Roland Harrison

1

Family Presence During Cardiopulmonary
Resuscitation

• Roland Harrison
• Brant Mahan
• David McAllister
• Jeff Struttmann

2
Family Witnessed Resuscitation

• Family witnessed resuscitation (FWR) is the act
  of allowing family members to be present during
  cardiopulmonary resuscitation of a loved one

3
History of Family Presence

• The ethical debate on whether family presence
  should be allowed spans over two decades, with
  the first study being conducted in 1987
• FWR has become significantly more relevant due to
  the increase of family members expressing a
  desire to be present during their loved ones last
  moments

4
Evidence of Increasing Trend

• Dingeman (2007) systematic review of literature
• 1991 - lt50 of parents wanted to be
  present
• 2001 - 87 of parents wanted to be present

5
Evidence of Increasing Trend

• Dingeman (2007) Systematic Review of Literature

• Meyers (1998) Descriptive Survey
• 96 of family stated the option should be given
• 80 stated they would stay if given the option

• Meyers (2000) Descriptive Survey
• 98 of patient family stated it their right to
  be present would do it again

6
Organizations Endorsing FWR

• American Heart Association
• 2000 recommendations
• Emergency Nurses Association
• Family facilitator
• American Association of Critical Care Nurses

7
Problem at Hand

• Although research indicates a rise in family
  desire for presence and proposes benefits to FWR,
  only 5 of hospitals have implemented a written
  protocol/policy
• MacLean (2003)
• Survey of 1500 ENA 1500 AACC nurses
• 948 respondents
• Only 5 worked on a unit with written policies

8
PICO Question

• Can having family present during cardiopulmonary
  resuscitation have positive benefits to both
  family members and nurses?

9
Family Perspective

• Boudreaux (2002) Review of Literature
• Of 47 mailed surveys of family members who
  remained present during resuscitation
• 44 (94) stated they would participate again
• 36 (76) stated benefits to adjustment to death
• 30 (64) believed presence was beneficial to
  dying loved one

10
Family Perspective
Dingeman (2007) Systematic Review of Literature

• Meyers (1998) Descriptive Survey
• 68 believe their presence was helpful
• 64 said it would help them to cope

• Meyers (2000) Descriptive Survey
• 100 stated it was helpful
• 98 stated it helpful to family/patient

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Benefits Proposed by Family

• Helps in understanding the seriousness of patient
  situation
• Decreases anxiety
• Witness everything possible was done
• Provides sense of closure
• Facilitates grieving process
• Chance to say I love you or Goodbye
• Facilitates role of caretaker

12
Surviving Patient Perspective

• Provides comfort
• Reminds staff of patients personhood
• Provided reason to fight

13
Benefits Proposed by Nurses

• MacLean (2003) Survey of 948 ENA AACN Nurses
• Provides emotional support
• Provides positive experience for families, staff,
  patients
• Provides guidance/increases family understanding
• Helps families make decisions
• Helps family to know all was done for patient
• Facilitates closure and healing

14
Positive Views of FWR by Nurses

• 92 of nurses supported FWR (Mangurten, 2006)
• 92 of Canadian Critical Care Nurses supported
  FWR (Fallis, 2008)
• 96 of ED nurses supported FWR (Dingeman, 2002)
• Ellison (2003) 13-item Survey of Nurses
• 56 wanted to be present if patient was a family
  member
• 87 wanted family present if they were the
  patient

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Opposing View

• McClenathan (2002) 30-item Survey of Nurses
• 543 physicians, 28 nurses, 21 allied health care
• 78 opposed family presence
• Nurses showed a more positive attitude towards
  FWR than physicians

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Reasons for Opposing

• MacLean (2003)

• Environmental
• Limited Space
• Chaos/Confusion
• Legal
• Litigation Family Complaints
• Staff related Issues
• Stress/Discomfort
• Impeding Work
• Inadequate Staffing

• Patient related issues
• Privacy
• Family related Issues
• Behaviors/Emotional Reactions
• Lack of Education/Understanding
• Family/Staff Relationships

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Evidence Disputing Opposing View

• Mangurten (2006)
• 100 of patient cases were uninterrupted
• 90 of clinicians believed family behavior was
  not disruptive
• 90 of clinicians stated their performance was
  not affected
• Dingeman (2007) Review of Literature
• 15 articles were reviewed and almost no instances
  of family interference were reported

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Evidence Disputing Opposing View

• Dingeman (2002) Systematic Review of the
  Literature
• Meyers (2000) Survey
• No family members reported any traumatic memories
  2 months after the event
• Boudreaux (2002) Critical Review of Literature
• Policies denying FWR may not meet the
  emotional/spiritual needs of family members

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Factors Affecting Support of FWR

• Ellison (2003) 13-item Survey
• Positive Attitudes to Resuscitation Strongly
  Correlated with
• Education
• Specialty Certification
• Professional Designation
• Specialty Area

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Affect of Experience on Desire for
Written/Unwritten Policy
MacLean (2003) Survey of ENA AACC Nurses
Experience with FWR
42
No Experience with FWR
28
Preferred Written Policy for FWR
21
Recommendations

• It is our recommendation that healthcare
  organizations adopt a FWR policy and a FWR
  education program to improve outcomes for
  families and nurses during cardiopulmonary
  resuscitation.

22
FWR Implementation Needs

• Need for Collaboration among specialty groups
  (Social, Pastoral, Physicians) to develop
  guidelines
• Involve Nurses in development and implementation
• Develop Educational resources for policies,
  practices, and programs supporting option
• Develop Educational resources for the public
• Need for continuing education to increase
  understanding of presence

• ENA (2005)

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Components for Policies, Procedures, and
Educational Programs

• Policies and procedures, and educational programs
  for professional staff should include the
  following components
• Benefits of family presence for the patient and
  family.
• Criteria for assessing the family to ensure
  uninterrupted patient care.
• Support for patients or family members decision
  not to have family members present.
• AACN (2004)

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Components for Policies, Procedures, and
Educational Programs

• Role of the family facilitator in preparing
  families for being at the bedside and supporting
  them before, during and after the event.
• Family facilitators may include nurses,
  physicians, social workers, chaplains, child life
  specialists, respiratory care practitioners,
  family therapists.
• Contraindications to family presence
• Family members who demonstrate combative or
  violent behaviors
• Uncontrolled emotional outbursts
• Altered mental state from drugs or alcohol
• Those suspected of abuse.
• AACN (2004)

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Importance of Education

• Bassler (1999)
• Survey of Nurses to show Educational Effects on
  Nurses Attitudes toward FWR
• Before Educational Class
• 56 said family should be given the option to be
  present
• 11 gave the family the option to be present
• After Educational Class
• 89 said family should be given the option to be
  present
• 79 planned on giving the option to be present

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Suggestions For Further Study

• Studies need to incorporate all pertinent
  demographics of the sample
• Age, race, relationship to family member,
  education, etc.
• Follow up studies regarding the experiences of
  adult patients who survive resuscitation while
  family was present and not present
• Programs that have protocols in place need to
  devise a way keep a registry of positive and
  negative experiences from both family and staff
  point of view
• Family interference, problematic levels of
  distress, need to be dismissed from the room
• This type of data may further play a part in
  allowing us to dispel health professionals fears
  regarding family presence.

27
New Research Questions

• What are the implications and beliefs of the need
  for family presence among individuals of
  different cultural backgrounds?
• What about individuals from various religious
  backgrounds?

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Thank You!