Should families be present during a code?

NsgChica · Jul 6, 2008

It all depends. I believe that patients have the right to have their family members there during their final hours...if the families' behaviors doesn't disrupt resuscitation efforts or foster an unsafe enviroment for patient, staff, or themselves. I believe patients also have the right to refuse that family be present during codes. We did a presentation on this topic in school and there are lots of conflicting literature about the benefits of family presence. Allowing family members to be present can help with closure...with the final thought being that we and the hospital staff did everything the could do to save our loved one. However, seeing what goes on in a code can be traumatic. I mean it isn't pretty. Outsiders may see CPR as abuse or causing more harm. They may become upset by the images. But some articles suggest that a debriefing, explaining what was done and why may be helpful in helping weary family members gain an understanding. Some articles also suggested that family presence may decrease families desire to sue hospital. So many pros and cons. It is difficult to call and each situation is unique and requires unique assessment.

Batman24 · Jul 6, 2008

If there isn't enough room for staff and equipment family then needs to leave the room. We could never fit 8 people into a room either. I would explain the lack of space in the room if questioned and say as an advocate you need to put your patient's need first and he was actively dying at that point. Getting to him and saving his life is your priority.

We do allow people in for codes but it depends on the situation. There are some where everyone has been asked to leave and others where 1 or 2 are present not 8. We do make sure there is someone to explain what is going on to them at all times.

woody62, RN · Jul 6, 2008

this question has been addressed here numerous times with a wide variety of opinions. it has also been addressed in several of the professional journals. the situation described, by the op is generally not acceptable. the impression that the family was divided hold rein to the confusion and disorder when the patient coded.

i support one family member being allowed in but with an assigned staff member who has been educated in handling and explaining what is happening. too many families do not want a love one to die alone. and while surrounded by nothing but medical staff. studies have shown that this works in relieving family stress and staff stress. it does not work when family is granted unfettered access during a code.

woody:twocents:

flightnurse2b, LPN · Jul 6, 2008

i honestly dont want family members in the room during a code. every single code i have participated in where a family member was present turned into a near circus. every single time there has been a family member present, we have had to call security because it ended up being so out of control. there is enough nursing staff, supervisors, techs, chaplains, radiology, respiratory, etc, in there to make room crammed as it is, without multiple family members standing in the way having a running commentary.

just recently coded a 40 y/o woman with CP who had been dependant on a vent and peg tube almost her whole life. mom slapped the doctor and said "you better bring my daughter back to the way i brought her in here". ER, ICU, Tele, M/S... makes no difference. a code is a code is a code and it can be very disturbing and scary for health care professionals nevermind family members who all they see is a dead/dying loved one and a big red cart with multiple noisy machines, tubes and lines and nursing staff frantically performing CPR and pushing medications.

one woman refused to let go of grandpa when we were charging the defibrillator and security had to physically lift her off him and remove her, one woman pushed me out of the way after MD had called the code and resumed compressions.... too many times screaming, hysterics, throwing things in the room or themselves on the floor, shaking the doctor by the shirt and saying "DO SOMETHING", and 10 people on their cell phone who act like you are in the way when you are trying to save their loved ones life and get mad when you say please turn your cell phone off because i am trying to shock moms heart into a normal rhythm.... i just have alot of trouble working like that.

i understand why they would want family present, i suppose to show them that either everything possible was done or to show how violent a resus is and get them to agree to let the pt die peacefully.. but if it were up to me, they would be asked to step out and a staff member would be responsible for going back and forth to give updates.

i know that i would want to die with dignity, in peace... not with my family members making a big ruckus. thats not to say that all families do that, but the 99% of the ones who have been present in the codes i've worked, have....

Ruby Vee, BSN · Jul 6, 2008

the family could not agree.
the family, crying and carrying on in the hall caused quite a disruption on our 42 bed telemetry unit insisting they had to be in the room to " be with him until the last second."

we tried to have a staff member stay with the family right outside the door to give them an explanation, but they insisted on being in the room at the patient's side.
unfortunately, we had to call security to take them to the day room where they stayed until it was all over and he was prounounced.
they were allowed in immediately after the gentleman was cleaned up a bit.
we are now getting flack back from administration saying the family should have been in the room. i disagree....
what's your opinion?

i've snipped your post a bit to illustrate why i agree with you. first off, the family couldn't agree about code status. since there was no active dnar order, he had to be coded and it was necessary to escort the family out of the room so that he could be coded. then the family was out in the hall, "carrying on" instead of in the family room or waiting room waiting for word. finally, security had to be called to escort them off the unit.

from what you've written, it sounds as if this family was given to noisy scenes and dramatics. even when they were allowed to wait in the hall outside their relative's room while he was being coded, they insisted upon having their own way. rather than comply with reasonable requests, they required security to assist them to do so. if ever a family should not be at the bedside during a code, it sounds as if they were it.

i know that including the family in codes is the "in vogue" way to go these days. be that as it may, there are some families that cannot be trusted to behave in a reasonable way. if your family was one of those, they belonged in the day room rather than the patient's room. if your administration is so gung ho on having family at the bedside, let them come and deal with the family during the code.

justme1972 · Jul 7, 2008

I think it should be up to the family.

Every family has a different "culture" within them on what they can tolerate and what they cannot.

I also think it can be in some ways therapeutic for them to see, just how many people are present at a code, how long a code gets worked, so if the patient dies, they have a visual of just how hard the staff worked to save their loved one.

I think they should just simply be told, To stay is your choice.

