Key Point

Family presence during CPR and invasive procedures appears to be beneficial for both patients and family members, with no disruption in patient care.

SAN FRANCISCO—Family presence during cardiopulmonary resuscitation (CPR) and invasive procedures has been a topic of debate in recent years but appears to be associated with beneficial outcomes for both family members and patients.¹ At the Society of Critical Care Medicine’s 35th Critical Care Congress, Cathie Guzzetta, RN, PhD, AHN-BC, discussed supporting arguments, outcomes, and staff fears associated with family presence during such procedures.

Dr. Guzzetta, currently Director of Holistic Nursing Consultants in Washington, DC, and a nursing research consultant at Children’s Medical Center Dallas, first became involved in family presence research in 1994 when she was employed as a research consultant at Parkland Health and Hospital System, also in Dallas. A nurse at Parkland, Theresa A. Meyers, BSN, RN, CCRN, CEN, asked, "Why do we ban all families from the bedside during CPR?" after nearly losing her job for allowing a couple to be present during the resuscitation of their 14-year-old son. "I said, ‘I really don’t have an answer for that,’" recalled Dr. Guzzetta.

Soon thereafter, Dr. Guzzetta began mentoring a series of studies probing the outcomes of this practice.

SUPPORT FOR FAMILY PRESENCE

In 1995, shortly after the incident at Parkland, the Emergency Nurses Association (ENA) developed clinical guidelines supporting the option of family presence during CPR and invasive procedures. Since then, several other organizations—including the American Heart Association (AHA) and the American Association of Critical Care Nurses—have issued guidelines supporting family presence, and in 2001, the ENA revised its guidelines. Additionally, family presence recommendations have been incorporated into curricula for training programs such as the AHA’s 2005 Advanced Cardiac Life Support Course and Pediatric Advanced Life Support Course and the ENA’s Trauma Nursing Core Course and Emergency Nursing Pediatric Course.

According to Dr. Guzzetta, all of the organizations recommend that a designated family facilitator—a nurse, chaplain, social worker, or child life specialist who is familiar with family presence guidelines and trained in crisis management—be involved to assist the family throughout the event. The family facilitator assesses the family to rule out possible combative behavior, emotional instability, or behaviors consistent with an altered mental state. If family members are judged as suitable candidates for family presence, and if a supervising physician or nurse agrees, the family is offered the option to be present during the emergency procedure. If the family accepts, they are escorted into the room by the family facilitator, who then finds a place for them to stand or sit, encourages them to support the patient, and stays with the family.

FEARS ASSOCIATED WITH FAMILY PRESENCE

Various surveys have been conducted in recent years to evaluate health care providers’ feelings about family presence during emergency procedures. Most notable, said Dr. Guzzetta, was a study published by Helmer et al.² Members of the American Association for the Surgery of Trauma (AAST), as well as a random sample of ENA members, were asked, "How do you feel about bringing families in?" Results indicated that more AAST members than ENA members considered family presence inappropriate during all phases of resuscitation and invasive procedures. AAST members were more likely than ENA members to believe that family presence interfered with patient care and increased the stress of the trauma team. More ENA members (60%) felt that family presence was beneficial, compared with AAST members (17.5%).

Shortly thereafter, "we saw a flurry of hypothetical surveys being sent out," said Dr. Guzzetta. One survey that was conducted at 81 Arkansas hospitals, revealed that only 38% of the medical professionals would consider allowing family presence during CPR.³ The most common reason for not allowing family presence was that the CPR scene was too traumatic for family members to view. A survey of 592 professionals who attended the international meeting of the American College of Chest Physicians in 2000 revealed that nurses were more likely than physicians to support family presence during CPR.⁴

Another study, by Sacchetti et al,⁵ indicated that emergency department personnel who had prior experience with family presence during resuscitation were more likely to favor the practice. The researchers concluded that "biases by emergency department personnel lacking experience with family member presence may limit its introduction into unfamiliar institutions."

