Should Families Be Present During Resuscitation?

from Medsurg Nursing ..

By Fitzgerald, Karen

Family presence during patient resuscitation has been discussed and debated since the early 1990s. Health care professionals and family members voice varying opinions on this topic, but research indicates that those who have had the experience found it positive. Should family members be offered the option to witness resuscitation efforts at their loved one's bedside? If family presence (FP) is allowed, does it positively or negatively affect the resuscitation efforts, the family, or the staff?

Pros and Cons

During a recent informal survey of nursing staff in medical- surgical, progressive, and intensive care units at a Long Island hospital, 50 nurses offered varying responses about allowing FP during patient resuscitation. Comments ranged from, "Absolutely not" to "Absolutely yes." Some of the arguments against FP included, "too traumatic for the family;" "there are too many people in the room already;" and "the code may continue beyond when it would normally be called." The situational arguments included, "If the patient is very young or very old, it would be OK;" and "If the code is expected, the family would be prepared, so it would be OK." Those with positive responses indicated that FP helped the family see that every- thing was done, and to bring closure to the patient's death. Is it a coincidence the positive responses were primarily from staff who had experienced family presence during resuscitation? MacLean, Guzzetta, White, Fontaine, and Eichorn (2003) noted a significantly greater percentage of respondents who preferred allowing family presence during resuscitation had previous experience with FP. Other researchers found nurses initially opposed to FP will change their attitudes after witnessing the connection between the patient and the patient's family and establishing their own relationship with the patient's family (Mian, Warchal, Whitney, Fitzmaurice, & Tancredi, 2007).

The range of responses to the question about FP reflects what researchers have found. For example, Alspach (2006) offered advantages and disadvantages to FP in the critical care setting (see Table 1).

Family Opinions

In 1994, the Emergency Nurses Association (ENA) adopted its first position statement on the issue of FP (ENA, 2005). Since then, the American Heart Association, the American Association of Critical- Care Nurses, the National Association of Social Workers, and the National Association of Emergency Medical Technicians have made recommendations supporting FP. A 1998 study tried to determine if witnessing resuscitation had any adverse psychological effects on bereaved relatives (Robinson, Mackenzie-Ross, Hewson, Egleston, & Prevost, 1998). Even though the sample size was small, researchers found no reported adverse psychological effects among the relatives who witnessed resuscitation; all of them were satisfied with their decision to remain with the patient. The resuscitation was not interrupted, and the decision to discontinue was not delayed because of the presence of a relative. Relatives did not comment on any of the technical or procedural difficulties encountered during some resuscitations. A more recent survey of 39 family members and 96 health care providers identified attitudes and experiences following FP (Meyers, Eichorn, Guzzetta, Clark, & Taliaferro, 2004). Researchers found 95% of family members said the visitation helped them comprehend the seriousness of the patient's condition and know every possible intervention had been done, and it allowed them to provide comfort and protection to a loved one. Overall, they viewed the experience as a positive one.

What Is Family?

According to the U.S. Census Bureau (2007), family is "a group of two or more people who reside together and who are related by birth, marriage, or adoption." A broader definition may be needed to include all individuals a patient in fact may identify as family. The Institute for Family-Centered Care (2006) defined family as "two or more persons who are related in any way - biologically, legally or emotionally; patients and families define their families."

Being Family-Centered

Historically, the sick received care from the family at home. Technologic advances led to provision of more health care by nurses in the hospital setting. Families often were excluded from providing for the needs of their loved ones (Nibert, 2005). Restricted visiting hours and limitation of visitors at the bedside further increased the distance between patients and their families. Traditionally, during resuscitation efforts, families were led from a room and away from their loved one, often into a private waiting area where they were left alone and uninformed. Frequently, the needs of the family at that time were not considered (York, 2004).

