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Should Family Members Have the Option to Be Present During Resuscitation Efforts?

Do you think you would want to bepresent during resuscitation efforts of aloved one or family member? Do youthink your family member would wantyou there? Would you like to have a sup-port person there for you or other familymembers to explain things and answerquestions? What if the hospital has a pol-icy or a protocol that provides specificguidelines for allowing family membersthe option to be present during resuscita-tion efforts? A policy or protocol couldresult in decreased stress for medical staffand family members.

One of the authors, who has 18years of experience in critical care,believed for many years that family mem-bers should not be present during resusci-tation efforts. This author is now con-vinced that there are times when familymembers should have the option to bepermitted at the bedside. This article willdiscuss the concerns and benefits of fam-ily presence; the education, policies andprotocols; and describe the role of a fam-ily support facilitator.

Standards and ResearchThat Support FamilyPresence

Family presence during resuscitationis a relatively new perspective. InNovember 2004, the AmericanAssociation of Critical Care Nurses(AACN) announced a practice alert stat-ing that “Family members of all patients

undergoing CPR and invasive proce-dures should be given the option of beingpresent at the bedside” (p. 1). This posi-tion is also supported by the AmericanHeart Association (AHA, 2005) and theEmergency Nurses Association (ENA,2005). Because these three professionalorganizations exert significant influenceon facility standards, acceptance of fam-ily presence during resuscitation is grow-ing (Laskowski-Jones, 2007).

Research has validated the beliefthat family members desire to be presentand actually benefit from being presentduring resuscitation (MacLean et al.,2003; Meyers et al., 2000). AACNreported that “Research and public opin-ion polls have found that 60%-80% ofconsumers believe family membersshould be given the option to be presentduring emergency procedures or resusci-tation efforts” (AACN, 2004, p. 1).However, the issue remains controversial,not just for family members, but also forhealth care professionals.

Concerns about FamilyPresence

Laskowski-Jones (2007) outlined sev-eral reasons why health care profession-als disapprove of family presence. First,there are the concerns about potential lia-bility and violations of confidentiality. Iffamily members witness an error or mis-understand the interventions, they maylose confidence in the competence of the

health care team or they may be morelikely to file a lawsuit, especially if thepatient dies. Second, they fear that fam-ily members will be traumatized by thesights, sounds, and odors. They may beunable to tolerate the graphic scene andthus faint and injure themselves. Third,some individuals cope with anxiety, fear,and grief through anger and violenceand this creates danger for all involved.Fourth, there is concern that family mem-bers may interfere with patient care. Theymay distract health care professionalsfrom patient care decisions and tasks,and possibly impede resuscitation inter-ventions. Finally, health care profession-als may have anxiety about their per-formance and may feel distress about notbeing able to keep professional distance.

Benefits of Family PresenceLaskowski-Jones (2007) also offered

reasons for allowing family members tobe at the bedside during resuscitation.Nurses and doctors may believe it is theright thing to do. The family member’spresence may increase the patient’sdesire to live, and encouragement pro-vided by a family member may stimulatethe patient’s will to fight to live.Conversely, the family member may offersupport and closure; thus, the patientmay feel it is alright to die. Family mem-bers may also be able to answer ques-tions about the patient’s medical condi-tion or history. By observing the healthcare professionals’ intense life-savinginterventions, family members may cometo the reality of the seriousness of the ill-ness and unavoidable death. Finally,family members can see that everythingis being done and/or has been done fortheir loved one.

A final reason for permitting familiesto be present during resuscitation effortsis that their presence may inspire hope inthe family and the health care providersproviding the resuscitation efforts. Miller

You are a medical-surgical nurse with many years of experience. Imagine that yourmother is in a hospital recovering from surgery without any complications. You havegone to the cafeteria to get something to eat. As you sit down, you hear “Code Blue”called to your mother’s hospital room. You race to the room to find it packed withnurses, doctors, and other hospital staff. They are performing CPR and defibrillation.An endotracheal tube is inserted and oxygen is being bagged through it. IVs have beenstarted in her arms and medications are being administered. You are frantic and cryout, “What happened? What’s going on? Mom! Mom!” A doctor yells, “Someone get herout of here!” Grasping your arm, a nurse hurriedly escorts you to the waiting room. Yousay, “Wait, I’m a nurse!” The nurse apologizes since she must return to assist in theresuscitation of your mother. You are alone and afraid, and you feel helpless. You prom-ised that you would never leave your mother when she needed you because she hasalways been there for you.

