[Tweety]

EMERGENCY NURSES ASSOCIATION
POSITION STATEMENT

FAMILY PRESENCE AT THE BEDSIDE DURING INVASIVE PROCEDURES AND RESUSCITATION


STATEMENT OF PROBLEM

Family-centered care recognizes the role of the family in the health and well being of the patient. It is characterized by collaboration among the patient, family, and health care professionals and recognizes that the family is a constant in the patient’s life (Eckle, 2001; Eckle & MacLean, 2001). In most instances, families are the patient's primary support system.

In 1993, the Emergency Nurses Association adopted a resolution to support the option of family presence during invasive procedures (IP) and resuscitation (CPR) (ENA, 1993). However, written policies allowing the option of family presence during IP and CPR are infrequent in emergency departments (MacLean et al., 2001). In a recent study of 456 emergency nurses and 473 critical care nurses (MacLean et al., 2001), only 9% of the emergency nurses indicated that their emergency department had written policies allowing the option of family presence during CPR and IP. A greater percentage reported that the emergency department had no written policy but allowed the option during CPR (68%) and IP (80%). Emergency nurses reported that only 1% of their emergency departments had written policies prohibiting family presence during IP and CPR, however, the option of family presence was prohibited for IP (20%) and CPR (32%) in the absence of a written policy. Written policies and practices allowing the option of family presence during IP and CPR continue to be underutilized in U.S. emergency departments.

Several investigators document the benefits of family presence during IP and CPR which includes knowing that everything possible was being done for their loved one; reducing anxiety and fear; feeling of being supportive and helpful to the patient and the staff; sharing critical information about the patient and the patient’s condition; maintaining the patient-family relationship; closure on a life shared together; and facilitating the grieving process in the emergency department and later at home (Bauchner, Waring, & Vinci, 1991; Meyers et al., 2000; MacLean et al., 2001; Robinson, MacKenzie-Ross, & Campbell-Hawson, 1998; Sacchetti et al., 1996; Timmermans, 1997). Patients indicated that having family present provided comfort, helped with coping and pain control, maintained the family bond, and reminded health providers that the patient was a person with a family who deserved dignity, and respect (Eichhorn et al., 2001; Robinson et al., 1998). In addition, the American Heart Association’s Guidelines 2000 recommended that providers offer families the option to remain with their loved one during resuscitation (AHA, 2000).

Although many patients, family members, and health care providers support the option of family presence, family members frequently are not given the option to remain with the patient during invasive procedures and resuscitation efforts. This separation during treatment occurs for a variety of reasons. Health professionals express concern that the event may be too traumatic for the family; clinical care might be impeded; family members might become too emotional or out of control; staff may experience increased stress with family present; ED rooms are too crowded; staff are focused on the patient and may not be available to assist family members; the shortage of nurses; and the risk of increased liability (Belanger & Reed, 1997; Eichhorn, Meyers, & Guzzetta, 1995; Eichhorn, Meyers, Mitchell, & Guzzetta, 1996; Eichhorn et. al, 2001; MacLean et al., 2001; Meyers et al., 2000; Redley & Hood, 1996; Rosenczweig, 1998; Sacchetti et al., 1996; Timmermans, 1997; Van der Woning, 1997). Yet, families reported that they would be present again if a similar event occurred (Belanger & Reed, 1997; Powers & Rubenstein, 1999; Meyers et al., 2000). In addition, investigators reported that there were no adverse psychological effects among family members and the operations of the emergency care providers was not disrupted when the option of family presence was used (Belanger & Reed, 1997; Meyers et al., 2000; Robinson et al., 1998; Sacchetti et al., 1996).

ASSOCIATION POSITION

ENA supports the option of family presence during invasive procedures and resuscitation.

ENA supports further research related to the presence of family members during invasive procedures and resuscitation and the impact it has upon family members, patients, and health care personnel.

ENA supports the development and dissemination of educational resources for emergency department health care personnel concerning policies, practices, and programs supporting the option of family presence.

ENA supports the development and dissemination of educational resources for the public concerning the option of family presence during invasive procedures and resuscitation.

ENA supports collaboration with other specialty organizations (including, but not limited to nursing, social and family services, pastoral care, physicians, and pre-hospital care providers) to develop multidisciplinary guidelines related to family presence during invasive procedures and/or resuscitation.

ENA supports healthcare facilities having in place policies and procedures allowing the option of family presence during invasive procedures and resuscitation.