Dr. Guzzetta said the most frequently documented concern is that family members will become too emotional and will interfere with patient care. "This concern is the number one legitimate argument against family presence. No one wants any interruption in patient care."

Other concerns, she said, include staffing shortages and high patient volumes, risk of litigation, interference with resident training, violation of patient confidentiality, and interference with resuscitation attempts. "To date, there is no research evidence that documents support for any of these fears," said Dr. Guzzetta.

OUTCOMES IN FAMILIES AND PATIENTS POSITIVE ALL AROUND

When discussing the outcomes of actual family presence events, "I would be remiss if I didn’t discuss the pioneers at Foote Hospital in [Jackson,] Michigan. They really were the ones who asked the questions back in 1982," Dr. Guzzetta remarked. Eighteen families whose loved ones had died in the emergency department were asked if they would have chosen to be present, if given the option. Seventy-two percent of family members said they would have wanted the option.⁶ In response to this finding, Foote Hospital created a family presence program, and 30 events were evaluated. The findings suggested that family presence was associated with positive outcomes and no interruption in patient care.

In 1998, Robinson et al⁷ published the only randomized controlled trial of family presence, noted Dr. Guzzetta. The study was terminated prematurely because after evaluating 25 cases, the team was convinced of the benefits of family presence and felt it would be unethical to deny families in the control group these same benefits.

Dr. Guzzetta noted that because of low survival rates following CPR, it has been difficult to assess patients’ opinions about family presence. Despite this obstacle, she and Ms. Meyers, in collaboration with several other colleagues, published their findings of patient, family, and health care provider perceptions of family presence during CPR or invasive procedures.^8,9 They reported that patients felt family presence comforted them, provided help, and served to remind providers of the patient’s personhood. They also indicated that family members reported feeling as though they had been given an active role in the care of their loved one when allowed to be present. This role may have been as simple as sitting on one side of the room and praying for the patient, encouraging the patient, singing to the patient, or touching the patient. Family members also reported that being present during emergency procedures removed doubt about what was happening to their loved one and reduced their anxiety and fears. "They could see that everything possible was being done," she said. Health care providers involved in these events reported that family members provided emotional support, translated for the patient, and furnished essential patient information.

Dr. Guzzetta said further research is needed, which should include quantitative and qualitative approaches, larger sample size, and consideration of the validity and reliability of assessment tools. She suggested that existing family presence programs create a registry documenting positive and negative outcomes of this practice. In cases of long-term hospitalization, researchers should determine whether a family facilitator is needed during every emergency procedure. In addition, more randomized clinical trials are needed to determine whether family presence influences how many times a patient is intubated, how much time is needed to perform a procedure, and whether complications arise from the procedure. In addition, it will be important to consider how the degree of invasiveness affects outcomes in family members and whether family presence has an impact on provider activities and costs.

WRITTEN POLICIES ON FAMILY PRESENCE ARE NEEDED

Dr. Guzzetta emphasized the importance of establishing written family presence policies in all critical care units and emergency departments. A survey of 1,000 critical care and emergency nurses, conducted in 2003, revealed that 95% of respondents worked in critical care units and emergency departments with no written family presence policies.¹⁰ "Because of the consistent body of evidence documenting the beneficial effects of family presence, we need to be working with physicians and administrators and organizations to adopt evidence-based practice guidelines for the option of family presence during CPR and invasive procedures," she concluded.

—Karen L. Spittler

References
1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: annual meeting of the Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000;48:1015-1022.
3. Pafford MB. Should family members be present during CPR? J Ark Med Soc. 2002;98:304-306.
4. McClenathan BM, Torrington KG, Uyehara CF. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Sacchetti A, Carraccio C, Leva E, et al. Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience. Pediatr Emerg Care. 2000;16:85-87.
6. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.
7. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
8. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001;101:48-55.
9. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000;100:32-42.
10. Maclean SL, Guzzetta CE, White C, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. J Emerg Nurs. 2003;29:208-221.

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