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Family Presence in Adult CPR

Study dispels myths of litigation, caregiver and family stress when relatives witness CPR in adult patients.

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When Jessica Duncan, BSN, RN, was barred from her father's resuscitation, she was appalled that she was in the waiting room during such a critical moment.

Duncan is the ICU charge nurse at Indiana University Health Ball Memorial Hospital, where family presence during adult CPR has been the norm for more than 10 years. She's never experienced a problem and said family presence is hardwired into Ball Memorial's culture.

"I can't believe how many hospitals don't have a policy allowing family presence during adult CPR," she said. "In the beginning, it's scary to think about having families in the room. But usually it's their favorite person in the world in that bed and they're so happy to be there, regardless of outcome."

Duncan's philosophy may be catching on at more hospitals.

A recent study published in March in the New England Journal of Medicine and the largest trial on this issue to date found that family members who observed resuscitation efforts were less likely to experience post-traumatic stress, depression and anxiety than those who did not witness the event. Furthermore, the presence of relatives did not affect the results of CPR, increase stress on the medical team or result in further lawsuits.

The study echoes endorsements for family presence by the Emergency Nurses Association, American Association of Critical Care Nurses and American Heart Association. Yet, when researchers polled reader opinions, only 31% favored family presence.

"Ten years ago, I co-authored a study on family presence and only 5% of hospitals had a written policy on the topic. When I saw the NEJM poll that only 31% of readers favored it, I was disappointed," said Cathie Guzzetta, PhD, RN, AHN-BC, FAAN, director, Holistic Nursing Consultants, Washington, D.C., and nursing research consultant, Children's Medical Center, Dallas.

Cultural Limitations

The article has initiated a lot of heated conversations among providers on its relevance to U.S. hospitals. The study focused on 570 French individuals whose family members were treated by medical teams in the pre-hospital phase.

Stephen Borron, MD, MS, FACEP, FACMT, the study's only American author said most CPR in France is delivered in homes before patients board ambulances with a doctor, nurse and driver (comparable to an EMT).

"Part of the difference is having a physician and nurse at the scene allows for a greater level of confidence that everything's being done. It's not to say the study isn't transferrable to our system, but the make-up of the emergency team is the biggest difference," he said.

Borron accounted for other cultural differences: more aggressive treatment in French ambulances (including pre-hospital thrombolysis), a less vigorous medical-legal environment and generally less violent population.

Importance of Establishing Policy

Though a growing number of U.S. hospitals are inviting family members of adults CPR patients into the resuscitation room, not all have a formal policy. Therefore, it's often the decision of the attending nurse or physician. Some hospitals allow family presence in the ICU only.

"I'm just waiting for the lawsuit to come from a family who was not allowed into the resuscitation or one saying families could come to CPR in the ICU but not in the ED," said Guzzetta.

ENA and AACN released guidelines and practice alerts surrounding family presence. Both organizations insist that they key is a uniform policy with a dedicated support person for family members and only one relative in the resuscitation room.

Family support facilitators can be chaplains, social workers or even volunteers.

"I think these facilitators are necessary for screening but also for explaining to families where they can sit, what body parts they can touch, etc," said Guzzetta. "There's got to be reassurance for the health team that things won't get out of hand."

Though Borron said there were no facilitators per se during the study, many of the ambulance drivers could clarify the proceedings for family members while the doctor and nurse concentrated on the patient.

Infection Control Concerns & HIPAA

Detractors say the possibility of flying bodily fluid complicates family presence. However, JoAnn Lazarus, MS, RN, CEN, president of the Emergency Nurses Association, said family members are not physically close enough to be touched by bodily fluid. If there is a concern, she said, facilitators should help them suit up.

Another grey area is HIPAA concerns. When a patient comes to the hospital with a family member, usually the relative is allowed to watch unless there's a potential abusive situation. In critical care units, nurses usually understand the family dynamic. A much quicker assessment must be made in EDs.

At Ball Memorial, during admissions and at shift change, adult patients are asked about family's involvement. Patients share a code word with the next of kin and staff only.

In the study, doctors expressed the most hesitation about family presence during resuscitations. But clinician family presence advocates say it's only a matter of time before families are as present in the resuscitation room as they now are in the delivery room.

"Being present really helps families see that the team is doing all they can," concluded Lazarus. "It prepares them for the fact that the CPR may not be successful. It's best for families and we're all about family centered care."

Robin Hocevar is on staff at ADVANCE.




     

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