RATIONALE

The core principles of family-centered care (Eckles, 2001; Eckles & MacLean, 2001; Institute, 1998) include:

Treating patients and families with dignity and respect.
Communication of unbiased information.
Patient and family participation in experiences that enhance control and independence and build on their strengths.
Collaboration in the delivery of care, policy, and program development, and professional education.

Every emergency department patient is a member of a family system with the family being defined as a person(s) who has an established mutual relationship with the patient. The family system is the major source of support for the individual during times of stress, crisis, and decision making. Research studies have shown that most families want the option to be present during invasive procedures, during their child’s medical procedures, and at the time of a loved one’s death (Bauchner, Vinci, & Waring, 1989; Bauchner et al., 1991; Meyers et al., 2000; Sacchetti et al., 1996). Seventy-five percent of the emergency nurses reported that families asked to be present during IP and 42% stated that families asked to be present during CPR (MacLean et al., 2001). However, the nurses also stated that many family members did not know they could ask to be present and staff did not always ask them (MacLean et al., 2001). Leske (1986) and Molter (1979) indicated that the most important needs identified by family members of critically ill patients are to:
be with the patient
be helpful to the patient
be informed of the patient's condition (including impending death)
be comforted and supported by family
be accepted, comforted, and supported by health care personnel
feel that the patient was receiving the best possible care

Ultimately, the patient and the family members are the individuals who have the most vested interests in the outcomes of invasive procedures and resuscitation. Therefore, these individuals in collaboration with their health care providers should make the decision regarding family presence. The option of family presence provides a means to enhance the care of patients in the emergency department.

REFERENCES

American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 102 (8 Suppl.), I-374.

Bauchner, H., Vinci, R., & Waring, C. (1989). Pediatric procedures: Do parents want to watch? Pediatrics, 84, 907-909.

Bauchner, H., Waring, C., & Vinci, R. (1991). Parental presence during procedures in an emergency room: Results from 50 observations. Pediatrics, 87, 544-548.

Belanger, M., & Reed, S. (1997). A rural community hospital’s experience with family-witnessed resuscitation. Journal of Emergency Nursing, 23(3), 238-239.

Eckle, N. (Ed). (2001). Presenting the option of family presence (2nd ed.). Emergency Nurses Association. Des Plaines, IL.

Eckle, N., & MacLean, S. (2001). Assessment of family-centered care for pediatric patients in the emergency department. Journal of Emergency Nursing, 27(3), 238-245.

Eichhorn, D.J., Meyers, T.A., & Guzzetta, C.E. (1995). Family presence during resuscitation: It is time to open the door. Capsules Comments Critical Care Nursing, 3, 1-5.

Eichhorn, D.J., Meyers, T.A., Mitchell, T.G., & Guzzetta, C.E. (1996). Opening the doors: Family presence during resuscitation. Journal of Cardiovascular Nursing, 10(4), 59-70.

Eichhorn, D.J., Meyers, T.A., Guzzetta, C.E., Clark, A.P., Klein, J.D., Taliaferro, E., & Calvin, A.O. (2001). Family presence during invasive procedures and resuscitation: Hearing the voice of the patient. American Journal of Nursing, 101(5), 26-33.

Emergency Nurses Association. (1993). Family presence at the bedside during invasive procedures and/or resuscitation. Resolution, 93, 2.

Institute for Family Centered Care. (1998). Core principles of family-centered health care. Advances in Family Centered-Care, 4, 2-4.

Leske, J.S. (1986). Needs of relatives of critically ill patients: A follow-up. Heart and Lung, 15 (2), 189-193.

MacLean, S., White, C., Guzzetta, C.E., Fontaine, D., Eichhorn, D.J., Meyers, T.A., & Desy, P. (2001). Family presence practices of critical care and emergency nurses in the United States. (raw data). Emergency Nurses Association, Des Plaines, IL.

Meyers, T.A., Eichhorn, D.J., Guzzetta, C.E., Clark, A.P., Klein, J.D., Taliaferro, E., & Calvin, A.O. (2000). Family presence during invasive procedures and resuscitation: The experience of family members, nurses, and physicians. American Journal of Nursing, 100(2), 32-42.

Molter, N. (1979). Needs of relatives of critically ill patients: A descriptive study. Heart and Lung, 8,
332-339.

Powers, K.S., & Rubenstein, J. S. (1999). Family presence during invasive procedures in the pediatric intensive care unit. Archives of Pediatric Adolescent Medicine, 153, 955-958.

