Family presence during pediatric resuscitation: An integrative review for evidence-based practice
from Caring For Our Future, Summer 2006
By Laura Nilbert, MS, RN and Dennis Ondrejka, PhD, RN
Many pediatric healthcare institutions lack guidelines to address the presence of family members during resuscitation. This integrative literature review was used to establish an evidence-based approach that would complement our institution’s philosophy of “family centered care.” The evidence supports partnering with the families.
Hospital staff ask families whether they want to be present during life-saving interventions by healthcare professionals. Families want to make the choice, and when they are present during resuscitation efforts, there is less litigation, anxiety, and second-guessing regarding the efforts and competence of the staff providing that care. No literature was found to support beliefs that family member presence is harmful to the family or the institution. A practice policy is provided that respects family choice and presence during life-saving measures in pediatric-care facilities.
Emergency Department (ED) clinicians often hear unsubstantiated fallacies associated with the risk of allowing family members to be present. Some of these fallacies include a belief that the family will be traumatized, a belief that family presence may lead to lawsuits, and a belief that the family may not understand what is happening to their loved one. These unsubstantiated beliefs often become associated with fear of risk or negative outcomes for the clinicians, hospital and family. McClenathan, Torrington, & Uyehara (2000) documented clinician resistance to family presence during resuscitation efforts with a survey study (N = 592). Only 14 percent of physicians and 17 percent of nurses would allow families to be present during resuscitation efforts.
Inconsistent practice or refusal to allow family members into resuscitation rooms do not fit the “family- centered care” model for many pediatric hospitals (Newton, 2000). An important clinical question to consider is: “Do family members benefit from witnessing the actual efforts made by hospital personnel to save their child?” What does the current literature reveal? An integrative review of the literature was conducted to answer the clinical question and to establish a policy based on best research evidence.
Literature Review
The literature was examined by searching MEDLINE, CINAHL and PUBMED starting Jan. 1, 1999 to Sept. 1, 2003. Keywords used were “pediatric resuscitation,” “family presence,” “emergency medicine,” “traumatic resuscitation” and “cardiopulmonary resuscitation.” After screening for research articles specifi c to family presence during lifesaving measures, the authors identified eight primary sources and three secondary research sources from various journals. These articles also identified the concerns and perceptions of family members, physicians and nurses pertaining to family presence.
The attitudes of doctors and nurses are common obstacles to family presence during resuscitation efforts (Tsai, 2002). Personal views of medical professionals are often accepted rather than questioned. Sacchetti, Carraccio, Leva, Harris & Lichenstein (2000) found that lack of confidence in clinical competence contributed to healthcare workers’ concerns with family presence in trauma rooms. They also found that personal experience with family presence was a key determinant in the clinicians’ acceptance of the practice (Sacchetti, et al., 2000). More experience with family presence resulted in fewer objections.
A survey of emergency nurses and physicians reported that fear of litigation was a major concern of clinicians (Beckman, et al., 2002). The staff were afraid that they might be observed making a mistake or saying something inappropriate during the event. One research literature review, Clark, Meyers, Eichorn, & Guzzetta (2001), summarized staff concerns with regard to the emotional states of family members. Staff concerns included beliefs that emotional outbursts or fainting might hinder or interrupt the resuscitation efforts, and emotional distress of family members might infl uence the emotional states of staff, resulting in a deterioration of skills. This review also cited research literature that found that emergency clinicians believed that families would fi nd chest compressions cruel and abusive to their child. In actuality, parents thought the opposite (Sanford, Pugh & Warren, 2002). Parents were grateful for the lifesaving efforts made by healthcare professionals and were less critical than clinicians of the visual impact of these efforts. Family presence facilitated a relationship between the medical staff and family through increased communication. In a critical review by Boudreuax, Francis & Loyacano (2002), another clinician belief was that family members might plead to either continue CPR under futile circumstances or to stop CPR prematurely.
A survey of U.S. and international critical-care providers found no evidence that family presence compromised resuscitation efforts (McClenathan, Torrington & Uyehara, 2002). There was evidence indicating reduced risk of litigation when a resuscitation event was observed by family members (Tsai, 2002). According to Tsai (2002), 95 percent of family members who were present during resuscitation stated that the events helped them understand the child’s condition was “grave,” and they did not question the decision to stop life-sustaining efforts.
Boie, Moore, Brummett & Nelson’s (1999) study demonstrated that more than 80 percent of family members wanted to be present during lifesaving attempts on their children. Overall, 97 percent of the family members who witnessed the event would do it again. Meyers, Eichorn & Guzzetta (1998) found that 80 percent of family members present during resuscitation efforts would have chosen to be present again if given the option. Family presence allowed the family unit to remain intact during the crisis, alleviating anger about being separated from their child at such a critical time (Eichorn, et al., 2001; Powers & Rubenstein, 1999).
Parental presence may result in improved psychological outcomes. Presence may actually facilitate the grieving process for the parent or guardian by helping them move beyond the immediate denial response to loss. Allowing family members to witness resuscitation efforts and say goodbye to their child facilitated the grieving process. A sense of realitywas obtained, reducing the likelihood of a long denial period (Sanford, et al., 2002).