A philosophy of family-centered care gained momentum in pediatric practice in the latter 20th century as research identified the effects of parental/child separation during hospitalization (Committee on Hospital Care, American Academy of Pediatrics [AAP], 2003). The idea of involving the family in aspects of care grew to include the hospital delivery room as husbands and other family members wanted to be present during birth (Dokken & Ahmann, 2006). Open visiting hours now are more common in various settings, and family members have become involved in many aspects of care that historically were reserved for nurses. At times, health care providers have resisted these changes. Viewing the family as a continuation of the patient should put these changes in perspective. Changing the way health care providers think about the patient and the family improves patient and family outcomes, increases patient and family satisfaction, builds on family strengths, increases professional satisfaction, decreases health care costs, and leads to more effective use of health care resources (AAP, 2003; Davidson et al., 2007; Institute for Family Centered Care, 2008). Families today are exercising their right to be present during resuscitation the same way they once did to have fathers present in the delivery room (Davidson et al., 2007). A family-centered philosophy requires that outdated rules and regulations that were imposed for the benefit of the organization or staff rather than patients or patients' families should be reexamined (Briguglio, 2007). According to the Institute for Family- Centered Care (2008), the core concepts of family- centered care include dignity and respect, information sharing, participation, and collaboration (see Table 2).

Emotional Well-Being

Effective implementation of FP includes the use of a liaison to assess the emotional well-being of the relative, explain what the family would witness in the room, and stay with the individual throughout the resuscitation (Henneman & Cardin, 2002). In addition, the liaison prepares the family for the loved one's appearance, the procedures being performed, and situations which might require them to be escorted from the room (Meyers et al., 2004). The liaison can be a member of the pastoral care staff or a nurse provider who is well versed in the resuscitation effort.

Sometimes family members may just want to say good-bye or offer reassurance and support to the patient. They want to know that everything possible is being done. Asking them to wait outside may further increase their anxiety and stress. Families indicated their presence during resuscitation or invasive procedures decreased worry, minimized the agony of waiting, helped them face the reality of the situation, lessened helplessness, and facilitated grieving in later months (Meyers et al., 2004). They also believed their presence had an effect on health care providers as a reminder of personhood, helping the providers view the patient as a person and part of a family.

Communication

Researchers identified family members' needs during a healthrelated crisis, including honest, consistent, thorough communication with health care providers (Duran, Oman, Abel, Koziel, & Szymanski, 2007). Open, honest communication can alleviate anxiety, provide information to the patient and family for making important decisions, and decrease litigation. Effective communication leads to greater comfort in families expecting the resuscitation, and helps staff determine family wishes in the event resuscitation is needed; it also increases the use of advance directives (Barclay & Lie, 2007). A health care provider may find it helpful to ask a family member contemplating FP, "If your loved one were able to speak for herself, what do you think she would want us to do for her?" (Davidson et al., 2007).

Future Plans

Because the majority of patients do not survive the resuscitation efforts, it is difficult to know if they may have wanted their family members present. This indicates the need for public education to discuss a family member's desire for FP in much the same way as advance directives and organ donation (Halm, 2005). As Azoulay and Sprung (2004) noted, "There is a need for raising public awareness that end-of-life care is more an everyday-life issue than a medical issue." In addition, the majority of research was performed in hospital emergency departments, critical care units, and pediatric care areas. Further research should be expanded to include medical- surgical units.

Conclusion

Only about 5% of institutions have written policies on FP, but 45% of the nurses surveyed allow FP (MacLean et al., 2003). Barriers to FP still remain, but a multidisciplinary approach with development of a written policy can address the obstacles and allow staff to reflect on the successes. I was pleasantly surprised by the discussions which ensued among nursing staff after my informal survey about FP. With the nurses more open to FP, staff members will be initiating conversation with patients and families, instead of waiting for the family to ask to remain in the room. More information about family presence during resuscitation can be found on the ENA Web site (www.enaorg).

Copyright Anthony J. Jannetti, Inc. Dec 2008

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