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Should the family stay?
The question of whether to allow family members to witness resuscitation or invasive procedures has elicited strong responses from clinicians.
May 1, 2007
By: Angela Briguglio, RN, MSN, APRN, BC
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After reading it you should be able to:

1. Describe how hospitals can promote family presence in critical care.
2. Discuss the pros and cons of having a family member present during life-saving procedures.
3. Describe the role of the family facilitator during life-saving procedures.

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Originally Posted May 2007

By Angela Briguglio, RN, MSN, APRN, BC
ANGELA BRIGUGLIO is a staff nurse with Loyola University Medical Center in Maywood, IL; a CNS at Advocate Illinois Masonic Medical Center in Chicago; and a nursing instructor at Loyola University. The author has no financial relationships to disclose.

The appendectomy patient on the unit was a 30-year-old man who made it through surgery with no complications. He'd been doing well and was anticipating discharge very soon. Late in the day, however, he de veloped shortness of breath and chest pain. His wife ran to get the nurse, but by the time they re turned to the room, the man was losing consciousness. The nurse called a code. As doctors raced in, a resident yelled, "Take her to another room, she can't be in here!"

The nurse had an assistant accompany the wife to a private waiting area. Distraught, the wife attempted to return to her husband's bedside until a chaplain arrived to comfort her. Meanwhile, her husband was undergoing numerous cycles of CPR and defibrillation. Despite the staff's efforts, he didn't make it; a pulmonary embolism had killed him. His wife never got to say goodbye.

Scenes similar to this one are played out frequently in U.S. hospitals, most of which have no policy regarding family presence during emergency or invasive procedures.1 More and more hospitals, however, are confronting the issue of whether family members should be permitted to remain with patients who are in life-threatening situations.2 Often, nurses are providing the im petus for allowing family presence. In fact, these professionals have been the most frequent authors of studies on the issue.3 As advocates for change, however, nurses may find themselves in the midst of an ethical debate regarding the benefits and risks of allowing family members to enter into what was once the healthcare providers' private domain.
Most hospitals don't have policies

For a long time, both doctors and nurses looked upon family members as guests in the hospital. There were rigid rules families had to follow when visiting their ailing loved ones.4

Critical care nurses, among others, began to ac tively question the enforcement of visiting hours, and over the past 20 years, family access to critically ill patients gradually increased.3 Even more re cently, several national organizations started adopting formal guidelines and practice statements advocating family presence during CPR and invasive procedures. Among these groups are the Emergency Nurses Association (ENA), the American Association of Critical-Care Nurses (AACN), the Society of Critical Care Medicine (SCCM), the American Academy of Pediatrics (AAP), and the American Heart Association (AHA).4,5

Indeed, AHA's current CPR guidelines are very clear on the issue: They recommend that healthcare providers offer family members the option of remaining with their loved ones whenever possible.6 Likewise, SCCM, in its recently issued clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU, recommends that hospitals develop a process to allow family members to be present when CPR is performed on their loved ones.7

Still, in a 2003 survey of ED and ICU nurses, only 5% of respondents reported working in areas that had formalized family presence policies.8 Additional research revealed that despite the lack of a written policy, many nurses were bringing families to the bedside when a patient was being resusci tated, and they were doing so without hospital approval.9

National news polls show that the nurses' actions are in synch with public attitude: Most people favor staying with loved ones who are undergoing emergency procedures.10 Moreover, a number of studies involving actual incidents found that most family members chose to be present during CPR or invasive procedures, and nearly all of them said they would do it again.10
Giving family a chance to say goodbye

Having a policy in place that gives families the option of being present during emergency or in vasive procedures has its obvious benefits. The ma jority of patients who undergo resuscitation don't survive, and allowing family members to stay during CPR gives them a chance to say goodbye during their loved one's final moments.11 And the family is able to see that the staff did everything possible to try to save the patient's life. In a recent study, relatives who had left the room during CPR out of fear of disturbing the intervention later reported that they regretted not having given support to their loved one.12

From the patient's perspective, having family members present can provide comfort, increase feelings of safety, and help ease fear, especially if the patient is a child.12 (It's interesting to note that among clinicians, there's more support for family presence during CPR of children than adults.13) Through this connection to their families, patients feel loved, supported, and less alone. Not only that, many patients believe it is their right to have family members present during life-saving procedures.10 Clinicians, too, may benefit, because family members can give on-the-spot medical information to the trauma team.2
Seeing resuscitation may be overwhelming

