CPR procedures and family presence during resuscitation

Problem Statement

Recent trends in intensive care have lead to a change in the way that medical personnel see the presence of family members during episodes of medical treatment, even in crisis and intervention settings. Family members are often considered to be extraneous elements in the medical care settings. Now, family members are seen more as important parts of the care of the patient in all settings - and by this we mean taking part in the patient's diagnosis, treatment, recovery and in some cases even the patient's death, as an active or passive process. In this case, it must be considered whether the typical past practice of having family members leave the room in a situation where intervention or resuscitation are being administered is being rethought. Should families be allowed the option to stay in the room when resuscitation is being provided for loved ones? What will the presence of family members in the room during therapeutic intervention do to change the outcomes? Will it make any effect on the process? How will the presence of family members affect the staff members? Are there any legal ramifications? Do family members in the room improve or impair the resuscitative attempts?

Related Research and Literature Review Allowing family members to stay in the room during resuscitation processes began in the early 1980s. Foote Hospital in Jackson, Michigan was the first to study the option. The family members of 18 patients who had died in the emergency department had been asked if they would have chosen to be present in the room while resuscitative measures were taken, had that been given as an option. For many years, the staff had considered what the ethical and emotional considerations surrounding removing family members would be, and decided ask the question (Hansen & Strawser, 1992). When seventy-two percent of the families questioned reported they would like to be present in the room, the hospital created a program in which families would be given this choice and then followed the outcomes. Thirty separate events were evaluated and the findings indicated that that the presence of family members in the room tended to be associated with more positive outcomes and appeared to cause no interruption in the critical care of the patient.

The project at Foote Hospital was of interest to several organizations, most proactive of which was the Emergency Nurses Association (ENA). In 1993, the ENA supported the concept of encouraging all health care professionals to offer families the option of being present during cardiopulmonary resuscitation (CPR). The ENA were active in developing guidelines in the development of policy and procedure surrounding the process. The ENA even provided educational booklets for family. Studies of the pros and cons for the process have been ongoing over the last twenty years. A study reported in the European Journal of Cardiovascular Nursing (2005) reviewed positive and negative experiences, attempting to establish a reason for the differences. This was done via a literature review. In this study, most patients and relatives who had been present during CPR administration has reported that the presence of the family has been a positive experience for them, reporting increased feelings of support and connectedness between family members, the patient and the care team. It appeared that in this study, being present was helpful in the grieving process. It is interesting to note that in this study, staff members who were polled felt the presence of family members in the room during CPR caused an increased degree of psychological stress for the family, to be dealt with on top of the grief and loss they had to feel. The first formal research study was done by Meyers et al (1998) in which the responses of family members were evaluated. Via a retrospective telephone survey, the families of patients who had died secondary to traumatic injury and treated at a hospital in Dallas were queried as to whether they had any beliefs, desires or concerns regarding the presence of family members in the room when CPR was being administered. Of the 25 families who responded to the survey, eighty percent of the families said they would have wanted to be in the room, ninety-six percent reported that they felt it was their right to be present. Another sixty-eight percent of the family members that responded to the survey reported they felt their presence would have been helpful to the family member and sixty four percent of participants felt their presence in the room would have been useful in dealing with grief. Concerns reported from families mostly surrounded the significance or seriousness of the patient's condition, and whether the patient would survive the resuscitative efforts. Ultimately, though a small study, the results were primarily supportive of at least providing family members with the option to be present during the administration of CPR.

Arguments against the practice include the fact that there is not enough research to support this change in practice. Most studies only evaluate very small numbers of patients and are based on retrospective survey. It is also feared that family members in the room increases the chance that their will be malpractice suits. Some healthcare providers feel the presence of the family will make the providers nervous. There has also not been a large study on the psychosocial impact on the family of witnessed arrest intervention. There is also concern that the presence of family members in the room violates a patient's right to privacy and usually surrounds the care of unconscious patients.

Even before the changes at Foote Hospital, it has longer been the practice in the pediatric community to allow family members to be present during resuscitative events. Many family members and staff feel more comfortable if, during the resuscitative event, it were possible for as escort to be present (Grice, Picton & Deacon, 1993). The escort is used to explain the process, prevent interference in the process on the part of the family and to provide emotional support. .

