today). Although these media sources may exaggerate reality, family members feel they have an idea of what they might see if they're present during resuscitation. Consequently, family members are asking to be present.2

Findings of one study suggest that relatives who weren't present at resuscitation attempts had more psychological difficulties throughout their bereavement than those who witnessed an unsuccessful resuscitation. The study also suggests that patients who survived CPR didn't feel that their confidentiality had been compromised by the family presence.5

Witnessed resuscitation also can have a profound psychological effect on patients' relatives. According to experts, involving the family during resuscitation can help families and patients meet their emotional and psychological needs during a crisis.6 The study indicated that feelings of fear and anguish experienced by the family were diminished, and family members were better able to cope with the loss of a loved one. Being able to say goodbye to a loved one also was a noted benefit.6 This connection to a loved one eliminated the feeling of not knowing what happened during a resuscitation effort and diminished the feeling of being left alone and separated from a loved one.7

Researchers found that 80% of family members who lost a loved one in the emergency department would have wanted to be present if the option had been offered to them.8 In another study, 94% to 100% of family members who were present during resuscitation stated they would do so again in the future. The same study revealed that the family members felt it was their right to be present. Being present helped them comprehend the seriousness of the patient's condition, reassured the family members that everything possible had been done, and helped ease their grief.2

Experts agree that family presence helps facilitate the grieving process in the event of death and assists with a sense of closure.8 This closure lets loved ones say goodbye while the patient may still be able to hear them. Overall, family-witnessed resuscitation may help the family member with the adjustment of death.9

Another supporting argument for family presence during invasive procedures or resuscitation events is that family presence can be viewed as a natural outgrowth of family-centered care, which regards the family as the patient's primary source of strength and support.10 Family presence is consistent with nursing's holistic view of the patient and the basic tenets of nursing itself: “to advocate for the primacy of the patient's interests by meeting the comprehensive needs of the patients and their families across the care continuum.”11 Health care providers who've experienced family presence during resuscitation report that having patients' families present provides an opportunity to educate the families about the patients' condition and facilitate family participation in caring for patients. It also reminds the staff of a patient's personhood and encourages professional behavior at the bedside.1

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Obstacles to family presence

Those who oppose family presence during resuscitation fear that family members may interfere with the resuscitation efforts. Some health care providers expressed concerns that during family-witnessed CPR, nurses may be taken away from the patient to support the family members.12 Another fear is that the resuscitation team may be less focused due to family presence, putting the patient at risk. One expert compared the critical task of resuscitation to piloting an aircraft, noting that like the cockpit, the resuscitation room should be free from distractions, which includes family members.9

Violation of patient confidentiality and privacy is another argument raised by those who oppose family presence. Family members not only see everything happening to the patient, but also might hear personal information they don't already know. Could a health care provider be open to claims of negligence? Patients or family members could bring a claim of negligence should they decide that their confidentiality was breached in a manner to cause them harm.7 The fear of increased litigation also is a concern with family presence during resuscitation. Nurses may feel that family members are watching them to determine whether they're doing everything correctly. Many health care providers fear litigation from family members who believe they've seen an error or inappropriate care.6

Another concern is family members' emotional state. Some health care providers fear that family members may be disruptive or lose control emotionally, hindering resuscitation.1 According to researchers, nurses found it difficult to remain emotionally detached and to deal with the emotions displayed by family members present.13 Other concerns are negative family responses such as fainting, combativeness, violence, or uncontrolled emotional outbursts.

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Moving forward

Organizations such as ENA, the American Association of Critical-Care Nurses (AACN), and the National Association of Social Workers support family presence during resuscitation and invasive procedures. Other organizations, such as the AHA and the National Association of Emergency Medical Technicians, have incorporated similar recommendations by way of policy statements and position papers.14 Guidelines for family presence have also been integrated into several training curricula, including: the AHA advanced cardiovascular life support course and pediatric advanced life support course, the pediatric emergency medicine resource, the ENA's trauma nursing core curriculum, and the emergency nursing pediatric course.15

Although the positions are well stated by these professional organizations, many facilities lack written guidelines to govern when families can be present. Facilities should consider developing written policies or guidelines on family presence to meet the needs of patients and their families, and to facilitate the delivery of consistent, safe, and caring practices for patients, their families, and staff.1 The ENA has developed resources to assist organizations in creating such guidelines. These resources have been endorsed by AACN and consist of a tool kit that includes educational slides, handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, and a sample family presence guideline.15 Administrators should review the literature supporting family presence and use the tools available to implement such policies within their facilities.

Education should include the potential benefits of and possible obstacles to family presence, practice scenarios, and introduction of the family facilitator role.16 A key point to remember is that family presence isn't a mandate but an option that may not be right for every family. The option shouldn't be offered to families who are combative or those who display extreme emotional instability, signs of intoxication or drug use, or altered mental status. In addition, family presence shouldn't be considered if family members are suspected of abusing the patient.14

Experts recommend that a family presence policy designate a support person to remain with the family at all times during the resuscitation, to explain what's happening, and to provide emotional support. The comfort of having a support person directly available can help to alleviate the concerns and doubts that family members may have if they aren't allowed to view the resuscitation.

Regardless of the outcome, family members need to have a sense of closure that everything was done to revive their loved one. Letting families be present during resuscitation could strengthen the bond between health care providers and the family. A health care provider should also examine his or her own feelings and beliefs in relation to family presence. Nurses should be provided with the tools and education necessary to assist family members in dealing with a possible loss, as well as accepting the outcome and emotions of the resuscitation.

Family presence during resuscitation and invasive procedures has posed an ethical dilemma for health care professionals for more than 20 years. The debate over whether the benefits of family presence outweigh the risks is likely to continue. The question is, should facilities adopt the recommendations of several professional organizations and implement formal guidelines advocating family presence, or should they continue to let health care professionals act upon their own beliefs related to family presence?

The need to open this discussion with administrators is very important to preserve the dignity of the patient, protect family members, and assist health care providers. Further research on this topic is also needed to support the relevant outcomes and benefits.

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