However, no child to be permitted to stay...especially if it's a parent...a child may never get that image out of it's head.

PiPhi2004 · Jul 7, 2008

I think in most cases, family should not be present. I have had a lot of issues with people not making family members DNRs and we have to go through this code stuff when there is no hope. I do believe, however, that if the family does see what the pt goes through and sees that we didnt just let the pt die and SAY we coded them then they might have a better view of us. I have had family members not trust that we were going to code the pt and refuse to leave. However, in our ICU the rooms are very small and theres no room for family members and the code team. They MUST stand outside in the hall if they want to watch and in this situation I fully allow them to see that we are doing everything in our power to save the patient BUT if you get in the way then security can deal with it, I dont have time.

I personally think in the case that if one or two family members are refusing to make the patient a DNR, and the rest of the family wants to let the patient go, the family should be sent outside and the one or two family members that wanted the code can stay and watch.

Another thing that bothers me is when we are expecting to code the pt any minute and 20 family members REFUSE TO LEAVE! If they really want the patient coded they should understand that removing 20 chairs in the room cuts into our time and we dont have time to deal with that. I have had to literally climb over people to reach my equipment while my manager does nothing to stop it and wants me to just do it to appease them.:angryfire

My own opinion: Unless the family member is made a DNR and death is soon to follow then all visitation rules apply. Only 2 at a time back, leave for shift change, and visiting hours are from 9 to 9. NO EXCEPTIONS!! If the pt is made a DNR, then let 20 people back to say goodbye and to be with the pt as they transition to death.

kmoonshine, RN · Jul 7, 2008

Family should be present, as long as it does not interrupt the resuscitation efforts. If space was an issue, it should have been stated that 2 family members/representitives could be present; but the rest of the family needs to wait in a "private area".

Sometimes, family members need to see that everything is being done. They should be allowed to touch the patient (like their feet, so long as it doesnt interrupt the resuscitaiton efforts), and as other posters previously stated, an assigned nursing staff member should remain with the family that are present, and this staff member should explain everything to them. Having someone explain what's happening during the code decreases the "hysteria". Many families also don't want to see their loved one die alone.

In my opinion, it was wrong to kick the family out. Unless they were throwing things or were a threat to staff or patients, then they should be given the opportunity to participate in the last moments of their loved one's death. If a nurse was with the family and explained everything to them as well as the "rules" ("you can talk to the patient, but you must watch your language and may not yell - if this happens, you will be asked to return to the private area"), perhaps the family would have acted more appropriately. If you think about it, the family was acting out to a situation that they were afraid of, and they probably sensed a loss of control. It must have been very scary for them, and people who are frightened and under anxiety burst- just like when you shake up a can of soda and then pop the top...

Faeriewand, ASN, RN · Jul 7, 2008

Our doctor stopped the CPR and then said to start it again because he was getting the family. Family came in during CPR and doc explained patient was dead, no way to bring him back etc etc. The family broke down but agreed in about 20 seconds and we stopped CPR for 2nd time. (they didn't know about the first) I thought the doc showed great sensitivity to this family. It brought them closure. They were out of the way until we were sure we couldn't bring the man back.

1st time CPR was stopped it was only about 15 or 20 seconds for doc to tell us what he was going to do.

TRAMA1RN · Jul 7, 2008

i am an er nurse, and have worked level 1 trauma to small rural er's i am totally for a family presense, if the rooms are small allow only the single family rep in the room. if you run enough codes you know how to conduct yourself with lay people present. old or young families deserve to have a presense in these terrible situations. it needs to bemade clear that they need to stay out of the way and try to conduct themselves with composure, if not they will need to leave. it is helpful if you have the staff, to explain what is happening during the code.

patwil73 · Jul 7, 2008

I too am for family presence during codes. I have often found in the situations where the person really shouldn't be coded - family presence often diminishes the time of the code.

There is no way that 8 family members would be able to stay in any of our rooms during a code - I often have to kick staff members out when we get too many, but 1 or 2 family members I try to make room for (usually at the foot of the bed, or near the head on the non-iv side).

Also people respond to terrible events (like codes) with a variety of coping mechanisms. Some cultures expect loud displays of emotion, others are more reserved. Staff members may tell jokes to overcome uneasiness. Understanding the cultural imperative behind how grief is handled might make it easier to deal with loud, demonstrative family members (these cultures exist in the US also, just because someone is born and raised American doesn't mean they might not respond with excessive displays).

On the other hand, some people are just used to getting their own way. A balance needs to be struck between assisting them with the dying and grieving process and helping the patient - in most cases the patient wins hands down. However, in certain code situations (those ones where the situation is hopeless, should have never been a code, etc) the family becomes more important. During those times, the patient is dead - regardless of the code length or what we do, the patient will remain dead. We are coding them for the family, so they can come to grips with the situation. In these cases, we do more for the family, more accomodating to allow them to process their grief, anger, denial.

And finally, there will be times when what you have decided is wrong, the actions you take turn out incorrectly. (Not saying this was the case here) Simply accept and learn from them and hope it turns out better next time. After codes, I tend to return to the unit and talk with staff members about their experience and see if there was anything we could have done differently to help, or if there was anything they needed to know to feel better (usually that their actions did not in fact kill someone). I also fill out a data sheet on each code, and I list mistakes I make along with others in the code (usually compresions to shallow or slow, ACLS protocols not followed, etc - but I have written down myself for failing to explain the change from ST PEA to paced PEA which led to a lengthened code situation).

Hope all this helps

Pat