Family presence during critical medical procedures and resuscitation

Family Presence During Procedures

One of the central problem areas in nursing is dealing with family presence in medical and procedural situations. This area is particularly problematic when the procedures involve critical and terminal health care issues. Various perspectives and studies state that the presence of family members at procedures can be both advantageous and disadvantageous in terms of medical and health care. The situation may also be compounded by ethical and moral considerations in the case of critical, terminal health care situations such as resuscitation; where the family may feel that they have a moral right to be present during any procedures. In some instances this might mean that family members interfere with medical and nursing procedures and performance. This was the finding from a study by Rattrie (2000), where the presence of family members was found to have a negative influence on nursing performance.

The history of hospital policy towards family presence has been generally to prevent or to frown upon the presence of family members at critical procedures.

However, this view has been reassessed in recent years and there is nowadays a strong trend towards the inclusion of family members in some procedures.

Many researchers and nursing professionals see the presence of family members as a positive factor in the healing and health care process.

However, there are many other studies which refer to the negative aspects of family presence. These studies point out that the nurse is often placed in a situation, when there is no specified policy, which requires delicate decision making. The nurse may find that he or she has to decide between the desires and demands of family members and medical and ethical requirements.

This paper will provide a critical overview of the development of these different views through a synthesis of the wide range of literature on the subject. This study will attempt to provide a clear exposition of the problematics of the issue of family presence as well as on overview of the possible solutions to this often controversial issue.

2. Literature review and history of the problem

The literature on the topic reveals that the issue of family presence has a long and controversial history. This is particularly the case during the past decade. For example, in 1992 a report from the Foote Hospital indicated that family presence was considered to be a positive aspect in critical and emergency situations. (Hanson C, Strawser D. 1992) There has however been widespread skepticism about the practice of family presence at procedures and in response to this Meyers et al. (2000) published a positive study of the response of health professionals to family presence in the emergency department of Parkland Memorial Hospital in Dallas, Texas. This report outlines the fact that nurses and physicians welcomed the presence of families at critical procedures. The report did however also indicate that the hospital staff was concerned about the emotional effect to the families during these procedures. (Meyers TA, Eichhorn DJ, Guzzetta CE, et al. 2000) Another study published by Eichhorn et al. also showed similar results. (Eichhorn DJ, Meyers TA, Guzzetta CE, et al. 2001)

However, as the literature attests, this positive response is a comparatively recent phenomenon. During the 1950's there was a strong belief within hospitals that it was not conducive to medial procedures and performance to have families present. Family members were strictly limited to visiting periods and during the periods of admission and discharge. A study by Johnson entitled the changing role of families in health care indicated that parents were separated from their children in order to prevent infection. (Johnson, B.H. 1990) However, as this study points out, there was a reassessment of this situation in subsequent years, particularly with regard to nursing attitudes. This attitude was reassessed in 1965 by the Association for the Care of Children's Health (ACCH), which was established to focus on the emotional needs of children in hospital. This Association was particularly concerned with changing the policies regarding family presence in hospitals. Among their recommendations was that the family should be recognized as an important constant in the child's life and that it should be incorporated into the overall health care strategy. (Johnson, B.H. 1990, p. 237) This tendency towards a more holistic approach which incorporated the family in the healing process was to grow in later years. This resulted in the present tendency to see the family as not obtrusive during procedures, but as a positive influence and factor in healthcare.

While there are many studies that support this view, the literature also attests to the fact that there is still opposition to family presence and that many medical authorities still oppose it. A recent report states that Despite growing support for allowing family members to be present during emergency medical procedures, only five percent of U.S. hospitals have written policies permitting such access during CPR or invasive procedures, according to a new survey of nurses co-sponsored by the American Association of Critical-Care Nurses (AACN) and the Emergency Nurses Association (ENA). In addition, approximately one-quarter of responding nurses say family presence is still prohibited for both resuscitation and invasive procedures, despite guidelines to the contrary." (Nurses' Study Finds Hospitals Still Limiting Access, 2003)

In contrast there are studies which express views that there is practical evidence of the positive influence and effect of family presence. One such study (Eichhorn, D. et al. 1996) shows that there is a movement to encourage family presence during critical procedures such as resuscitation. Studies during the nineties showed that there was a growing tendency to admit family members to critical procedures. In a study entitled Parental presence during procedures in an emergency room: results from 50 observations (Bauchner et al. 1991) it was found that there was a growing feeling that parents and family member had a right to attend procedures, especially with regard to child patients "The residents and nurses indicated that parents should stay with their child for the following procedures: laceration repair, 66%; venipuncture, 58%; intravenous cannulation, 48%; arterial blood sampling, 32%; suprapubic aspiration, 20%; and lumbar puncture, 14%. In the emergency room studied, it appears that for venipuncture and intravenous cannulation, the majority of parents stay with their children. Parental decision to stay or leave is frequently made without discussion with the physician." (ibid)

Meyers TA, Eichhorn DJ, Guzzetta CE, et al. 2000. 32-43.)

As stated in the introduction, one of the most serious problems that face nursing professionals with regard to family presence is that nurses may find themselves in the middle of an ethical dilemma, which may in turn affect their efficiency. A study in this regard by Ainslie Nibert, entitled, Teaching clinical ethics using a case study family presence during cardiopulmonary resuscitation, states that Critical care nurses often find themselves in the midst of challenging ethical situations that involve conflict between the needs of critically ill patients and the patients' family members and the preferences of physicians and other healthcare providers who initiate and manage resuscitation measures. Yet, many critical care nurses have reported that they received little preparation in their basic education programs to deal with these sensitive issues. (Nibert, Ainslie T. 2005)

This may constitute a moral dilemma as the study points out. "A moral conflict exists because two opposing obligations collide: an obligation to the family members who desire to be present with their loved one during CPR and an obligation to the healthcare providers who do not want patients' family members to witness resuscitation efforts." (ibid)

The study suggests that resolving this ethical dilemma lies in hospital and medical policy which would allow for clear instructions for "reinforcing the existing policy that prohibits their presence, or selectively permitting them to be present on the basis of screening according to predetermined criteria." (ibid) Nibert establishes four areas that should be taken into consideration when assessing the implications of family presence. These are (1) medical indications; (2) patients' preferences; (3) quality of life; and (4) social, economic, and health policy issues. (ibid) Another aspect is that nursing staff may find that the presence of family members may affect their authority.

Brown and Ritchie (1990) reported nurses were threatened by the perceived loss of authority that was associated with increased parent participation.

An important aspect in attempting to resolve this problem is the fact that many medical institutions do not have a firm set of policy guidelines on this issue. In a survey of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. It was found that "nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer that it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended. (Desy, Pierre. 2003)

Conclusion

Despite a growing movement in support of family presence, many healthcare professional still continue to resist adopting the practice. One of the arguments made is that "not enough research supports making a change in practice." (Mason, Diana J. 2003) There are no easy solutions to these issues. On the one hand the tendency to allow family presence is justified by factors such as family dignity and moral and psychological support. On the other hand there is also justification in the assertion that family presence may be counterproductive, not only for the nursing and medical staff but also for family members who may be emotionally traumatized. Part of the answer to this dilemma lies in the clarification of policy, as has been suggested, and in the improvement in nursing training to deal with the issue of family presence. As Nibert suggests:

Nurse educators teaching critical care courses can increase students' understanding of ethical dilemmas by having the students participate in a clinical analysis of a case study... In small groups, students can begin their analysis of the issue by reviewing the current literature on family presence. Discussion of findings with their peers helps students identify key issues within the ethical dilemma. (Nibert, Ainslie T. 2005)