The opinions and feelings of staff are also to be considered in this situation. (Redily & Hood, 1998). A study from Australia reviewed the experiences of staff in this situation. In general, healthcare staff was supportive of the concept of family presence in the room during resuscitation, and saw it as an opportunity for the family to help the loved one die with dignity and surrounded by familiar faces. While advocates believe the process quite helpful, the low survival rates that follow CPR sometimes make health care providers uncomfortable. A study by Helmer, et al, evaluated the members of the American Association for the Surgery of Trauma (AAST) about how they felt about the patients' family members being present. More AAST members reported belief that the presence of family members in the room during all phases of resuscitation and invasive procedure was inappropriate. This number was greater than a similar number of members of ENA who has also been polled. Primary reasons for not wanting family members in the room were the beliefs that family presence interfered with patient care and significantly increased patient stress. Another survey done of attendant at the American College of Chest Physicians in 2000 (McClennathen, Torrington, Uryhara, 2000) reported that nurses were more likely to encourage family member presence in resuscitative situations than their physician colleagues.

Healthcare providers also expressed concern regarding physical assault from family members if outcomes were negative. There were also fears about liability and litigation, or a feeling of loss of control over the code situation. Families and healthcare providers both expressed concern that the presence of the family in the room may result in prolonged and ultimately futile resuscitative efforts since the team may be less likely to suspend a code they felt futile in the presence of family members. For this reason, the main focus of this research study will surround a relatively under evaluated element of the question, and the examination of issues of concern to intensivists, emergency room and critical care workers, those who are most likely to be involved in the administration of CPR with family present.

Objectives Since the mid-1990s, the exclusion of family members from the resuscitation room has become less likely and medical settings in which resuscitative care may be administered. Because of this, more emergency departments and intensive care units have developed guidelines for family presence in resuscitation. While public support for this process is strong, little is known about the support of this process by staff members. Over 100,000 resuscitation attempts occur in this country every year. For the purpose of our study we will interview patients, family members, and staff members to evaluate their feelings surround witnessed resuscitation events.

Research Procedure Methods An emergency department is a difficult place to administer a survey, and follow-up may be difficult for reasons of patient confidentiality. For this reason, this study will be conducted primarily on the patients and staff of an intensive care unit at a local multi-specialty teaching hospital in a large metropolitan city. The survey will continue for six months or until 100 patient surveys are completed, whichever comes first. The participation of the staff is entirely voluntary and while staff will be encouraged to participate it will not be mandatory and staff members will only be approached once with the survey placed in their mailboxes at work. Staff members will be allowed to return the surveys in a locked box placed off the unit and in an unobserved area for maximum anonymity. It would be our goal to receive completed surveys from at least fifty percent of the nursing staff and at least fifty percent of the medical provider staff for the staff element of the study to be valid. For medical provider staff, we will only request surveys from individual who manage patients at least 3 days out of the week on the intensive care units. Consultants, dieticians, laboratory or radiology staff will not be polled, since their involvement in resuscitation would be unlikely and minimal. For nursing staff, we will ask for anyone who works at least 20 hours per pay period with experience in intensive care for greater than one year, or at least participation in five resuscitative events, no matter what the outcome. This is primarily because we want survey results to be based upon previous resuscitative experience and not simply on personal opinion without the benefit of experience.

For the patients we interview we will focus primarily on those patients preparing for elective surgery which none-the-less will likely require intensivist intervention after the procedure. Every member of the staff as well as intensivists and anesthetists will be provided with a written, anonymous questionnaire and asked to return the same within twenty-four hours. Patients between the age of 18 and 85 will also be recruited. The patients will be those who have been scheduled to perform elective cardiac or vascular surgery where the patient would have to spend a period of post- operative recovery in the intensive care unit. Each patient will be asked to complete the questionnaire in the presence of one of the researchers. This will be a questionnaire with specific questions but will also allow the patient space to make comments. Only patients who have next of kin willing to participate will be allowed to participate, since a questionnaire will also be provided to the family members and paired responses will be analyzed.

In order to increase the likelihood of compliance with the survey, it will be short in nature (something that can be completed in five minutes or less). The patients will have to be English speaking. The survey will consist of 7-10 questions regarding CPR experience, feelings about the presence of family members in the room during resuscitative efforts and demographic data to determine experience, age and education. The data will be complied and transferred to a standard worksheet. A standard analysis tool such as x2 or the Future will be used.

The procedure for the survey, and all tools used within the survey will be reviewed and approved by the local ethics committee. Patients and staff member demographic information will be blinded and identifying information will not be collected. Patients will be asked to complete an informed consent form, however, consent for participation in the survey is considered implied by the completion of the survey. The patient's impressions on the survey would not be considered enough to change existing advanced directives or code situations, or local protocols and procedures. This will be outlined clearly in the informed consent, and should patients wish to speak to someone about code status or advance directives, then referral will be made according to local protocols. Patients who are considered "No Code" or have Do Not Resuscitate orders in the chart will be approached for or included in the survey. All surveys will be hand written. No remuneration or gift will be given for completing the survey.