Running head: FAMILY MEMBER PRESENCE
A review of the Research on
Family Member Presence during Resuscitation
Cheryl Klinkner
Ferris State University
November 15, 2011
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FAMILY MEMBER PRESENCE
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Abstract
Family member presence (FMP) during resuscitation (CPR) has been a controversial issue for
many years and has caused widespread debate. This review of research examines surveys and
literature in professional journals from 1992 to the present. Evidence shows FMP during CPR
can be beneficial to some families and detrimental to others; additional research needs to be done
in order for an absolute answer to be determined.
Keywords: family member presence, resuscitation, research, CPR, FMP
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Family Member Presence during Resuscitation
Purpose of the Review
Over the last 20 years, family member presence (FMP) during resuscitation (CPR) is
considered to be one of the most controversial issues in health care. Some health care
organizations have instituted policies to allow FMP during times when family members would
previously have been banned from the bedside or treatment room (Hanson & Strawser, 1992).
Attitudes of healthcare workers and families toward FMP vary greatly (Bordreaux, Francis, &
Loyacano, 2002). Debate continues over whether or not FMP is beneficial to the patient, family
or health care providers.
The purpose of this review is to organize information obtained from professional
organizations and journals from 1992 to the present on FMP during CPR. This paper will
challenge the traditional model of banning family members from the bedside and will present
both sides of the issue. Looking at both the negatives and positives and where additional
research needs to be done.
History
FMP during CPR can be traced back to 1982 at Foote Hospital in Jackson, MI, in which
there were two separate incidents when family members demanded to be present (Hanson &
Strawser, 1992). One person after riding in the ambulance during resuscitation, refused to leave
the patient. Another begged to enter, if only for a few minutes, to be with her husband, a police
officer who had been shot. A chaplain stayed with the family members who were allowed in.
When these two specific situations were evaluated, positive feedback came from both families
and staff. This initiated a survey at Foote Hospital to determine if there was interest in being at
the bedside during resuscitation of a loved one (Doyle et al., 1987). Of the 18 surveyed, 13
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(72%) responded that they wished they had been present during resuscitation. A program was
instituted at Foote, with a follow-up survey in 1985 by the same group which produced more
conclusive and applicable findings. 64% thought their presence was helpful and all family
members involved felt the healthcare team did everything possible to help their loved one.
Nearly all respondents said they would do the same thing again (Doyle et al., 1987). All of the
early research pointed to the benefits of FMP and called for more extensive research to be
initiated.
A group at Parkland Memorial Hospital in Texas conducted a study at the request of their
physicians regarding FMP during CPR. Their hope was to secure enough convincing data to
support a FMP program at their facility (Eichhorn et al., 2001). Their results confirmed those of
the previous study at Foote Memorial Hospital as 96% of the families surveyed wanted to option
of being present with their family member during resuscitation (Eichhorn et al., 2001).
Professional Organization Statements
In 1993, the Emergency Nurses Association (ENA) developed and adopted a policy
favoring FMP during CPR. It was formally published in 1994 and was last revised in 2010
(Emergency Nurses Association, 2010). The ENA states, “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” (Emergency Nurses Association, 2010, expression 7).
Following the release of the ENA’s statement on FMP during CPR in 1994, other
respected organizations developed supportive statements. The American Heart Association
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(AHA) took a stand on FMP in 2000. The AHA agreed to allow FMP and called for additional
research since debate continued national and internationally (Shelton, 2000).
In 2004, the American Association of Critical Care Nurses (AACN) officially endorsed
the guidelines set forth by the ENA and stated these guidelines are easily adaptable to critical
care units. In 2010 AACN published their latest revision of their practice alerts stating,
“Evidence is mounting that family presence during resuscitation and invasive procedures is
beneficial to patients, families and staff. Meeting the psychosocial needs in a time of crisis
exemplifies care driven by the needs of patients and families” (Martin, 2010, para. 3).
All three organizations believe FMP during CPR requires a team approach. They all
agree a specially trained team member should accompany the family member at all times
(Bordreaux et al., 2002). This will promote a smooth event without family member interference,
will keep the family informed about what is happening and will help provide support to the
family during the stressful time (Hanson & Strawser, 1992).
Even though the ENA, AACN and AHA lay out clear and concise directions on
establishing a FMP program at any facility, most healthcare organizations have no written
guidelines or policies on the issue. Despite a survey in 2003 by MacLean et al, only 5% of the
AACN and ENA nurses surveyed stated their institutions had written a formal policy favoring
FMP during CPR. Of those surveyed, 45-50% had informal verbal policies allowing the option
of FMP during CPR. Most healthcare workers even cite their policy to keep families out, despite
the fact that only 1% of the nearly one thousand institutions surveyed actually have a written
policy against FMP (Maclean et al., 2003).
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Family Perception of FMP
In nearly every study done to date, family members overwhelmingly want the option for
FMP during CPR at least presented to them (Doyle et al., 1987; Eichhorn et al., 2001). While
the positive response rates varied slightly, typically 80-90% at least wanted the option to stay,
though usually not as many would choose to stay every time. A major benefit to FMP shows an
increased satisfaction with patient care, regardless of outcome (Grice, Picton, & Deakin, 2003).
FMP during resuscitation allows the surviving relative to see with his own eyes the extent to
which the team went in order to save their loved one (Grice et al., 2003). The fact that surviving
family members are able to witness how hard the code team worked and see with their own eyes
everything that was done, may actually decrease the risk of legal action (Bouchner, Waring, &
Vinci, 1991).
Another theme emerged from family surveys was the belief that it is a family members
right to be there with their loved one, no matter the circumstances (Mangurten et al., 2005).