Redley, B., & Hood, K. (1996). Staff attitudes towards family presence during resuscitation. Accident and Emergency Nursing, 4(3), 145-151.

Robinson, S., MacKenzie-Ross, S., Campbell-Hawson, G., et al. (1998). Psychological effect of witnessed resuscitation on bereaved relatives. Lancet, 352, 614-617.

Rosenczweig, C. (1998). Should relatives witness resuscitation? Canadian Medical Association Journal, 158(5), 617-620.

Sacchetti, A., Lichenstein, R., Carraccio, C., et al. (1996). Family member presence during pediatric emergency department procedures. Pediatric Emergency Care, 12(4), 268-271.

Timmermans, S. (1997). High touch in high tech: The presence of relatives and friends during resuscitation efforts. Scholarly Inquiry of Nursing Practice, 11(2), 153-168.

Van der Woning, M. (1997). Should relatives be invited to witness a resuscitation attempt? Accident and Emergency Nursing, 5(4), 215-218.


Developed: 1994.

Approved by the ENA Board of Directors: April 1994.
Revised and Approved by the ENA Board of Directors: September 1994.
Revised and Approved by the ENA Board of Directors: May 1996.
Approved by the ENA Board of Directors: September 1998.
Revised and Approved by the ENA Board of Directors: July 2001.

© Emergency Nurses Association, 2001.







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[Tweety]

Here's another brief article.

http://ajcc.aacnjournals.org/cgi/content/full/12/3/190


Obviously, for and against can go tit for tat. And everyone can come up with examples of family presence during a code that didn't work out well at all.

[ClaireMacl]

From a personal point of view, I wouldn't like my last memory of my loved one being someone pumping on their chest.

I've been in the situation a few times where a patient has crashed while relatives are with them, it poses a few problems I feel. In the situations I've seen, the family will, understandably, become hysterical. Now, while this is a normal reaction, it can impede upon our efforts to begin CPR, I've seen a relative throw themselves over a relative and refuse to move - out of grief, so we have no way of accessing the patient.

Distraught members of families also mean that one of the team who should be assisting in CPR will inevitably be separated from the patient to calm the family and explain what is happening when their skills would be better used assisting.

Provided the family was not prohibiting me doing my best to save their relative, I would let them stay if that was their choice, but to be honest, its not something I would advocate. The situation does change, however, if it is a child. I don't think anyone has brought this up so far, but I think I would actively encourage parents to be present during CPR, provided they wished to and it did not impede upon treatment.

It's such a difficult topic to decide on. I don't think it should be ever encouraged as part of the grieving process, but should be guaged on individual cases.

[Tweety]

Originally Posted by ClaireMacl

From a personal point of view, I wouldn't like my last memory of my loved one being someone pumping on their chest.

I've been in the situation a few times where a patient has crashed while relatives are with them, it poses a few problems I feel. In the situations I've seen, the family will, understandably, become hysterical. Now, while this is a normal reaction, it can impede upon our efforts to begin CPR, I've seen a relative throw themselves over a relative and refuse to move - out of grief, so we have no way of accessing the patient.

Distraught members of families also mean that one of the team who should be assisting in CPR will inevitably be separated from the patient to calm the family and explain what is happening when their skills would be better used assisting.

Provided the family was not prohibiting me doing my best to save their relative, I would let them stay if that was their choice, but to be honest, its not something I would advocate. The situation does change, however, if it is a child. I don't think anyone has brought this up so far, but I think I would actively encourage parents to be present during CPR, provided they wished to and it did not impede upon treatment.

It's such a difficult topic to decide on. I don't think it should be ever encouraged as part of the grieving process, but should be guaged on individual cases.

This is why I think first it's important to have some sort of training and education, and the family members should have someone there supporting them.

My hospital asks family members to leave the room, and someone usually stays with them outside the room or walks them to a waiting room.

Fortunately I haven't witnessed any hysterics. Most family members cry and even sob outside the room, wondering what's going on, some trying to peek into the room. It's very important to have someone supporting this person, talking to them, explaining things to them, keeping them calm.

Again, we all have our stories and there are plenty of stories of family presence that didn't go well. There are also plenty of positive stories, even though it's a horribly tramaumatic experience for sure.

[casper1]

One thing I feel in absolutely essential if a family member is witnessing a code, is a dedicated staff member who stands by the family explaining code procedures and what medications are being given who provides support to the family during a trying time for everyone involved patient, staff and family.

