Patient- and Family-Centered Care
Family Presence During Resuscitations and Invasive Procedures
By Maureen Connor, RN, MPH; Valerie McCarty; Dana M. Thompson, MD, MS, FACS;
Philip R. Fischer, MD; and the Consortium for Maximizing Family-Centered Care
This second article in a four-part series on patient- and family-centered-care (PFCC) focuses on family presence during resuscitations and invasive procedures. Continuing the story from the first article in the series (Homme et al., 2014), Max’s mother relates her experience as she prepared to be separated from her son during surgery and then subsequently at her son’s bedside when the team performed a cardioversion procedure.
It was an act of kindness that cut through all of my initial denial. A nurse started taking photos of me with Max, and I realized she was doing it because I might have no other pictures of him. The cardiac surgeon told us Max had an 85 percent chance of survival. We’d lost a child in miscarriage, on the wrong side of the same percentage. Of course anything less than 100 percent is unacceptable for the survival of your child, and the helplessness I felt as they whisked Max to surgery was the most terrible and terrifying experience of my life. Having someone update us during his surgery, and discuss it afterward, gave us some grounding. Later, however, during a bedside cardioversion procedure when they decided to shock him back into rhythm, I felt strongly that I wanted to stay with him. Now, I acknowledge that it might have been best for me and Max if I hadn’t been nearby during some of the painful procedures during his first few days.
The Effect on Patients and Families
Most family members in many countries and cultures want to be at their loved one’s bedsides during resuscitations and emergent invasive procedures (Masa’deh et al., 2013; Lederman & Wacht, 2014; Porter et al., 2014). Some studies suggest that family members who are physically present experience decreased anxiety and feel that everything possible is being done to support their loved one’s care. Family members also report that their presence enables them to provide emotional support to the patient (McGahey-Oakland et al., 2007). Studies conducted at a variety of international sites also show strong support among medical and nursing staff for family presence during resuscitation and invasive procedures as a means of benefitting both patients and families (Kuzin et al., 2007). However, not everyone agrees that family presence is good for families, and a majority of physicians in one international poll disagreed with family presence during resuscitation on the basis of concerns about interference with care and with adverse effects on family members (Colbert & Adler, 2013). Despite these reservations, a number of professional organizations, including the American Heart Association, have adopted guidelines or position statements affirming family presence (ECC Committee, 2005; Henderson & Knapp, 2005).
During Max’s extensive hospitalizations, his parents’ reactions ranged from being submissive “model parents,” leaving the room for minor procedures, to asserting their parental rights to remain with him during the cardioversion. (They never considered staying with Max in the operating room when he was under the effects of general anesthesia.) Looking back on the experience, Max’s mother now admits that it may not have been in either her or Max’s best interest to remain with him during some of his painful procedures. It is essential to remember that each family is unique. Occasions where staff intervention is required to support the family in choosing whether to be present with their child may occur. It is also important for institutions to develop protocols to ensure high-quality medical care and appropriate family involvement in their own settings (Colbert & Adler, 2013).
The Effect on Clinicians
While study results vary, there is some evidence that staff members view family presence during procedures favorably. In one study, nursing staff had a more positive attitude about family presence during procedures and cardiopulmonary resuscitation (CPR) than did physicians (Boudreaux et al., 2002). Within physician groups, those with increased experience were more likely to support family presence during interventions (Kuzen et al., 2007). One study of pediatric residents reported greater comfort with family presence during procedures other than CPR. In fact, those residents with more advanced training had an increased level of comfort. Similarly, staff education interventions focusing on family presence during resuscitation lead to improved acceptance of this activity (Feagan & Fisher, 2011). Some of the reasons staff members were reluctant to support family participation included the threat of future litigation, staff distraction, and staff stress during procedures. Some evidence suggests that the presence of family members does not have an adverse impact on patient outcomes (Duran et al., 2007; Bradford et al., 2005).
Given the variable levels of support among medical and nursing staff for allowing family presence during procedures, creating a standardized protocol can potentially benefit all involved by removing inconsistent approaches in the clinical setting (Powers & Rubenstein, 1999). Still, however, there is not universal readiness to accept family presence during resuscitations (Ganz & Yoffe, 2012). One study of preferences and attitudes concluded that physicians not favoring family presence were guilty of “medical paternalism” (Tripon et al., 2014). Reviewing literature and experience, one editorialist notes the risk of post-traumatic stress disorder in non-present family members and concludes that family presence in the current age is a necessity (Bauchner, 2014).
Practical Implementations
In 2005, focus group meetings were held to air “for” and “against” ideas about allowing family presence during resuscitations in the emergency department at the Mayo Clinic’s Rochester, Minnesota, campus. Leaders held discussions and decided to have a trial period of offering family members the option to be present. The resuscitation team was enlarged to include one or two individuals (often a nurse and a chaplain or social worker) to stay near the family to provide support and information. The senior physician leading the resuscitation maintained the authority to opt out of having family members present and, depending on how things were going, of having family members relocated to a calmer area nearby. This has worked very well over time. Lessons learned during the trial period were incorporated into what are now standard policies facilitating family presence during resuscitations and invasive procedures in the emergency department setting.
Similarly, Lucile Packard Children’s Hospital in Palo Alto, California, has implemented protocols addressing family presence during resuscitations. A family-centered approach was used in the planning and implementation of Packard’s “code” protocol. For example, key decision makers met with Packard Children’s Family Advisory Council (composed of family members of current or former Packard patients) to discuss best ways to include the parent in code events. Thereafter, specially trained parents from the Department of Family-Centered Care were assigned to participate on the code planning committee. The initial code protocol was then brought back to the Family Advisory Council for validation. Finally, code simulation trainings were conducted in which members of the Family-Centered Care Committee simulated the role of the parent to give staff an opportunity to practice the new code protocol in a safe learning environment. A videotape of this training has been shown to all clinical staff and has resulted in a clear understanding of the role of parents in codes.
