Family Presence During Resuscitation in the
Emergency Department
Does One Size Fit All?
What is it?
This?
What is it?
Or This?
Definitions
Family presence during resuscitation (FDPR) is defined as ‘the presence of family
in the patient care area, in a location that affords visual or physical contact with
the patient during…resuscitation events’.
Source: Clark AP, Aldridge MD, Guzzetta CE, et al. Family presence
during cardiopulmonary resuscitation. Crit Care Nurse Clin N Am.
2005; 17:23-32.
Definitions
Family presence during resuscitation should be viewed as being part of a spectrum of
family participation during the delivery of patient centered care in the ED.
Patient centered care: "Providing care that is respectful of and responsive to individual
patient preferences, needs, and values, and ensuring that patient values guide all
clinical decisions."
Institute on Medicine. "Crossing the Quality Chasm: A New Health
System for the 21st Century". 26 November 2012.
Spectrum
Minimally Invasive - Throat Swab
Medium - Urinary catheter insertion
Highly Invasive – CPR, Cardiac massage, etc.
Roughly correlate to risk, prognosis, emotional response, AND controversy.
Definitions
Family: A person or group with a continuing, established legal, genetic, and/or
emotional relationship with the patient (relative, caregiver, significant other, etc.).
Source: Children's Hospital of Philadelphia Revised
EMERGENCY DEPARTMENT GUIDELINES
Definitions
Resuscitation: A sequence of events, including invasive
procedures, which are initiated to sustain life and/or prevent
further deterioration of the patient’s condition.
Invasive Procedure: Any intervention that involves
manipulation of the body and/or penetration of the body’s
natural barriers to the external environment. This even
includes “minor” procedures such as IV placement, urinary
catheterization, suturing, fracture reduction, lumbar
punctures, etc.
Source: Children's Hospital of Philadelphia Revised
EMERGENCY DEPARTMENT GUIDELINES
Proponents for Family Presence
American Heart Association
American Academy of Pediatrics
Ambulatory Pediatric Association
Emergency Nurses Association
Emergency Medical Services for Children
Published guidelines/courses
EMSC FCC Guidelines (2000)
AHA CPR Guidelines (2000, 2005)
Pediatric Advanced Life Support (2002)
Advanced Pediatric Life Support (2004)
Emergency Nursing Pediatric Course (2004)
Trauma Nursing Core Course (2002)
Emergency Medical Services for Children. Guidelines for
providing family-centered care. 2000.
Proponents for Family Presence
To enhance EOL care in the Emergency Department, the American College of
Emergency Physicians believes that emergency physicians should
“Encourage the presence of family and friends at the patient’s bedside near
the end of life, if desired by the patient. (1)
Family member presence during invasive procedures or resuscitation should
be offered as an option to appropriate family members and should be based
on written institution policy developed in cooperation with departments such as,
but not limited to social services, pastoral care, risk management, nursing and
medical staff. (2)
Source: (1) ACEP Board of Directors, "Ethical Issues at the
End of Life"
(2)Position Statement - Emergency Nurses Association
Supporters Say
Helped for family to see that everything had
been done
Positive experience for the family
Enhanced communication - provide history for
nonverbal patients
Facilitated education
Facilitated grief process
Source: 2012 ENA Emergency Nursing Resources Development
Committee
Studies Show
94 to 100 percent of families [who asked to be] involved in
family presence events would do so again.
A majority of adult patients indicated that would be their
preference despite believing it may be traumatic for the
family.
A majority of family members believed their presence during
resuscitation was comforting to their child.
Source: 2012 ENA Emergency Nursing Resources
Development Committee
Non-Supporters Say
possibility of families interfering with the process and
disrupting care
increased performance anxiety and stress on the
part of clinicians
interference with the process of teaching
may be too traumatic for families
misinterpretation of procedure
increased risk of litigation
Challenges to Consensus
Evidence is based on surveys and expert opinion NOT controlled studies
Objections are based on anecdotal and theoretical concerns
Controlled studies cannot be blinded and are either unethical or irrelevant
(use mannequins, simulations, family surrogates, etc.).
Even the surveys have selection or cultural bias.
Family Presence During Invasive
Procedures and Resuscitation
Literature base consists primarily of surveys of provider beliefs & practices
60 to 80% of families believe they want to be present during ED care
Providers are somewhat less supportive
RNs generally more supportive than Physicians
Senior Physicians more supportive than trainees
Support decreases with increasing acuity and/or intensity of the procedure
Source: Eppich WJ, Arnold LD. Family member presence in the pediatric
emergency department. Current Opinion in Pediatrics 2003; 15:294-8.
Do These Factors Sound Familiar?
ACEP: Factors Placing Providers and
Patients at Risk in the ED
Overcrowding
Complexity of emergency patient and family needs
Shortage of healthcare workers
Uncontrollable nature of workflow
Declining health status of patient populations
Language barriers
Limited access to primary and specialty care providers
Lack of established relationships between ED staff and
patients
Source: American College of Emergency Physicians. Patient safety in the emergency
department environment report, 2001. Available at: http://www.acep.org.
Policy for Family Presence?
Who will be the family advocate during resuscitation efforts
How many family members (and which ones) can be
present in the room at one time
When family will be allowed into the resuscitation room
What the family's responsibilities will be
Where family can be in the room
Under what circumstances to make exceptions
Who will write the policy
Family Facilitator
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•
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The option of family presence should NOT be offered
without someone serving in this role.
Family Facilitator (AKA “Family Support Person”) is
trained to:
Provide support
Prepare the family regarding what to expect
Provide rationale for any procedures
Remain with the family at all times as
there can be highly emotional moments
Family Facilitator
Family Facilitator has NO direct patient care responsibility, and is assigned
exclusively to assist the family.
What Not To Do
Things to Consider
Size of the ER and number of staff
Physician experience and comfort level
(beware Emperor's New Clothes Syndrome)
Cultural differences – likelihood of interference
or hysteria
“Cell Phone Phenomenon” - ANY level of
interaction with family WILL take cognition
Team communication must NOT be impaired
Things to Consider
Moral hazard - that we will tend to create
policies that emphasize “positive outcomes”
in terms of survivor satisfaction instead of
patient outcome
Blanket policies which automatically exclude
or include family members from being
present during resuscitation or invasive
procedures will inevitably cause harm
Knowledge/experience/training of the relative
Things to Consider
Patient preference and confidentiality
Emotional connection and actual relationship
to the patient
Emotional reaction of relative in dynamic situation
Written policies will either recognize the
physician's role as “captain of the ship”
or run the risk of unintended consequences
Main Points
The option of family member presence should be
encouraged for all aspects of emergency care.
Family presence should never be forced on a family or
the emergency staff.
Relatives who remain with loved ones who are in critical
condition often express appreciation for the efforts of
emergency teams.
Providing the best care for patients is the primary goal
of emergency physicians and nurses.
Source: American College of Emergency Physicians Policy Statement.
“Patient- and Family-Centered Care and the Role of the Emergency Physician
Providing Care to a Child in the Emergency Department.”2012.
Main Points
Any written policy should be tailored to a hospital's specific circumstance
ED physicians should not be forced to practice outside of their comfort zone
simply to satisfy the terms of an FPDR policy or staff expectations
No FPDR policy can or should replace a physician who is using clinical judgment,
common sense, and the “golden rule”
Questions and Discussion