Family Witnessing Code Activities

allnurses Guide · Aug 27, 2005

I didn't say this, even though I WOULD take the position that the death of a child is more traumatic.
I SAID that a parent can make decisions for a minor. An adult is different. If you truly believe that we should go down this road, then consent to witness should become part of advanced directives.
Unless that patient gives expressed consent for witnesses, then it is a violation of right to privacy. We cannot boldly declare that patients have rights, unless of course WE decide they aren't worth merit. The inherent problem is that a crashing patient cannot consent to witnesses. And a potential witness cannot understand the ramifications of what is being offered to them.
This reminds me of the old days, where a patient's advance directives ended the moment a family member objected. It's basically what we are saying now: a patient's right to dignity is only as good as a family member's objection. Only, it's not the family members, per se, violating that right and dignity. It's US, for offering to undermine it.
I wouldn't call this advocacy. (and consent is only one of many concerns).
As far as citing my material, I was compiling it on Word and the program crashed. I'll have to go back over it again - but alot of the data comes from AAST (amer assoc of surgery for trauma), the ENA (emergency nurses assoc) and, I believe, the College of ER Physicians.
Siri, you said you did a thesis on this topic. Can you quote a study w/ a significant statistical population? If we want our colleagues to take nursing research seriously, then we must apply the same rigid standards that we expect of others.
I'll be back after I recompile some data.
~faith,
Timothy.

Thanks Timothy - that is what I thought you said.

steph

ZASHAGALKA, RN · Aug 27, 2005

I'll have to post in 2 parts, because I had to change computers due to this one being unstable at the moment. (time to defrag).

Wall Street Journal 10/12/04

Staying With Patient in ER Or ICU Can Have Benefits

"A survey of 600 critical-care doctors and nurses released two years ago in the cardiac-care journal Chest found that 80% of physicians disapproved of having family members present during invasive procedures, while only 57% of nurses objected. Although the American Medical Association has yet to take a position on the issue, the American Association of Critical Care Nurses and the Emergency Nurses Association both support family presence."

***

From a 1999 study by Amer Asso for Surgery of Trauma:

More AAST than ENA (Emer Nurses Assoc) members (98% vs. 80%) felt that FP during all phases of TR (trauma resus) was inappropriate. Fewer AAST members felt that FP was a patient right when compared with ENA members. AAST members were more likely to believe FP interfered with patient care and increased the stress of trauma team members. The majority of AAST and ENA members had experience with FP during TR (55.1 vs. 67.7%. However, the impressions of their experiences were widely disparate, with 63.6% of ENA and only 16.8% of AAST members indicating that the experience was beneficial.

Conclusion: Attitudes toward FP during TR are significantly different between AAST and ENA members. Because of these differences in opinion, implementation of a FP policy is likely to create conflicts between trauma team members and may interfere with the effectiveness of the trauma team.

***

From American College of Emergency Physicians:

About 5 percent of U.S. hospitals have written policies permitting family presence during CPR or invasive procedures, according to a survey published in the Journal of Emergency Nursing and the American Journal of Critical Care.

The views of medical personnel can affect the appropriateness of the practice. If emergency staff are sufficiently uncomfortable with the presence of family - to the point it might impact their performance - then family members should not be present.

Some physicians believe family presence should be allowed in every department, while others believe it should be prohibited. With strong feelings and good supporting arguments on both sides of this issue, it's not surprising there is no universal approach to family presence in all hospitals.

From ACEP's guidelines on family presence: Family presence should never be forced on either the family or the emergency department staff.

~faith,

Timothy.

Thunderwolf, MSN, RN · Aug 27, 2005

Whoa, what a thread! I'm somewhat torn on this. However, Tim raises most excellent points.

Unless that patient gives expressed consent for witnesses, then it is a violation of right to privacy. We cannot boldly declare that patients have rights, unless of course WE decide they aren't worth merit. The inherent problem is that a crashing patient cannot consent to witnesses. And a potential witness cannot understand the ramifications of what is being offered to them.
This reminds me of the old days, where a patient's advance directives ended the moment a family member objected. It's basically what we are saying now: a patient's right to dignity is only as good as a family member's objection. Only, it's not the family members, per se, violating that right and dignity. It's US, for offering to undermine it.
I wouldn't call this advocacy.

Good points have been raised, thus far, in this discussion...on both sides. However, although torn, I have to stop myself and ask, "who is the patient? and "what is the objective of a code?"