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(2000) argued that when family andhealth care providers believe a deathwas a “good death,” they leave feelingpositive about the experience. Whenfamilies see that “all was done,” theymay thank the health care workers andleave with a sense of peace. Familymembers may feel they were there in thelast moments and will carry these feelingswith them. Health care workers may alsofeel inspired and renewed, knowing thefamily truly believed that “everything wasdone” and it was the patient’s time to die.

In order for family members to bepresent at the bedside during these criti-cal times, it is essential to increase aware-ness of the new standard of care amonghealth care professionals. Informationabout situations in which family members’presence has been beneficial in otherinstitutions may also promote comprehen-sion and a more positive attitude.

Education, Policies, andProcedures

Documents that support this changein practice need to be developed andimplemented. AACN (2004) has pro-vided recommendations for policies, pro-cedures, and educational programs forhealth care professional staff. These rec-ommendations include the benefits offamily presence for the patient and fam-ily, criteria for assessing the family toensure that patient care will not be inter-rupted, the role of the family support facil-itator, support for family members orpatients who decide not to have familymembers present, and contraindicationsto family presence.

Mian, Warchal, Whitney, Fitzmau-rice, and Tancredi (2007) offered gen-eral guidelines for developing standardsfor family presence during resuscitationor an invasive procedure:

In selected situations, family membersmay be permitted in the patient carearea during either invasive proce-dures and/or resuscitation. Thehealthcare team will be responsiblefor assessing the needs of the patientand their families and arranging forthe visit. (p. 56)

Definitions of family member, familysupport facilitator, and resuscitationshould be identified in the policy or pro-tocol. See Table 1 for the specific issues

Mian and colleagues (2007) recom-mended to be addressed in a policy.

Family Agreement Tool andFamily Support Facilitator

Mian and colleagues (2007) notedthat the policy or protocol should includea script for a “family agreement tool”which is enforced by the family supportfacilitator. The family agreement toolshould state specific guidelines or rules tobe followed in order for the family to bepresent during resuscitation efforts. Theseinclude how long the family may stay atthe bedside, how many family membersmay be at the bedside at one time,where they may stand, and under what

circumstances they will be asked toleave. It should be stressed that thepatient’s health care is the greatest prior-ity, and they will be asked to leave thebedside if they interfere or attempt tointerfere with any interventions. A samplescript for nurses to use as a family agree-ment tool is included in Table 2.

The family support facilitator shouldbe present at all times. The facilitator maybe a staff nurse, clinical nurse specialist,physician, chaplain, social worker, orother specially trained staff member whois assigned to support the psychologicalneeds of the family, explain interventions,and answer questions. Given the respon-sibilities for family support, the facilitator

Note: Adapted from Mian et al., 2007.

1. Designate who will be the “family support facilitator.”

2. Screen and assess family members to ensure those who attend will be able tocope and not interfere with resuscitation efforts.

3. Request permission from the resuscitation team for family to be present.

4. Prepare the family members with what to expect, and inform them that theteam’s priority is resuscitation of the patient.

5. The facilitator should escort the family to the bedside and stay with the familyat all times.

Note: Adapted from Mian et al., 2007. See AACN (2004) and ENA (2005) for additional recommendations.

Mian and colleagues (2007) recommended that family members attending resusci-tation efforts agree to all of the following before going into the treatment area.Keep in mind this is a “script” for the family support facilitator to use when talkingwith families – not a form for family members to sign.1. The family support facilitator will remain with family members while in the treat-

ment area, answering all of the family members’ questions and explaining themedical care.

2. Family may only be able to be present for a few minutes due to treatment activ-ity. The family support facilitator or the team may ask the family to leave.

3. The family support facilitator will try to get family members as close as possi-ble – to touch and talk to the family member.

4. The family members can leave any time they want.

5. The team is in charge of the treatment.

6. Only 1 or 2 family members may be in the treatment area at one time.

continued on page 6

Table 1.Recommended Guidelines for a Family Presence Policy

Table 2.Sample Script for a Family Agreement Tool

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should not be expected to participate inany aspect of the invasive procedure orresuscitation efforts. Additional responsi-bilities of the family support facilitatorinclude assessing family members forcomprehension of the situation, copingabilities, need or desire to be with thepatient, and ability to leave or ask forassistance if unable to tolerate the situa-tion. The facilitator should screen for fam-ily issues that would exclude them frombeing present at the bedside such as agi-tation, combativeness, extreme emotionalinstability, altered mental status, andintoxication (Mian et al., 2007).

