Should Family Members be Present During Invasive Procedures and CPR?

Abstract & Commentary

Meyers and colleagues surveyed family members and health care providers to determine outcomes of implementing an emergency department (ED) policy that permitted family presence during invasive procedures (IP) and CPR. The family member was required to: 1) be older than 18 years of age; 2) share an established relationship with the patient; and 3) not demonstrate behaviors suggesting extreme emotional instability, intoxication, an altered mental state, or combativeness. Outcomes were measured using two surveys (family, health care provider) completed less than 72 hours after the event, and an interview with the family member completed two months after the event.

The study took place at a large university-affiliated level 1 trauma center in Dallas, Texas. Of 54 family members approached, seven (13%) refused to participate, eight (15%) did not complete the two-month interview, and 39 (72%) completed the survey and interview. These 39 family members were 40 ± 13 years of age, predominately female (72%), and most often a son/daughter (31%), spouse (28%), or parent (23%) of the patient. They observed 24 IP and 19 CPR. The health care providers participating in the study included nurses (n = 60), residents (n = 22), and attending physicians (n = 14). The IP most frequently performed were endotracheal intubation, central line placement, lumbar punctures, chest tube insertion, and orthopedic reduction. Overall patient mortality was 56%.

Most family members (97.5%) indicated they had a right to be present and would do it again. Benefits cited by family members during interviews included relief from wondering about what was happening, verbal and visual knowledge about the patient’s condition and care, ability to provide comfort and care, and the opportunity for closure. Problems included concerns about patient comfort, patient survival, staff competence, and costs of care.

Health care providers differed in their opinions. Nurses were more likely to support family presence during IP (P < 0.001) and CPR (P < 0.001) than residents. Attending physicians were also more likely to support family presence during IP (P = 0.03) and CPR (P < 0.001) than residents. Benefits of family presence as perceived by health care providers included greater understanding on the part of the family about efforts made for the patient, more time for education, and more professional behavior by care providers. A minority of health care providers (15%) felt that efforts were more aggressive during CPR than they might have been if a family member was not present. (Meyers TA, et al. Am J Nurs 2000;100:32-42.)

COMMENT BY LESLIE A. HOFFMAN, PhD, RN

Tradition supports excluding family members during CPR and IP because of concerns that the event might be too traumatic, clinician activities might be negatively affected, or risk of liability might increase. However, several recent studies have reported findings that suggest that family presence can be a beneficial experience. Using Emergency Nurses Association guidelines, Meyers et al developed a policy that included guidelines for such visits, including patient/family assessment, preparation of families for the visit, and support during and after the visit, and prospectively tested outcomes of its use. Results demonstrated that family presence was a beneficial experience despite more than half (56%) of the cases resulting in death of the patient.

Study data did not suggest differences in perception based on age, gender, education, or relationship to the patient. There were no instances in which a family member became disruptive and, based on the two-month interviews, no evidence of traumatic memories. These positive findings may have been, in part, due to the fact that observation in the ED was frequently (47% CPR, 21% IP) part of a continuum, as the family member present in the ED was also present in the prehospital setting.

Health care providers differed in their evaluations of the benefits and problems associated with family presence. More nurses (87%) than attending physicians (77%) or residents (33%) supported family presence during IP. Also, more nurses (96%) than attending physicians (79%) or residents (19%) supported family presence during CPR. These findings suggest that individuals with more experience in the ED setting or a longer relationship with the patient were the most supportive.

This study was conducted in one setting, only enrolled participants who met entry criteria and agreed to participate, and did not include attending physicians who were unwilling to enroll their patients. Thus, study findings should be replicated in other settings. Perhaps the most positive outcome of the study was the response of the institution. Following completion of the study, a written procedure for family presence was implemented in the ED and, in November 1999, adopted for hospital-wide use.

Presence of a family member during invasive procedures and CPR was viewed most favorably by:

a. attending physicians.

b. residents

c. nurses.

d. triage staff.