One of the many challenges that nurses face in the rural acute care setting is the frequent change in transition of duties experienced by a nurse generalist. Knowing what to do in any given situation and maintaining competencies in every area can be challenging. In addition to these challenges, there's minimum staffing to contend with. Minimum staffing in our rural ED consists primarily of one nurse and one physician, and when working the evening shifts some departments aren't required to stay in house but do remain on call. The following is an ethical situation that I faced while working the evening shift as the ED nurse in a rural acute care facility.
A page was received for the ED nurse to assist an elderly woman from her car. As I approached the car, I realized that this elderly woman, Ms. E, and her sister, Ms. M, were distant relations of mine. As I helped Ms. E into a wheelchair, she began telling me what occurred throughout the day and why she decided to come to the ED. She had been to the clinic earlier that day with generalized complaints of nausea and achiness.
The patient's sister, Ms. M, entered the ED and continued to describe the facts and that Ms. E wouldn't eat. As I assisted Ms. E onto the cot, I noticed that her color had changed and she was no longer responding. Ms. M stood in the small room and said nothing as I moved her to reach for the telephone to page a code. Upon returning to Ms. E, I began CPR. Another nurse arrived from the medical-surgical unit to assist and after 10 minutes the physi-cian arrived.
The ancillary staff began to filter into the ED somewhat surprised to see members of my family there. The physician and ancillary staff continued to work around Ms. M, who stood wherever she was out of the way. With every hand available working on Ms. E, no one was able to console Ms. M or explain what was happening to her sister. The social worker could have come in, but by the time she made it, the code would have been finished. The physician asked Ms. M whether she would step out, and knowing that this was her last living sister and that Ms. M was in a state of shock, I answered for her, as she could only nod yes or no. Ms. M didn't want to leave her sister's side, and acting as a family advocate, I supported her decision.
Supportive review of the literature
Family presence during resuscitation efforts has been a controversial issue for many years in the healthcare field. An article written by Fell in 2009 described a personal perspective of working in the ED and having a relative come in who wasn't feeling well, not unlike my own experience, which resulted in a code situation with family presence during this event. She described the effects of this traumatic event from her uncle's perspective, which he acknowledged in appreciation of everything that he had seen being done for his wife. Witnessing a code event and everything that goes into it may help to alleviate questions about what was done to reverse the negative outcome from happening.
However, there isn't a "perfect" code. At times, healthcare providers may treat other members of the team disrespectfully, perhaps due to the stress of the situation. Machines don't always work as they should; there may be difficulty establishing I.V. access or an inability to do so, sounds of adequate CPR may involve cracking of bones, or there may be the possibility of not being able to establish an airway at all. In order to have a positive effect from family member presence during a resuscitation event, it's imperative to have a desig-nated individual for support to explain what is or isn't happening. As stated by Fell, "ac-tions or interventions may be misinterpreted, leading to the assumption that the code team is incompetent." Another article, written by Engelhardt in 2008, also described the necessity and responsibility of the support person to assess how ready family members are for witnessing their loved one during resuscitation efforts in a healthcare facility.
Of the articles researched from 2005 to 2009, there's little evidence related specifically to rural settings. This is an area that needs further research, as rural settings deal with general-ist-type care with limited resources and personnel. There's evidence to suggest that many healthcare facilities don't have established policies or guidelines related to family presence during resuscitation events. With the increasing focus on the delivery of quality nurs-ing care, it's necessary within each institution to provide guidelines for the presence of family members to witness events related to lifesaving measures.
As stated by Engelhardt, "implementation of family presence guidelines can be difficult, and should fit within the institution's framework, with success depending upon the attitudes of the healthcare team." In 2005, an article by Nibert discussed the need "for nurse educators to design and teach undergraduate nurses in the ethical decisions needed during these events." However, this may be difficult as programs are currently overflowing with the basic informa-tion needed to start in this complex, but rewarding profession.
Integration into the nursing profession
In the facility in which I practice, there are positive attitudes exhibited by the healthcare team related to family presence; however, there's limited access to personnel during critical events such as resuscitation, making continuity of care very difficult in all situations.
It's imperative for healthcare institutions to establish an ethics committee to address the issue of family presence during resuscitation. For example, in order for this information to be integrated into the facility in which I practice, it will need to be addressed at a medical staff meeting for providers and at manager meetings, so that ancillary staff can be aware of the fam-ily when in a critical situation and explain what events are happening. An awareness of the importance to provide support for family members should be incorporated throughout the fa-cility.
In order to provide continuity of care, it's necessary to develop some sort of guidelines for dealing with family members when experiencing these critical situations, as well as re-sources available for support in a spiritual sense. Having experienced this myself, I feel that I'm more aware of my surroundings, as well as making sure that what I say in a stressful environment is respectful to the patient and family.
The effects over time of offering family presence during resuscitation will need to be researched in a more comprehensive way, and the effects of these experiences on family members post-resuscitation efforts may need to be analyzed. Due to the fact that resuscitation may be needed in any environment, having guidelines may not be appropriate in all situations.
As we move forward, I believe that this issue will be addressed and incorporated into every local and national nursing organization. When this occurs, it will be easier to facilitate its in-ception into healthcare organizations nationally, as regulatory agencies will oversee policy and procedure development and follow through. It has been shown that if offered the option to be present during a loved one's resuscitation or invasive procedure, most families would accept the chance. Offering this option to family members is at the heart of nursing as a pro-fession and caring as a model of practice.
Learn more about it
Badir A, Sepit D. Family presence during CPR: a study of the experiences and opinions of Turkish critical care nurses. Int J Nurs Stud
Emergency Nurses Association. Position statement: family presence during invasive procedures resuscitation in the emergency department. http://www.ena.org/SiteCollectionDocuments/Position%20Statements/FamilyPresence.pdf
Engelhardt E. Family presence during resuscitation. J Contin Educ Nurs
Fell O. Family presence during resuscitation efforts. Nurs Forum
Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care
Nibert AT. Teaching clinical ethics using a case study family presence during cardiopulmonary resuscitation. Crit Care Nurse