TV programs like ER and House portray CPR or “code blue” situations as exciting and successful. Recently, an actor in one prime-time drama “defibrillated” a patient over his gown. When was the last time you did this?

The media inundates us with erroneous information about the way hospitals operate and the way patients respond, and this misinformation forms the basis of the public’s beliefs about hospital operations. These beliefs carry over into real-life expectations. For instance, the public believes that CPR is successful 60% to 75% of the time while it is actually successful only 10% to 15% of the time.¹

Television shows frequently depict a false picture of the role of families during patient resuscitation, as well. The TV family is restricted from the resuscitation area — or is in the area, but impeding the staff’s efforts. In the real world, allowing families to be present while their loved ones undergo CPR or invasive procedures can benefit the patient, family, and healthcare staff.

Way back when

Years ago, death was a family affair, with family members providing emotional support to the dying person. Medical breakthroughs and technological advances made it possible to prolong a dying person’s life, and patients began to be transported to the hospital before death. Over time, hospitals adopted the practice that family members could not watch the sometimes-grueling resuscitation attempts.

As nurses, we know that the family is included in our care of the patient. Should family members be allowed to watch the resuscitation? Should they be able to touch the patient? These questions surround the issue of family member presence during code situations and invasive procedures. By being familiar with the history of family presence and the concerns, legal implications, and policy recommendations surrounding it, nurses will be better able to advocate for what they believe is best for both patients and families.

Since the 19890s, much has been written in professional journals about family presence. At first, discussion focused on letting parents be present during a child’s medical procedures to alleviate separation anxiety. Later in that decade, the focus expanded to family members in general and their wishes to be present during the resuscitation attempts of loved ones.² In the early 1990s, the healthcare community began to seriously consider whether the presence of family members might benefit patients during CPR.

In 1990, Foote County Hospital in Jackson, Mich., became the first hospital in the U.S. to develop a program allowing family members to be present during patient resuscitation. The program came about after a woman requested to be at the bedside of her police officer husband, who was undergoing resuscitation efforts after an acute MI. A pastoral support person in the ED made the request to the physician on the woman’s behalf.³

Support grows

In 1993, the Emergency Nurses Association went on record supporting the option of family member presence and in 1994 wrote a position statement on the issue. (See sidebar.) In 2000, the American Heart Association and an international consensus group revised their resuscitation guidelines, with the revisions including support of family presence during CPR.⁴ The AHA also recognized that family members present during CPR require support. In 2003, the American Academy of Pediatrics published a position paper supporting family presence during invasive procedures.⁵

Facing the challenges

Not all healthcare providers feel comfortable with family presence. A review of the literature reveals three common concerns:^6,7,8

1. Clinicians fear that family members will be disruptive and interfere with care.
2. Healthcare providers are concerned about the psychological effects on family members witnessing resuscitation.
3. Hospitals worry that the family will be critical of the actions of the code team and will be more likely to initiate litigation.

Resuscitation attempts are neither clean nor pretty. The situation is, in reality, controlled chaos. Medical personnel have specific roles in this setting, and they must carry out their tasks uninhibited. Opponents of family presence argue that family members may disrupt care, but the data don’t indicate that they do.⁶ In one study, a majority of ED providers in a university teaching hospital felt that having family present did not interfere with patient care and that being present was beneficial to family members.⁷ Another survey, a hospital program evaluation, found that nurses felt family members were rarely disruptive and were in “in awe of the activity in the room.”³ In addition, the nurses viewed the patient as a part of the family unit, clinical tasks remained a priority, and staff continued to function professionally.³

By planning ahead for family presence and having staff members accompany families to the resuscitation, hospitals can prepare family members — to some extent — for what they will witness. The staff member, often a nurse, tells family members where to stand and what type of contact they may have with the patient.

As nurses, we have always made the patient’s family our concern, second only to the patient. In a resuscitation attempt, when the code team is caring for the patient, the nurse’s focus falls upon the family members by providing them with reassurance, updates, and a caring heart.

Source of trauma?

Some nurses are concerned that family members will suffer mental trauma as a result of witnessing resuscitation attempts.⁸ But most nurses have reported that families have shown no visible signs of mental trauma after witnessing resuscitation attempts. In fact, one study found “no reported adverse psychological effects among the relatives who witnessed resuscitation, all of whom were satisfied with their decision to remain with the patient.”⁸ In this study, the family members were chaperoned by professionals who provided emotional support and technical information. Family members who chose to be present for resuscitation attempts reported that they were confident that everything that could have been done for their loved ones was done. In addition, they said that being present facilitated the grieving process.⁸