So why aren't more hospitals permitting families to stay with their loved ones during a crisis? The medical community remains divided over the issue, with the majority of hospitals still discouraging family presence. Critics contend that family members have been barred for good reason: Over crowded EDs and hospital rooms can be distracting to the medical staff, which needs to concentrate on the patient. And family members can easily be overwhelmed by the graphic images they see.2

Even in hospitals that encourage family presence, the concept isn't universally embraced.1,2 Research has shown that support for family presence is voiced more often by nurses than by attending physicians, and least so by residents.14

Among the concerns expressed by clinicians is the possibility of physical assault by distraught family members. Other opponents fear that family members may misinterpret what the healthcare team is doing, which may result in more lawsuits. Still others predict a loss of control over medical interventions. For instance, a trauma team reluctant to terminate a code in the presence of a patient's family member might prolong a futile resuscitation instead.4

As Joseph A. Stirt, MD, staff anesthesiologist with Richmond Community Hospital in Virginia, put it, "CPR is one of the most frightening things in the world—and I'm a doctor who participates. I can't even imagine the trauma and stress that might result from a civilian watching."15
Families need guidance

Despite the concerns, studies indicate that fam ily presence doesn't usually interfere with medical interventions when the focus is on a pa tient's survival.16 To en sure there are no disruptions in care, AACN and others recommend that a designated family facilitator prepare family members for the event and guide them through the experience. Family facilitators are specially trained nurses, social workers, or other qualified staff that stay with the family throughout the patient's procedure or resuscitation.17 The fam ily can ask questions of the facilitator instead of interrupting the medical team.

Facilitators also assess the family throughout the procedure or resuscitation, and may intervene, if needed.4 They determine whether it's appropriate for a family member to be present, and may bar anyone who is emotionally unstable, combative, abusive, or impaired by drugs or alcohol.17
Important points to consider

Besides training the healthcare team to be able to work with the additional stress of family presence, hospitals must consider other important questions when developing a family presence policy, including: What is the role of the family facilitator? How many family members—and which ones—may be present in the patient's room at one time? When will the family be allowed into the resuscitation room? What circumstances warrant exceptions? Where in the room may the family be? What are the family's responsibilities?

In a hospital with a written policy, the scenario might play out something like this:

A 50-year-old female with a diagnosis of COPD has been hospitalized for three days. Her husband George is at her side when he doesn't have to be at work. Around dinnertime, the woman tells her husband, "I'm warm and sweaty and just don't feel well." George calls the nurse, who arrives to hear the patient complaining of pain in her chest and left arm. The patient stops breathing and the nurse calls a code.

As the code team rushes in, George is holding his wife's hand and telling her, "Hold on. I'm here." One of the doctors asks him what happened, and George remains calm as he answers.

During CPR, one nurse explains what the doctors are doing, while other nurses help with defibrillation and drug administration. About two minutes later, the patient opens her eyes. She looks at her husband and appears calm.

It turned out that George's wife had a massive heart attack. Luckily, she recovered after some time. Her husband thanked the medical team for allowing him to remain in the room. In turn, the doctors thanked him for answering their questions about his wife.
Be an advocate for family presence

Without universal written policies for family presence, you may find yourself in a difficult position when a crisis occurs and family members request to be at the bedside. To learn more about how to explain the complexities of critical care to family members—in easy and understandable terms—visit www.myicucare.org/SCCM/MyICUCare/ Support+Brochures/.

Encourage your nurse manager and co-workers to become advocates for a family presence program on your unit. By becoming involved in educational and research endeavors that increase awareness of the potential advantages of family presence, you and fellow nurses can play an important role in making sure that individuals who choose to remain at patients' sides may do so. You also may want to push for written policies that provide consistent, safe, and caring practices for patients, families, and providers.12 For information on establishing a policy. Above all, remember, most patients have a family, and when those family members enter your unit, you're responsible for them as well.
REFERENCES

1. American Association of Critical-Care Nurses & Emergency Nurses Association. "Nurses' study finds hospitals still limiting access for patient families during emergency procedures." 2003. www.aacn.org/AACN/mrkt.nsf/Files/ FPFinal/$file/FPFinal.pdf (22 Feb. 2007).

