Study: Patients supportive of family presence during lifesaving procedures
Hospital policies help providers in critical time
The topic of family presence with patients undergoing emergency lifesaving measures such as cardiopulmonary resuscitation (CPR) and invasive procedures has been a controversial one since the mid-1990s. At that time, a small group of emergency medicine and critical-care providers across the country began allowing family members to stay with patients during these events.
Supporters of the practice, simply known as family presence (FP), claim that family members should be allowed to stay with the patient when possible, to minimize the trauma they feel if the patient does not survive. Supporters also contend that families who are present say they are able to have some control over how their loved one is treated.
Opponents of FP claim that such visitation could compromise patient care if family members were physically in the way or if they distract the health care team from its task.
However, follow-up studies of patients, families, and providers experienced with allowing FP found those fears to be largely false. The majority of family members and providers who experience FP find it a positive experience.1,2
For example, a study published in the May 2001 issue of the American Journal of Nursing,3 finds that patients who undergo lifesaving or invasive procedures also largely approve of FP, and say it is not only beneficial for families but for patients as well.
In the study, nine patients who had undergone emergency lifesaving procedures in the emergency department of Parkland Health and Hospital System, a large, level-1 trauma center in Dallas, were interviewed approximately two months after the event. Eight patients had invasive procedures performed, and one had CPR. The subjects answered a series of questions designed to elicit how they felt about the presence of their family members.
Overall, several themes emerged: patients felt that their family members’ presence comforted them; that it provided help; that it served to remind providers of the patient’s "personhood" it helped maintain patient-family connectedness; that family members were comforted and helped; and that patients felt that family presence was a right.
"This data are from the same study that we published in February of 2000, when we looked at provider and family responses,"1 says Diana Mason, RN, editor-in-chief of the American Journal of Nursing. "At that time, no one had looked at the patient side and analyzed those responses. This is the first time that anyone has looked at anybody’s responses to allowing family presence. And, I think it provides the important perspective that is very in favor of, in the patient’s view, of having the family present."
Hospital policies needed?
An important piece of the two papers published out of the Dallas study is the inclusion of the hospital’s policy on FP, which specifically delineates:
- situations in which FP is to be considered;
- who will be designated to remain with family members during the episode;
- how families will be "screened" to determine whether they will be allowed to remain in the room with the patient while the procedure is going on.
"The criteria that were set up for this study follow the protocol established by the Emergency Nurses Association; those criteria have to do with whether the family members seem like they are going to be able to emotionally handle it, or they are going to become hysterical, whether they are under the influence of any substance that might impair judgment, etc.," explains Mason.
Some providers have questioned whether it is ethical to screen family members without their knowledge in order to make a determination about whether they should be allowed to go back to the room with the patient, says Dezra Eichhorn, RN, lead author of the article. Eichhorn is a former emergency department (ED) nurse now working as a nurse practitioner in Arkansas.
"Some people feel that it is an opportunity that should be offered across the board to everybody," Eichhorn says. "I thought we were doing the right thing by assessing them and making sure they were OK. But, some have said that we are making the decision for them and assuming that they cannot handle a given situation. At that point in time, we felt it more important to err on the side of caution rather than have any problems occur."
The criteria in place rule families out if they are extremely unstable or combative (not just upset) or under the influence of some type of substance, such as alcohol or drugs, she adds.
However, some ethicists have questioned the practice of making judgments about family members without informing them, says Mason. "It raises the issue of cultural bias in that determination, if the criteria are not explicit, and if you are not telling the family, I need to make a decision about whether you can go in the room.’"
Changing hospital culture
At many hospitals, excluding family members from the rooms or bedsides of patients during emergency procedures is a common practice in the ED or intensive-care unit (ICU) — so common that attempts to bring family members in often meets with significant resistance, says Theresa Meyers, RN, a former nurse at Parkland, who currently works at Memorial Hospital in Colorado Springs, CO.
It took Meyers and fellow nurses at Parkland five years of research and advocacy to get a policy in place to allow family presence there, she says.
In 1994, Meyers brought the mother of a critically injured teen-age boy to his bedside in the ICU while CPR and other resuscitative measures were performed. Although the resuscitation was unsuccessful, the child’s parents were able to touch him and talk to him during the last moments of his life, an experience that the child’s mother later said helped her deal with her son’s death.
However, Meyers actions caused a stir among members of the medical staff and almost cost her job, she says.
At an institution that never before had FP, it might be beneficial to develop a concrete policy and get the buy-in of administration and physicians, she says. "I am not saying I think you should only do this if you have a definite policy in place, because I think it needs to be done more often. But it is something to consider."
The policy that was developed at Parkland was not necessarily to "defend" the practice, but to have it in black and white and provide it to anyone who questioned the practice, says Eichhorn.
"It shows that we had support, it was reviewed by a multidisciplinary team, and we got input from every department, from infection control to running it by the legal department," she says. "A lot of times, the docs just think, Well, you’re just going to rush in here with every family member,’ and it makes them nervous."
Will a right’ become an obligation?
One issue for ethics committees and providers to consider is how to ensure that family members who still don’t want to witness invasive procedures still feel comfortable saying no if they are offered the option.
"Is family presence a right, an obligation or a privilege?" asks Mason. "I think that’s an important issue to look at. In the original study, 13% of families still did not want to go into the room."
Some advocates for FP compare the practice to that of allowing fathers into the delivery room to witness the birth of their children — a practice once considered taboo.
"But, we’ve seen the whole issue of fathers in the delivery room become an expectation," continues Mason. "I know of a person at work who had a friend who did not want to go into the delivery room, but his family and friends were so appalled he felt that he had to."
Meyers agrees that part of any approach to establishing FP as a hospital policy needs to include measures to support family members who do not wish to be present.
"The thing I always go back to is to look at it as an option," she says. "I don’t think it is appropriate in every situation. But, we need to be able to raise the questions: Is the family here? Do they want to come in?’ If they don’t want to come in, the key is to not make them feel badly or guilty if they do not. You want to support them in that decision."
Remember the patient
It’s also important not to forget the patients undergoing the procedure, adds Thomas Schwarz, RN, former ED nurse at Northern Duchess Hospital in Rhinebeck, NY, and editorial director of the American Journal of Nursing.
In an editorial accompanying the May article, Schwarz expressed support for the research and policy developed at Parkland but reminded providers to consider consulting the patient (if the patient is conscious and able to respond) before approaching family members.
"I am an emergency room nurse with more than 25 years experience. But, more recently, I have also been the patient in several instances," Schwarz says. "And I have children. I know my children, and there are times when I can see that it would not be in anyone’s best interest to have them in the room if I were that patient in extremis."
The Parkland policy is a wonderful resource for other providers, he adds. "And they emphasize asking the family and bringing together all of their resources to help the family cope with that situation. But don’t forget the patient."
As much as he might want to say goodbye to his son or daughter or wife, he would not want their last vision of him to be traumatic, Schwarz says.
"If someone were to come to me as I lay on a stretcher and said, Your family is outside; do you want us to bring them in?’ Depending on the situation, I might say no. I just hope someone asks me, as well."
Sources
- Diana Mason and Thomas Schwarz, American Journal of Nursing, 345 Hudson St., 16th Floor, New York, NY 10014.
- Theresa Meyers, 1400 E. Broad St., Colorado Springs, CO 80909.
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