After the family agrees to the familyagreement tool, the family support facili-tator should consult with the health careteam and inform them of the family’sdesire to be present. In addition, the facil-itator should consider whether the time isappropriate, given unit activities or situa-tions. Then the family should be preparedby the family support facilitator, who willexplain the situation and what they mayexpect to observe as the patient is receiv-ing treatment (Mian et al., 2007).

The family support facilitator shouldescort the family members to the bedsidewhere the facilitator will remain to pro-vide support, explain interventions, andanswer questions. If possible, the familyshould be able to see, speak to, andtouch the patient. After the “code” isover, whether resuscitation efforts havebeen successful or not, the family supportfacilitator should escort the family to aprivate area, provide clinical updates,and continue to offer emotional supportto the family.

Debriefing for family members canprovide an opportunity for them to dis-cuss their perceptions of the situation,questions, and fears about the patient’sillness or lifesaving interventions (Mian etal., 2007). Debriefing will also be bene-ficial for the health care workers, espe-cially if the patient outcome is unex-pected or unfavorable. The health careworkers can discuss, evaluate, and offersuggestions for improvement of the proto-col as needed.

Family Presence MayInspire Hope

In conclusion, the AHA, ENA, andAACN recommend that the standard of

care should be that families are given theoption of being present at the bedsideduring resuscitation efforts. Further, thereis evidence of positive benefits to familypresence when the situation is appropri-ate. Resuscitation efforts are intense andstressful, but they may be more beneficialto the patient and family members thanmedical staff may actually comprehend.

As nurses, we recognize the impor-tance of family relationships, particularlyduring potential end-of-life events. It is theobligation of health care professionals toease the stress of these events wheneverpossible, and family member presencemay provide a means to alleviate familystress.

ReferencesAmerican Association of Critical Care Nurses

(AACN). (2004). AACN practice alert:Family presence during CPR and invasiveprocedures. Retrieved from http://w w w. a a c n . o r g / W D / P r a c t i c e /Docs/Family_Presence_During_CPR_11-2004.pdf

American Heart Association (AHA). (2005).AHA guidelines for cardiopulmonaryresuscitation and emergency cardiovascu-lar care. Retrieved from http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-6

Emergency Nurses Association (ENA). (2005).Family presence at the bedside duringinvasive procedures and cardiopul-monary resuscitation. Retrieved fromhttp://www.ena.org/SiteCollectionDocuments/Position%20Statements/Family_Presence_-_ENA_PS.pdf

Laskowski-Jones, L. (2007). Should familiesbe present during resuscitation? Nursing2007, 37(5), 44-47.

MacLean, S.L., Guzzetta, C.E., White, C.,Fontaine, D., Eichhorn, D.J., Meyers,T.A., & Desy, P. (2003). Family presenceduring cardiopulmonary resuscitationand invasive procedures: Practices ofcritical care and emergency nurses.American Journal of Critical Care,12(3), 246-257.

Meyers, T., Eichhorn, D., Guzzetta, C., Clark,A., Klein, J.D., Taliaferro, E., & Calvin,A. (2000). Family presence during inva-sive procedures and resuscitation: Theexperience of family members, nurses,and physicians. American Journal ofNursing, 100(2), 32-43.

Mian, P., Warchal, S., Whitney, S., Fitzmau-rice, J., & Tancredi, D. (2007). Impact ofa multifaceted intervention on nurses’and physicians’ attitudes and behaviorstoward family presence during resuscita-tion. Critical Care Nurse, 27(1), 52-61.

Miller, J.F. (2000). Coping with chronic ill-ness: Overcoming powerlessness (3rd

ed.). Philadelphia: F.A. Davis.

Linda B. Charron, BSN, RN, CCRN,CSC, is a Critical Care Nurse, High PointRegional Health System, High Point, NC.

Donald D. Kautz, PhD, RN, CNRN,CRRN, CNE, is an Assistant Professor, TheUniversity of North Carolina Greensboro,Greensboro, NC.

Acknowledgment: The authors grate-fully acknowledge the editorial assistanceof Ms. Elizabeth Tornquist with this article.

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