2. The Wall Street Journal. "Hospitals let families witness procedures: Staying with patient in ER or ICU can have benefits, but some doctors object." 2004. pqasb.pqarchiver.com/wsj/access/ 710873731.html?dids=710873731:710873731&FMT= ABS&FMTS=ABS:FT&date=Oct+12%2C+2004&author= &pub=Wall+Street+Journal&edition=Eastern+edition& startpage=D.1&type=91_1996&desc=Hospitals+Let+Families+ Witness+Proce dures (22 Feb. 2007).

3. Nibert, A. T. (2005). Teaching clinical ethics using a case study: Family presence during cardiopulmonary resuscitation. Crit Care Nurse, 25(1), 38.

4. Aldridge, M. D., & Clark, A. P. (2005). Making the right choice: Family presence and the CNS. Clin Nurse Spec, 19(3), 113.

5. Mangurten, J., Scott, S. H., et al. (2006). Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department. J Emerg Nurs, 32(3), 225.

6. American Heart Association. "Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 2: Ethical issues." 2005. circ.ahajournals.org/cgi/content/full/112/ 24_suppl/IV-6 (22 Feb. 2007).

7. Davidson, J. E., Powers, K., et al. (2007). Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004 – 2005. Crit Care Med, 35(2), 605.

8. MacLean, S. L., Guzzetta, C. E., et al. (2003). Family presence during cardiopulmonary resuscitation and invasive procedures: Practices of critical care and emergency nurses. Am J Crit Care, 12(3), 246.

9. Guzzetta, C. E., & Clark, A. P. (2004). Restrictions on family presence in the ICU. JAMA, 292(22), 2721.

10. Guzzetta, C. E., Clark, A. P., & Wright, J. L. (2006). Family presence in emergency medical services for children. Clinical Pediatric Emergency Medicine, 7(1), 6.

11. Dunn, H. (2001). Hard choices for loving people (4th ed.). Herndon, VA: A&A Publishers, Inc.

12. Emergency Nurses Association. "Family presence at the bed side during invasive procedures and cardiopulmonary re sus citation." 2005. www.ena.org/about/position/PDFs/ 4E6C256B26994E319F66C65748BFBDBF.pdf (22 Feb. 2006).

13. Gold, K. J., Gorenflo, D. W., et al. (2006). Physician experience with family presence during cardiopulmonary resuscitation in children. Pediatr Crit Care Med, 7(5), 428.

14. Meyers, T. A., Eichorn, D. J., et al. (2004). Family presence during invasive procedures and resuscitation: The experience of family members, nurses, and physicians. Advanced Emergency Nursing, 26(1), 61.

15. Bookofjoe. "Behind the medspeak: Would you want to witness CPR being performed on a loved one?" 2004. www.bookofjoe.com/2004/10/ behindthemedspe_30.html (22 Feb. 2007).

16. Sacchetti, A., Paston, C., & Carraccio, C. (2005). Family members do not disrupt care when present during invasive procedures. Acad Emerg Med, 12(5), 477.

17. American Association of Critical-Care Nurses. "Practice alert: Family presence during CPR and invasive procedures." 2004. www.aacn.org/AACN/practiceAlert.nsf/Files/ FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf (22 Feb. 2007).
Family presence: Getting started

"Presenting the Option of Family Presence," developed by the Emergency Nurses Association (ENA) and endorsed by the American Association of Critical-Care Nurses (AACN), is a resource to help you establish written policies and procedures that support family presence during emergency or invasive procedures. It includes educational slides and handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, a sample family presence guideline, and other supporting documents. You can purchase it for $48 by calling AACN at (800) 899-2226, or going online at my.aacn.org/ecomtpro/Timssnet/products/ TNT_products.cfm. To order it through ENA, go to www.ena.org/store/index2.asp.

AACN also endorses the American College of Chest Physicians' "Critical Care Family Assistance Program Replication Toolkit," an action plan for creating a family-friendly critical care environment. You can order it through AACN for $150.

Another source of information on family presence is the AACN Practice Resource Network, which can be reached at (800) 394-5995, ext. 217.

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About the Author
Angela Briguglio, RN, MSN, APRN, BC
About Angela Briguglio, RN, MSN, APRN, BC
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