The comfort zone

When providers don’t have experience with family presence, they often are hesitant to participate in a resuscitation attempt with family members in the room. Experienced physicians are more comfortable with the practice of family presence. One study involving nurses and attending and resident physicians found that while nurses and attending physicians favored family presence, residents were much less likely to approve.⁹ Residents felt that having a family member present led to more anxiety in the room, created disturbing memories for parents in the case of a child being resuscitated, and hindered the success of the procedure.⁹

Another study found that most physicians and nurses felt that parents should be present for some invasive pediatric procedures, but as the invasiveness of the procedure increased, fewer physicians and nurses felt parents should be present.¹⁰

Another argument against family presence involves the education of residents and new nurses.⁷ Nurses and residents must learn actions to take during CPR and must practice these skills until they become second nature. But critics believe it is difficult to provide instruction with family members present. One solution would be to review a typical resuscitation and the roles of each healthcare provider with new staff members before an actual event. Prior instruction would probably eliminate, or at least minimize, the need for instruction during the code. The family’s chaperone could use any instruction the staff does do to educate the family about the care their loved one is receiving.

Errors occur, regardless of our good intentions. At one time, when only nursing and medical staff were present for resuscitation efforts, errors could be concealed within the confines of the resuscitation room. Now some clinicians fear that family members will notice errors and pursue them in the form of a lawsuit. But research shows that family members present during resuscitation attempts are largely appreciative of the efforts to save their loved ones and are not critical of staff performance.³ In fact, there are no documented cases of lawsuits arising from family presence.⁶

The role of rapport

Patients who have a rapport with their nurses and believe the nurses are delivering care with their best interests at heart are less likely to sue, even in the case of a bad outcome, according to one nurse expert.¹¹ Nurses should provide quality care without obsessing about the risk of a lawsuit, pay special attention to evolving clinical care standards, and communicate effectively with patients and families.¹² One reason that lawsuits have not arisen may be that through family presence, nurses are incorporating those principles into their daily practice. What better way to communicate with the patient’s family members, for instance, than providing a step-by-step explanation of the resuscitation process while they look on?

What patients prefer

Inherent to the concept of family presence are the preferences of the patient. One study revealed that 74% of patients would prefer having a family member present during resuscitation and that 88% indicated they would want a family member to be allowed in the room if the person requested to be present.¹³ Eighty percent of family members reported that they would want to be present during a loved one’s resuscitation.¹³ This study found no conflict between patient and family wishes, i.e., that in all cases in which relatives desired to be present, patients supported that desire or expressed indifference.

Advance directives have become a common and accepted way for people to make their wishes about treatment known if they are not able to speak for themselves. Many healthcare providers believe preferences about family presence should become a standard part of advance directives.

When discussing advance directives, nurses can encourage patients and family members to discuss whom patients would want in the room with them during a resuscitation attempt. One study showed that although 72% of participants wanted family members present, most of that number wanted only certain family members present, and about one in five patients, who tended to be older and white, did not want any family present.¹⁴ (The study authors do not recommend allowing family members to be present without prior knowledge of the patient’s wishes.¹⁴

Policies in place

Healthcare providers prefer to have a policy in place on family presence^4,15-17 although no policy can cover all scenarios. The following are some issues to consider when developing a policy:

• Encourage collaboration among staff members, including physicians, nurses, social workers, and pastors, while developing and implementing multidisciplinary guidelines.
• Determine the patient’s wishes if there is time.
• Never pressure a family to attend a resuscitation.
• Determine whether a chaperone or family facilitator will be present and what healthcare staff member will fill the role. In some facilities, the chaperone is called the patient representative or patient advocate and is a nurse or social worker. For each resuscitation attempt, the patient representative and the chaplain are notified. They work with the family to assist and educate them in the ED.
• Determine how many family members are allowed based on issues such as space in the room.
• Explain to family members where they should stand, what they will witness, and if they may touch their loved one. Explain that the patient can probably hear them and encourage them to talk to their loved one.
• Have a chair nearby for family members who feel faint.
• Do not allow family members under the influence of alcohol or drugs in the resuscitation room. Consider that victims of violence may have visitors who intend further harm. A gunshot victim, for instance, may be followed into the ER by the person who perpetrated the violence.
• If possible, allow the family to determine how long they wish to be present. The family may wish to be present for the entire resuscitation attempt or for only five or 10 minutes.
• Take care of the staff’s mental health. Allow an opportunity for the staff members involved to attend a critical incident debriefing session with qualified counselors. This is also an ideal time for new staff to ask questions and discuss their feelings about the incident with other staff members.

Statistics on the number of hospitals allowing families to be present are difficult to come by, but the debate about family presence is intense, with more and more hospitals, journals, and professional associations tackling the issue. Family presence can be an exciting opportunity for nurses to practice family-centered medicine. Nurses have been at the forefront of this practice, promoting and encouraging it for many years.