[VickyRN]

Originally Posted by casper1

One thing I feel in absolutely essential if a family member is witnessing a code, is a dedicated staff member who stands by the family explaining code procedures and what medications are being given who provides support to the family during a trying time for everyone involved patient, staff and family.

ITA. If such a policy is enacted, then the facility must ensure that proper supportive staff are available. Otherwise, this will put inordinate stress on nursing and other interdisciplinary healthcare members, as well as exposing them to an increased risk of lawsuit.

[Ruby Vee]

Originally Posted by BabyRN2Be

I'm just curious if anyone has seen this happen, family members becoming disruptive during a code.

Anyone had this happen?

.

Had a wife (somewhat dramatic under the best of conditions anyway) fling herself, shrieking at my NM. I suspect she was trying to fling herself into the NM's arms to be held, but NM wasn't prepared for the onslaught and went down on a floor already slippery with blood and body fluids, hysterical wife on top of her. That put a halt to family witnessing codes in that unit for awhile!

Another wife became overwrought and jumped on one of the residents, screaming and whacking away at him with her oversized purse. Chaplain that was supposed to be with the wife just stood there with mouth gaping open . . . not a pretty sight.

While I would want to BE there for my family (and Hubby wouldn't mind) I wouldn't want anyone witnessing MY code. And in general, I'm against the whole idea. There's nothing wrong with a little staff comfort, either.

Ruby

[ZASHAGALKA]

Originally Posted by Tweety

EMERGENCY NURSES ASSOCIATION POSITION STATEMENT

Actually, this was the first place I looked when I was researching it.

In another thread (the now famous 'can you be a nurse without Jean Watson' thread), to you, I suggested that the politics of academia limits what the ivory tower gang can say that is relevant to the bedside. Those politics limit their research to what is 'academically' accepted by their peers.

Nursing academia is entrenched on this idea. They have drawn a line. Do you think an academic in nursing can now publish ANYTHING negative of FP? I don't. So, because it's now a political sin (or rather a CLM - career limiting move) for any nursing organization or academic to go against FP, everything nursing has to say on the topic going forward is biased.

Why? Because anything NEGATIVE about FP will not be published, plain an simple. Not in nursing, not by TPTB. If you only publish the results that support your opinion and conveniently neglect what doesn't, that is bias. I went looking into FP yesterday. Read the quotes I found on it. Do you think it's possible that I also found positive aspects of FP, aspects I conveniently failed to post. I admit it, I'm biased and opinionated on this issue. But. I'm not passing my input off as unbiased 'research'.

I think nursing academia could have brought this up short of making absolutes that alienate not only our other peers, but a good percentage of ourselves. This is a tough issue, with equally substantive opinions on both sides. But it's just like nursing academia to take a stand without regard to what ANYBODY in the real world, nursing included, think on the topic. (57% of nurses disagree with FP).

Nursing Academia is quick to point out that HOSPITALS must included bedside nurses from design to implementation on issues that affect the bedside nurse. But that are loath to follow their own advice.

~faith,
Timothy.

[canoehead]

If a family member is witnessing a code I think all responsibility for their actions is removed (and they shouldn't have to feel guilty for that). But, I think that in a situation of life or death there should not be a person present who could possibly fling themselves on the bed and then claim it was the code team's responsibility to make sure they didn't interfere with the resuscitation. The code team already has a full and immediate obligation to the resuscitation. If they are in a situation where they are dividing their attention at all I think it is a breach of care to the patient on the bed.

Funny thing, I would absolutely, positively want to be there if my family member was coded, but I feel just as strongly that I would NOT want anyone witnessing my code. I can't put my finger on why, or how to resolve such an hypocritical personal opinion. Does someone else have the insight I lack?

[ZASHAGALKA]

Originally Posted by canoehead

Funny thing, I would absolutely, positively want to be there if my family member was coded, but I feel just as strongly that I would NOT want anyone witnessing my code. I can't put my finger on why, or how to resolve such an hypocritical personal opinion. Does someone else have the insight I lack?

This is a common thought.

And it's EXACTLY why families cannot be surrogate decision makers for a patient in this situation. It is impossible to distinguish between your wishes as a family member and the potential wishes of the patient in this situation. And the gold standard for family members as surrogates isn't what they (the family) want, but their input into what the patient would want.

And the gold standard also isn't what nurses want the families to do, in order to create a standard.

Without a patient's actual consent, FP is a violation of privacy.

~faith,
Timothy.