Isn't it enough for the family to see "the results" of a code? If the patient survives, the family and team can each give a welcome sigh. If the patient doesn't survive, aren't the results pretty evident? Regardless of outcome, the family knows the patient is being or has been coded...so, what's to see?...but the gore and additional trauma to the loved one's body during the code itself. Has anyone done follow up studies regarding PTSD symptoms of family members who were exposed to this? It begs to ask this considering how even ER staff and paramedics become traumatized with the strangers THEY code coming into THEIR lives...who are not family. Doesn't it make some sense that witnessing a family member in a code may be just a little more traumatizing? I just don't know. I think further studies need to be conducted on this and pulled together for additional comparison before a positive conclusion can be made that it is in the best interest of the patient and/or the family. In saying all of this, and what it could trend to, what's next?...family gowned and masked at the operating table or at the autopsy table at the county morgue...well, why not?

Here is my bias (we all have bias). If I was in a code, I would not want my family to see me, nor my body, go through the "mechanics" of a code: being disrobed, catheterized, chest tubed, intubated, seeing my life blood on the floor or on the hands of the code team, hearing my ribs crack or seeing my chest cracked, or my secretions being suctioned into a canister...all in the matter of minutes. I would not want MY family to witness this...why would I? If I don't allow my children to watch R rated movies, why would I consent to my family viewing this happening to me? I really think that this is a quite normal, human reaction to shelter my loved ones from all this. I guess the question that follows is...would you want your family to witness it to you? But, I think, in general, most lay persons (and maybe professionals as well) would probably say a resounding NO if the tables were turned. I'm not really trying to play devil's advocate here, but inviting posters to view it from the perspective of the person who is being coded who unfortunately cannot speak for him/herself during this chaotic, horrific event. In a less horrific example, let's say on the Med-surg floor, I have to cath a patient. What does common sense tell one regarding the family being present at the bedside during THIS procedure? Isn't it IMPLIED that consent would NOT be given by the patient to have the family there, witnessing the catheterization...up close and personal? Isn't the expectation to ask the family, on behalf of the patient, to step out until the procedure is done? What would THE PATIENT think or say if the nurse took it upon him/herself "to invite the family in" instead, implying that it is OK? Is this not what we are implying when we ask the family in during a code?...disregarding the patient. Does the patient become less of a human being, just because he/she is unconscious on an ER table? And...who is to say that the patient doesn't HAVE SOME awareness during this event? At least for the moment as you read this, do not view it from the family perspective, but from the patient perspective who is on the table. At this moment, place yourself there...on the ER table. When we shift our perspective in this manner, family choice to step in and witness becomes somewhat a moot issue.

So, in summary, I think it is reasonable that the patient would NOT give consent to family in witnessing his/her code...unless maybe, prior consent, was given...better yet, in writing (like a living will). So I have to agree with Tim at this stage of the debate. If I'm on the ER table being coded, what happened to my right to privacy and dignity, especially in front of my family and friends? Who would stand up for me and be an advocate on my behalf?

ZASHAGALKA, RN · Aug 27, 2005

Part 2

From NYT 15May01

"Family presence is very controversial because it's a radical departure from standard operating procedure," said Dr. R. Stephen Smith, a professor at the University of Kansas School of Medicine and the trauma director of Via Christi Medical Center in Wichita, Kan. "It elicits extremely visceral responses, regardless of what side of the issue someone is on."

. . ."If you have to take a big long needle and stick it into the heart to let the blood out, it might seem terrible to someone even though it's a lifesaving procedure," said Dr. Gail Anderson, the medical director for Harbor-U.C.L.A. Medical Center.

"When you're flying a plane, you don't want a lot of family members coming into the cockpit; you want the pilot focused on getting up and down safely," Dr. Anderson said.

. . .While 33 percent of the surgeons believed that it was never appropriate for family members to be present in a resuscitation, only 5 percent of nurses agreed. Among those who had experience with family presence, 74 percent of the doctors viewed it negatively compared with 27 percent of the nurses.

* * *

VA - Ethics Hotline Call, August 14, 2001

Gary Abrams, Neurologist, Bioethics Committee, San Francisco VA: I have a question. Where do we draw the line on this. What if a family wants to videotape the resuscitation? Where does the local judgment of the professional community come into this particular argument?

Dr. Berkowitz: I will take a stab at this one. I think allowing the onlookers that that premise is predicated on the fact that it is justifiable because it will do some good, either for the family or for the patient, by providing support and a presence. I am not sure that you could say the same about making a videotape. So to me that is over the line. That's my personal opinion.

* * *

This is an MD who has served on several panels on the topic:

From: Tim Buchman

Date: 17.06.98 04:43 GMT

There is a substantial difference between the scope and urgency of interventions when one is trying to preserve life and those when one revises to the priorities of comfort care measures. I do not think it is helpful for families to watch the often hurried, sometimes desperate measures involved in a major trauma resuscitation whereas I always think it is helpful for families to be present and participate in the process of dying. . .

I applaud efforts to involve famlies and friends in the process of care--but there is a time, a place, and an appropriate scope for involvement. Twenty minutes after the car crash, in the trauma bay watching the insertion of a chest tube somehow strikes me as less than appropriate.