Concern has been expressed that family members may experience negative emotional and
psychological consequences as a result of FMP. Robinson evaluated the psychological effects of
witnessing resuscitation of a loved one and in a randomized study where 13 family members in
the intervention group were offered FMP during CPR and 12 family members in the control
group were not (Robinson, Mackenzie-Ross, & Campbell Hewson, 1998). In 22 cases of death,
18 family members were interviewed and completed tests at 1 and 6 months after resuscitation
most thought their grief was eased by sharing last moments with their loved one. Those who
remained in the resuscitation room with a support person were no more distressed than those
who did not witness the resuscitation (Robinson et al., 1998). Also in Robinson’s study of
relatives who were present during resuscitation, it is reported all three patients who survived
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were content that a relative had remained with them during CPR and felt supported by their
presence (Robinson et al., 1998. This study was to continue for 18 months but was discontinued
early when the research team had become convinced of the benefits of FMP during CPR
(Robinson et al., 1998). There is not a lot of evidence to support excluding family members
who wished they could have been present but were not allowed.
Patients Perception of FMP
Hearing is the last sense to cease and many seemingly unconscious patients may have
some awareness of their surroundings. Aware of their family’s presence and hearing their
encouraging, loving words, a patient may find strength to survive or take comfort if he or she is
dying. Family support can help a patient feel less alone and vulnerable amongst strangers. If a
patient is dying he may prefer to see a loved one instead of the code team. In a study by Eichhorn
et al (2001), adult patients’ reactions and thought on FMP were investigated. Patients perceived
many benefits of FMP. Most patients believed their family member was comforting to them,
that they were their advocates for them when they couldn’t speak for themselves and that they
reminded the health care providers of their humanity (Eichhorn et al., 2001). Some patients
indicate it was their right to have a family member with them if they chose. “I think family
should be allowed to come in anytime if the patient wants them. It makes the stress easier on the
patient” (Eichhorn et al., 2001, p. 52). In the largest study to date, Benjamin interviewed 200
emergency room patients and after describing the nature of resuscitation, found 72% would want
family members present if a cardiac arrest were to occur (Benjamin, Holger, & Carr, 2004).
However, 56% of these positive responders only wanted certain family members at the bedside.
Being shut out the resuscitation process can increase family members’ feelings of
helplessness, anxiety, panic and guilt. But what happens if the patient doesn’t want his family at
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his bedside. A patient might want his loved ones to remember him as he looked when he was
alive and well, rather than during the last moments of CPR. He might want to face death alone.
Who really knows whose wishes are being met, the patients or the families?
Healthcare Providers thoughts on FMP
Healthcare Provider’s opinions regarding FMP during CPR vary according to one’s
profession, specialty and level of comfort and experience. Several surveys have shown between
86% to 96% of nurses endorse FMP, compared with 50% to 79% of physicians (Critchell &
Marik, 2007). A survey by Meyers found less experienced physicians exhibited lower
enthusiasm, with only 19% of residents supporting FMP (Meyers et al., 2000). Differences
between physicians and nurses on this issue remain when evaluating the responses of those who
have actually witnessed FMP during CPR. MacLean found that nurses who had experience
escorting families to the bedside were significantly more likely to support policies allowing
family presence than nurses who had not (Maclean et al., 2003). When healthcare providers
were placed in the role of the patient, 87% stated they would want a family member with them
(Ellison, 2003).
Most of the fears and concern have developed from literature. It is perceived family
members may get in the way during resuscitation. It has also been a concern that staff members
would experience more emotional stress and the stress may inhibit their performance.
Healthcare providers also fear family members who witness errors or misunderstand what they
see or hear may be more likely to sue, especially if the patient dies. Hanson reported from
discussions with nurses at Foote Hospital that families rarely become disruptive (Hanson &
Strawser, 1992). They seem overwhelmed by activity in the room and frequently had to be led to
the bedside and encouraged to touch and speak to their loved one (Mangurten et al., 2005).
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Nurses did find that FMP made it more difficult to remain distant and unemotional during the
code. Identification with family members brought emotions closer to the surface making the
incident more difficult to deal with later. In 100% of the family presence cases, patient care was
not interrupted (Mangurten et al., 2005).
Many clinicians indicate FMP is an effective time to do teaching with the family about
the seriousness of the patient’s condition (Meyers et al., 2000). “Some of the respondents (39%)
perceived family presence as an opportunity to promote open communication between staff and
family” (Ellison, 2003, p. 518). Additionally FMP seems to encourage more professional
behavior during the resuscitation. Some clinicians surveyed felt there were less inappropriate
comments made and less frequent sarcastic humor (Meyers et al., 2000).
Conclusion
Though the research base for FMP has increased significantly over the last 10 years, the
need for more in-depth, well constructed studies continues. Much progress has been made since
1982 when the researchers from Foote Hospital in Michigan began their work. Most studies
found in a review of the literature on FMP are survey or observational in nature. The samples
sizes were small, demographics of the samples were not provided and the interpretation of the
data is difficult to understand, which prevents comparison of results. Additional research of an
experimental design is needed to study the short and long term effects of FMP on healthcare
providers, families and patients. It is known 64-96% of family member’s surveyed desire to be
present during resuscitation of a loved one. Healthcare providers are still uncertain about the
helpfulness of FMP during CPR. No research has shown that FMP is harmful and evidence
continues to grow indicating FMP is beneficial. While there may continue to be a lot of
discussion, the time for action has come. It is time to move forward. Our patients deserve to
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have the right to chose and if unable to decide, it should be up to their loved ones to decide if
they should be allowed at the bedside during CPR.
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