Family Presence During CPR: A Research Proposal

Introduction and Problem Statement

Recent trends in intensive care have led to a change in the way medical personnel view the presence of family members during episodes of medical treatment, even in crisis and intervention settings. Family members were historically considered extraneous elements in medical care settings. Today, they are increasingly seen as important participants in all aspects of patient care — including diagnosis, treatment, recovery, and in some cases even the patient's death, whether as an active or passive presence.

Given this shift, the longstanding practice of requiring family members to leave the room when resuscitation or other interventions are being administered is being reconsidered. Several key questions frame this issue: Should families be allowed the option to remain in the room when resuscitation is being provided for a loved one? What effect will family presence have on outcomes? How will it affect staff members? Are there legal ramifications? And does the presence of family members in the room improve or impair resuscitative attempts?

Review of Related Literature

Allowing family members to remain in the room during resuscitation processes began in the early 1980s. Cardiopulmonary resuscitation (CPR) had long been administered behind closed doors, but Foote Hospital in Jackson, Michigan became the first institution to formally study the alternative. Family members of 18 patients who had died in the emergency department were asked whether they would have chosen to be present during resuscitative measures, had that option been offered. Staff had long considered the ethical and emotional implications of removing family members from the room and decided to pose the question directly (Hanson & Strawser, 1992).

When seventy-two percent of the families surveyed reported they would have wanted to be present, the hospital created a program offering families this choice and then monitored outcomes. Thirty separate events were evaluated, and the findings indicated that family presence tended to be associated with more positive outcomes and appeared to cause no interruption in critical patient care.

The Foote Hospital project drew the interest of several organizations, most notably the Emergency Nurses Association (ENA). In 1993, the ENA formally supported encouraging all healthcare professionals to offer families the option of being present during CPR. The ENA played an active role in developing guidelines, policies, and procedures surrounding the practice, and even produced educational booklets for families.

Research into the pros and cons of family presence has continued over the past two decades. A study published in the European Journal of Cardiovascular Nursing (2005) reviewed positive and negative experiences with the aim of identifying the factors driving those differences, using a literature review methodology. In that study, most patients and relatives who had been present during CPR reported it as a positive experience — citing increased feelings of support and connectedness between family members, the patient, and the care team. Being present also appeared to be helpful in the grieving process. Notably, staff members who were surveyed believed the presence of family members caused increased psychological stress for the family, adding to the burden of grief and loss they were already carrying.

The first formal research study on this topic was conducted by Meyers et al. (1998), which evaluated the responses of family members through a retrospective telephone survey. Families of patients who had died from traumatic injuries and been treated at a hospital in Dallas were asked about their beliefs, desires, and concerns regarding family presence during CPR. Of the 25 families who responded, eighty percent said they would have wanted to be in the room, and ninety-six percent reported they felt it was their right to be present. Sixty-eight percent believed their presence would have been helpful to the patient, and sixty-four percent felt it would have aided their own grieving process. Family concerns centered primarily on the severity of the patient's condition and uncertainty about whether the patient would survive. Despite its small sample size, the study's results were broadly supportive of offering families the option to be present during CPR.

Even before the changes at Foote Hospital, it had long been common practice in the pediatric community to allow family members to be present during resuscitative events. Many family members and staff reported greater comfort when an escort was present during the event (Grice, Picton & Deacon, 1993). The escort's role was to explain what was happening, prevent family interference with the care team, and provide emotional support.

Arguments Against Family Presence

Arguments against the practice include the claim that there is insufficient research to support this change in practice. Most studies evaluate small numbers of patients and rely on retrospective surveys. There is concern that family presence in the room increases the risk of malpractice litigation. Some healthcare providers worry that the presence of family members will make providers nervous or distracted. Additionally, there has been no large-scale study on the psychosocial impact on families who witness a resuscitative arrest intervention. Some providers also argue that family presence may violate a patient's right to privacy, particularly since resuscitation typically involves unconscious patients who cannot consent to being observed.