Discussion
Trends are changing to allow patients and families greater control over end-of-life issues, and family presence is one way that family-centered care is being encouraged. Clearly, most families have a desire to be with their child during resuscitation efforts, and nearly all of them want it to be their personal choice. Healthcare professionals must overcome their own anxiety, false beliefs and fears to encourage families to meet their needs during lifesaving efforts for their children. There are numerous clinician beliefs and practices that are not evidence-based. Most parents are able and willing to be present during lifesaving events. Each situation should be examined individually by including the desires of the family in the decision-making process. At a minimum, the evidence is clear that families want to be consulted regarding their presence during resuscitation efforts on their child. Designating someone to be available to support the family and to answer their questions may avoid or reduce confusion about the resuscitation process. Appendix A provides an example of a policy that is based on this integrative review of the literature.
Policy and Procedure for Practice
Subject: Family member presence during lifesaving procedures.
Purpose: To provide patients and families with care that is consistent with the family-centered care model and the research evidence related to life-saving procedures.
Definitions: Family Member: A relative, legal guardian or loved one with whom the patient shares an established or legal relationship.
Support Staff: A member of the healthcare team who is not providing direct care. This individual serves as a resource to the parents or guardians and is available to clarify what is happening, to explain how the patient is responding, and to answer any questions the family may have. Examples of support staff may include a chaplain, social worker, child-life specialist, emergency medical technician (EMT), paramedic, clinical assistant, nurse, physician or physician assistant.
Procedure
- A person on the rescue healthcare team who is assigned as support staff has a discussion with the family members about how they would like to be involved, and whether they want to be in the procedure area, such as a trauma room.
- Before entering the procedure area, support staff make a final determination about the family members’ abilities to be present without interference or danger to themselves, such as fainting. Once in the room, the family members are directed to a place to sit or stand that is not a barrier to the care of the patient.
- Support staff are responsible for establishing boundaries or limits related to family-member presence. These include the following:
- Only two persons are allowed access at one time.
- All communication goes through the support staff.
- Family members can ask questions through the support staff during the procedure.
- If family members do not want to be present, the support staff will regularly keep them informed of what is occurring and the status of the patient.
- Support staff will provide anticipatory guidance to family members. This includes, but is not limited to descriptions of patient appearance, the general atmosphere that they may encounter, medical equipment and terminology.
- Debriefing by the support staff should be at the pace of the parents or guardian with some input from the attending physician regarding the result of the resuscitation effort.
References
Beckman A, Sloan B, Moore G, Cordell W, Brizendine E, Boie E, et al., (2002). Should parents be present during emergency department procedures on children, and who should make that decision? A survey of emergency physician and nurse attitudes. Academic Emergency Medicine, 9(2),154-157.
Boudreaux E, Francis J, Loyacano T. (2002). Family presence during invasive procedures and resuscitation in the emergency department (A critical review and suggestions for future research). Annals of Emergency Medicine, 40(2), 193-205.
Boie E, Moore G, Brummett C, Nelson D. (1999). Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Annals of Emergency Medicine, 34(1), 70-74.
Clark A, Meyers T, Eichorn D, Guzzetta C. (2001). Family presence during cardiopulmonary resuscitation and invasive procedures. A researched based intervention. Critical Care Nursing Clinics of North America , 13, 569-575.
Eichorn D, Meyers T, Guzzetta C, Clark A, Klein J, Taliaferro E, et al., (2001). Family presence during invasive procedures and resuscitation: hearing the voice of the patient. American Journal of Nursing, 101(5), 48-55.
McClenathan B, Torrington K, Uyehara C. (2002). Family member presence during cardiopulmonary resuscitation. A survey of US and international critical care professionals. Chest Journal, 122(6), 2204-2211.
Meyers T, Eichorn D, Guzzetta C. (1998). Do families want to be present during CPR? A retrospective survey. Journal of Emergency Nursing, 24(5), 400-405. Newton M. (2000). Family centered care (Current realties in parent participation). Pediatric Nursing, 26(2), 164-168.
Powers K, Rubenstein J. (1999). Family presence during invasive procedures in the pediatric intensive care unit. ARCH Pediatric Adolescent Medicine, 153, 955-959.
Sacchetti A, Carraccio C, Leva E, Harris R, Lichenstein R. (2000). Acceptance of family member presence during pediatric resuscitation in the emergency department (effects of personal experience). Pediatric Emergency Care, 16(2), 85-87.
Sanford M, Pugh D, Warren N. (2002). Family presence during CPR (New decisions in the twenty-first century). Critical Care Nursing Quarterly, 25(2), 61-66.
Tsai E. (2002). Should family members be present during cardiopulmonary resuscitation? New England Journal of Medicine, 346(13), 1019-1021
Abridged and used with permission from: (c) 2005 Elsevier Inc.. All rights reserved. The full article can be found in The Journal of Pediatric Health Care, (March, 2005), volume 20, issue 2, pages 145-147.
