Should family members be present during resuscitations?
Many ED nurses argue that family members have a right to be present when their loved ones are near death, but some feel that this practice is inappropriate and problematic for caregivers
When an ill or injured patient is brought to the ED, many nurses are now insisting that the best place for a loved one isn’t the waiting room. Instead, they argue, worried family members should be allowed to stay as close to the patient as possible—even at the bedside during resuscitation efforts.
The controversy over allowing family members to witness resuscitations is playing out in EDs across the country. (For arguments on both sides of the issue, see Point-Counterpoint on page 55.) "It’s a black and white issue with no gray areas," explains Mary Anne Belanger, RN, CEN, an emergency nurse at Wooster Community Hospital (OH), where allowing family presence has been standard practice for two years. "Many emergency nurses, who are control-oriented by nature, want no part of this at first glance."
Some ED physicians and nurses are adamantly opposed to the practice. "If I had only one thing to worry about during a resuscitation, it would be getting the patient alive again," emphasizes Rashmi Kothari, MD, FACEP, assistant professor in the department of emergency medicine at the University of Cincinnati Medical Center (OH). "What I don’t want happening in the middle of an arrest is a family member passing out, screaming hysterically, or trying to run toward the patient, and all of a sudden I’m stuck having to deal with that person while I’m running a code."
Some ED personnel fear patient care will suffer if caregivers censor themselves in front of family members. "That’s not just in terms of inappropriate joking or laughing, but medical information as well," says Kothari. "I’d be kind of hesitant to ask if the patient was HIV positive or had taken crack cocaine in front of a family member."
Seeing is believing
When family presence was first discussed at Children’s Hospital in Columbus, OH, 80% of staff were resistant to the idea. They feared legal risks, hysterical family members, and loss of control, says Nancy Eckle, RN, MEN, CEN, a clinical nurse specialist who helped to implement the ED’s family presence policy. Several staff members who were strongly in favor of family presence formed a team, with the goal of changing negative attitudes.
ED staff were invited to a series of discussion forums to express their opinions about family presence. "The forums helped us learn what concerns people had, and also helped us to identify the biggest resisters, so we could work on them individually," recalls Eckle. "The most convincing argument we came up with was asking them, If this was your son or daughter, where would you want to be?’" she notes.
Once staff members had experienced family presence, their attitudes began to change. "After people had experiences where things went really well, they were less resistant," Eckle reports. "Now, if the staff is gathered around the bedside, people will look up and ask, Are the mom and dad here yet?’ If the parent hasn’t arrived at the facility yet, people feel badly and will go on a search mission to locate them."
At Wooster Hospital, a survey was conducted to gauge ED staff attitudes about family presence. "It was a resounding, No! We don’t want to do this!’" recalls Belanger. Still, to give the practice a fair chance, family members were occasionally invited to observe codes when care providers were in agreement. After a year, the results of a second survey revealed a dramatic turnaround in staff attitudes.
"They realized family members were no threat to them and became less inhibited," says Belanger. "They were so afraid their care was going to be critiqued, but family members don’t care about your technique. All they’re seeing is you trying to do your best to save their loved one." When things don’t go well, witnessing resuscitation efforts can help family members cope with a loved one’s death, she notes. (See related story on helping family members grieve on page 54.)
During one family-witnessed code at Children’s in Columbus, there was a heated discussion over the need to intubate a child. "The parents were so focused on their child, they did not even realize there was a potential debate going on over a care issue," recalls Sharon Deppe, RN, BSN, now the clinical coordinator of the ED at Columbus’ Grant Medical Center, which also recently implemented a family presence policy.
Several physicians at Wooster were dead set against family presence, recalls Sandra Reed, RN, BSN, the clinician who first presented the idea to staff. "But, when they realized other physicians were doing it without problems, they were willing to try it," she says. To avoid unexpected resistance, the ED’s new policy on family presence was discussed in advance of hiring a new emergency physician group.
Although impromptu testing of family presence can work well in some cases, it’s usually best to have a formal policy in place. "Staff will have legitimate concerns that need to be addressed beforehand," says Donna Strawser, RN, BSN, CEN, education specialist at W.A. Foote Memorial Hospital in Jackson, MI, which has had a family presence policy in place since 1983. "Staff will not be 100% comfortable trying this, so the more guidelines you have, the better you’ll be starting out." (For more information on implementing a family presence policy, see the related story on this page.)
As with any practice change, there needs to be an ongoing commitment. "If you set this up to fail, it will," stresses Deppe. "You’ve got to provide the necessary components for success." That includes buy-in from the medical staff, having support personnel who prepare the families adequately, and ongoing training for new staff members," she says.
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