The Mayo Clinic and Lucile Packard Children’s Hospital now successfully accommodate family members during resuscitation and invasive procedures. Teams worked together, and processes evolved over a period of time as staff familiarized themselves with the new practices. Staff were assigned to focus on the family (rather than on the resuscitation/procedure), and physicians retained autonomy to alter family presence if and as needed in specific settings. As noted in the literature, creating a protocol helped to standardize the approach to family presence during codes and invasive procedures, thus supporting the efforts of all involved.
Maureen Connor is a healthcare consultant at Claremont Consulting Partners in Arlington, Massachusetts. She may be contacted at mconnor97@comcast.net.
Valerie McCarty is coordinator at Mended Little Hearts of Southeast Minnesota in Rochester, Minnesota.
Dana Thompson is division head of pediatric otolaryngology head and neck surgery at Ann & Robert H. Lurie Children’s Hospital of Chicago and professor of otolaryngology at Northwestern University Feinberg School of Medicine in Chicago.
Philip Fischer is professor of pediatrics at Mayo Clinic in Rochester, Minnesota.
References
Bauchner H. (2014). Parental presence during cardiopulmonary resuscitation: uncommon, but yet necessary. Archives of Disease in Childhood, 99(4), 305–306.
Boudreaux, E.D., et al. (2002) Family presence during invasive procedures and resuscitations in the emergency department: A critical review and suggestions for future research. Annals of Emergency Medicine, 40(2), 193–205.
Bradford, K. K., et al. (2005). Family member presence for procedures: The resident’s perspective. Ambulatory Pediatrics, 5(5), 294–297.
Colbert, J. A. & Adler, J. N. (2013). Clinical decisions. Family presence during cardiopulmonary resuscitation—Polling results. New England Journal of Medicine, 368(26), e38.
Duran, C. R., et al. (2007). Attitudes toward and beliefs about family presence: A survey of healthcare providers, patients’ families, and patients. American Journal of Critical Care, 16(3), 270–279.
ECC Committee, Subcommittees and Task Forces of the American Heart Association. (2005). 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 112, Suppl:IV–1
Feagan, L. M. & Fisher, N. J. (2011). The impact of education on provider attitudes toward family-witnessed resuscitation. Journal of Emergency Nursing, 37, 231–239.
Ganz, F. D. & Yoffe, F. 2012. Intensive care nurses’ perspectives of family-centered care and their attitudes toward family presence during resuscitation. Journal of Cardiovascular Nursing, 27, 220–227.
Henderson, D. P. & Knapp, J. F. (2005). Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures. Pediatric Emergency Care, 21, 787-791.
Homme, J. H., Connor, M., McCarty, V., & Fischer, P. R. (2014). Patient- and family-centered care: Advancing quality and safety with bedside rounding. Patient Safety & Quality Healthcare, 11(2), 20–25.
Kuzin, J. K., et al. (2007). Family-member presence during interventions in the intensive care unit: Perceptions of pediatric cardiac intensive care providers. Pediatrics, 120(4), e895-e901.
Lederman, Z. & Wacht, O. (2014). Family presence during resuscitation: Attitudes of Yale-New Haven hospital staff. Yale Journal of Biology and Medicine, 87(1), 63–72.
Masa’deh, R., Saifan, A., Timmons, S., & Nairn, S. (2013). Families’ stressors and needs at time of cardio-pulmonary resuscitation: A Jordanian perspective. Global Journal of Health Science, 6(2), 72–85.
McGahey-Oakland, P., et al. (2007). Family experiences during resuscitation at a children’s hospital emergency department. Journal of Pediatric Health Care, 21(4), 217–225.
Porter, J. E., Cooper, S. J., & Sellick, K. (2014). Family presence during resuscitation (FPDR): Perceived benefits, barriers and enablers to implementation and practice. International Emergency Nursing, 22(2), 69–74.
Powers, K. S., Rubenstein, J. S. (1999). Family presence during invasive procedures in the pediatric intensive care unit. Archives of Pediatrics and Adolescent Medicine, 153, 955–958.
Tripon, C., Defossez, G., Ragot, S., Ghazali, A., Boureau-Voultoury, A., Scépi, M., Oriot, D. (2014). Parental presence during cardiopulmonary resuscitation of children: The experience, opinions and moral positions of emergency teams in France. Archives of Disease in Childhood, 99(4), 310-315.
One Voice |
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| The Consortium for Maximizing Family-Centered Care was established during a panel presentation at the “One Voice: Patient- and Family-Centered Care Program” at the Mayo Clinic in Rochester, Minnesota, on November 13, 2008. Since that time, the Consortium has collaborated on this series of articles and some of the material in the series was taken from the program. Consortium members (and co-authors of each paper in this series) include: | ||
| Maureen Connor, RN, MPH Healthcare Consultant Claremont Consulting Partners Arlington, Massachusetts Philip R. Fischer, MD Cezanne Garcia, MPH |
Jason H. Homme, MD Assistant Professor of Pediatrics Pediatric Residency Program Director Mayo Clinic Rochester, Minnesota Valerie McCarty Patricia F. Sodomka, FACHE, MS, MHA |
Dana Mara Thompson, MD, MS, FACS Division Head- Pediatric Otolaryngology Head & Neck Surgery Ann & Robert H. Lurie Children’s Hospital of Chicago Professor of Otolaryngology Northwestern University Feinberg School of Medicine Chicago, Illinois Farris Timimi, MD Karen I. Wayman, PhD |