* * *

This proposal of having families present during resuscitation is a classic example of planning without understanding, theory without practice, and of course, nursing leadership without nursing.

Arthur Lam MD

Seattle, WA

I didn't say the last thing: but it's a telling comment by an MD.

~faith,

Timothy.

ZASHAGALKA, RN · Aug 27, 2005

I've dominated this thread. My apologies to that.

Let me say that I'm am not discrediting the opposing point of view.

There are credible and substantial arguments on both sides of this coin. But that is exactly why this will always be a controversial topic.

Would I say that families can NEVER be in the room? No. But I think it also shouldn't be a 'standard'.

Have I seen families in the room during a code? Yes, I have. Do I approve? Not really, for several reasons, previously stated. But the families I've seen present were passionate about being there, which is a far cry from being 'invited'. I dont think it should be offered, but, by the same token, I've seen that it is often (not always, but often) not refused.

It's a difficult issue. I'm guess I'm glad that it's being discussed, but not if it's to the exclusion of the opposing point of view. This is one of the problems with nursing theory. Most of the articles I researched acknowledge that nursing is leading the way on this issue. It seems we go out of our way to adopt views without regard to our professional peers and then we wonder why we aren't treated as professional peers.

I won't say that I won't comment anymore, or that I'm dropping the topic - I think it can readily be inferred that I have an impassioned point of view. LOL. But. While I might respond to a comment here or there, I will take a step back and allow other opinions to emerge.

~faith,

Timothy.

NurCrystal22 · Aug 27, 2005

I don't think I would want to see the CODE, I would trust the everything was being done to save/help my family member, I think it would be too traumatic for me personally.

~Crystal

Thunderwolf, MSN, RN · Aug 27, 2005

Thanks Tim and thanks to the rest of our peers who have kept to the meaning of a lively, yet civil, debate. When we are able to share our viewpoints respectfully, we all benefit from the interaction.

Wolfy

Tweety, BSN, RN · Aug 27, 2005

I was involved in a code when I first became a nurse. A young Native American man was being coded, his Native American wife was standing in the room with arms raised, praying and the rest of his family were around the bed. We coded him for over an hour because the wife was positive that she could pray hard enough for him to live. Our doc couldn't persuade her to stop. She got angry with anyone who tried to talk to her. We all took turns, had to call in extra staff to help from the ER, it was awful.
Finally the young man's brother took his sister-in-law's arm and pulled her from the room and talked to her firmly that her husband, his brother, was gone. She finally let us stop.
It was very difficult.
steph

The woman must feel a bit better knowing that you and she did everything possible to save her loved one. She would never have that peace and tramatized for life had she not been there. You guys on the other hand perhaps learned something and learned how to deal with this situation in the future, but hopefully weren't tramatized for life.

Tweety, BSN, RN · Aug 27, 2005

I won't say that I won't comment anymore, or that I'm dropping the topic - I think it can readily be inferred that I have an impassioned point of view. LOL. But. While I might respond to a comment here or there, I will take a step back and allow other opinions to emerge.
~faith,
Timothy.

Timothy, I appreciate your point of view always. I personally don't want to dominate this thread either, but am not shy about offering my two cents.

Tweety, BSN, RN · Aug 27, 2005

This is why we need to sell DVDs - so everybody can watch.
A tad bit of sarcasm there, but I was doing some on-line 'research' on this and there was actually a debate in a VA teleconference on Ethics whether videotaping a code was 'over the line'. It was, barely. But it seems to be where we are heading.
I noticed, during my look, that the Docs are strongly against family presence (80%) and nurses are 57% against this practice - from a 2002 study from the journal 'Chest' as reported in the Wall Street Journal 10/12/04.
I also noticed that most of the so-called advanced nursing research on this issue was widely dismissed by the various DOC organizations because they couldn't find any studies that fielded more than 50 participants, and, in most cases, those studies included BOTH codes AND lessor invasive procedures. One of the so-called landmark studies involved only 19 resusitation events. 19!? And this is where we are hanging our hat for national standards?
~faith,
Timothy.

There indeed has not been any widescale studies. Certainly studies done at individual facilities can't be generalized to all populations. But no need to totally dismiss it either.

Indeed, if you poll most nurses and docs (particularly resident docs) they are against family presence. However, when programs, education and family feedback (this is important as well, because sometimes we have to put aside our own feelings and care for the families and listen to what they have to say after they've witnessed their loved one's being coded), nurses and docs change their minds more towards supporting the idea. My interest in this topic however has been from a nurses and family member's perspective, not the doctors.

Tweety, BSN, RN · Aug 27, 2005

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.

.

Tweety, BSN, RN · Aug 27, 2005

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.

Family Witnessing Code Activities

Would You Want to Watch a Family Member Undergoing a Code>?