Critical care nurses reported unmet need for education on family presence during resuscitation. Nurses wanted information on:

• team training;

• implementation;

• communicating with families.

Critical care nurses’ needs for education on family presence during resuscitation are not being met, found a recent survey of 395 critical care nurses.1

“As this topic was first reported in the literature three decades ago and has been repeatedly recommended in practice guidelines, it is surprising that nurses’ needs for education are still not being met,” says study author Kelly Powers, PhD, MSN, RN, an assistant professor in the school of nursing at the University of North Carolina at Charlotte.

Guidelines recommend critically ill patients’ family members be offered the option to be present during resuscitation, yet the practice remains controversial.2 “It is important to determine the reasons for this controversy and interventions that may improve guideline implementation,” says Powers.

The study specifically focused on education as a possible intervention. “It has been shown to improve nurses’ perceptions and self-confidence in prior studies,” notes Powers. Some key findings include the following:

• Only one-third of nurses received education on family presence during resuscitation.

• Eighty-three percent indicated they wanted such training. “So although some may have received education, they still desired more information,” says Powers.

• Sixty-one percent of nurses received requests from family members to be at the bedside during resuscitation. Qualitative data revealed that nurses wanted help with these requests. “Specifically, they wanted to be educated on how to communicate with and support family members, and how to handle difficult situations should they arise,” says Powers.

• Nurses wanted information on team training and how to implement family presence during resuscitation.

“As the focus on providing family-centered care continues to gain momentum, it is essential to educate nurses and other providers so they are more likely to honor family members’ wishes,” says Powers.

It is important to recognize that the critical care experience affects the family, too. “While our primary focus during resuscitation must be on the patient, we cannot forget our duty to care for their family as well,” says Powers.

An umbrella term used for negative psychological symptoms that can result is “Post-intensive Care Syndrome-Family,” or “PICS-F.” “Offering family the option to remain at the bedside during resuscitation has been shown to significantly reduce the frequency of the psychological symptoms that characterize PICS-F,” says Powers.

Patient survival rates following CPR are low. “Anyone who has witnessed a ‘code’ knows that they can be brutal and often do not end well,” says Wayne Shelton, PhD, a professor at Albany (NY) Medical College’s Alden March Bioethics Institute.

Most patients who arrest and receive CPR in a hospital do not survive resuscitation. Even more do not survive to discharge. “The benefits of CPR, especially outside the ICU setting, are often assumed to be greater than the data actually indicate,” says Shelton.

When families are invited to witness the team perform CPR, they may feel they are participating in the care of the patient, as opposed to just playing a passive role waiting in the hallway for the latest news. Nevertheless, many physicians are not entirely comfortable allowing families in the space where a code is being performed.

“If the family is not allowed to witness the code, a good care team will make sure the family is kept updated on what is happening,” says Shelton. Someone, perhaps a nurse or chaplain, remains with them to provide support.

“My sense is whether or not to allow families to witness a code should be decided on a case-by-case basis,” says Shelton.

Clinical ethics consultants often get involved in cases when the patient is very sick or dying, and CPR is not medically indicated or is medically inappropriate. “Based on the patient’s medical condition, the physicians in charge have determined that CPR would not provide a benefit, add to suffering, and prolong the dying process,” says Shelton. Yet some families want “everything done,” including CPR.

“It is interesting that CPR, within the culture of medicine, is most often not viewed like other medical procedures,” says Shelton.

Surgery, for example, is routinely withheld if the patient is not clinically a candidate for the procedure. “There is no obligation to take a dying patient into the OR if, in the judgment of the surgeon, the patient would in all likelihood die due to the procedure,” notes Shelton.

Though the same determination can be made at times about CPR on certain patients, physicians are required to ask family surrogates for consent to make the Do Not Resuscitate (DNR) order.

“Most family surrogates are reasonable and do not want their loved ones to experience unnecessary suffering before they pass,” says Shelton.

But some families will not give consent to a DNR order, and demand CPR for a patient who is actively dying. “In an effort to get their consent, at times some physicians may invite the family into the room to witness the code so they will see just how brutal the procedure is on this very sick patient,” says Shelton.

The physician’s hope is that the family will change their minds. “From an ethical point of view, this is untenable,” says Shelton. To ethically justify such a strategy, one would have to believe that CPR is obligatory and should be performed in all cases where the family did not give consent to a DNR.

“At some point, as determined clinically by expert physicians, because of the patient’s medical condition, to perform CPR would be a violation of the obligation to do no harm,” says Shelton. This logic holds for all other medical procedures. “But in the culture of medicine, strongly influenced by a certain interpretation of the law, CPR is sometimes viewed differently,” says Shelton.

Clinical ethics consultants often are brought in to help resolve these conflicts. “Often, families, with time to vent their concerns and fears, are able to shift their thinking about goals of care from recovery to comfort,” says Shelton.

At other times, it is necessary to state clearly the limits of the physician’s obligation. This includes not only respecting patient and surrogate autonomy, but also beneficence and nonmaleficence, notes Shelton.

“One option that clinical ethics consultants make clear to the physician is not acceptable is what is referred to as a ‘slow code,’” says Shelton. That is when the care team asks the family to leave the room, and then goes through the motions of doing CPR, but in a way that doesn’t injure the patient.

“The benefit of this strategy is that is reduces harm to the patient. But the ethical downside is that it is deceptive,” says Shelton. It gives the false impression to the family that everything was done when that was not the case.

“From an ethical perspective, providing full disclosure to the family about the limits of the physician’s obligation to provide CPR is essential,” says Shelton.

Effective communication and trust should be the underpinnings of any situation involving the possibility of CPR, says Shelton.

Families want to be kept informed and be respected, Shelton says, regardless of whether they are allowed in the room during CPR or are given limits about the physician’s obligations.

“The issues under consideration will have greater chance of being resolved to everyone’s satisfaction if there is a sound relationship between the care team and family,” says Shelton.


1. Powers KA. Family presence during resuscitation: The education needs of critical care nurses. Dimens Crit Care Nurs 2018; 37(4):210-216.

2. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med 2007; 35(2):605-622.


• Kelly Powers, PhD, MSN, RN, Assistant Professor, School of Nursing, University of North Carolina at Charlotte. Phone: (704) 687-7736. Email: kpower15@uncc.edu.

• Wayne Shelton, PhD, Professor, Alden March Bioethics Institute, Albany (NY) Medical College. Phone: (518) 262-6423. Email: sheltow@amc.edu.