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Family presence during invasive procedure and resuscitation

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    Abstract

    This paper attempts to find the wisdom behind the demand of the family members to be present at the time of the invasive procedures and Cardio Pulmonary Resuscitation for their patient relatives who happen to be their children or parents or kith and kin. This is called for only in times of emergency and life-threatening situations. This paper concludes that ideological considerations should not come in the way of the family members witnessing the event. The caregivers and physicians should be generous enough to allow their presence without giving any room for adverse remarks on their efficiency from the family members. Ensuring sufficient safety provisions in place, they should welcome the idea wholeheartedly reckoning the prospect that they can also be patients during the period of their lifetime.

    Once, it was considered undesirable for family members to be present near the patients at the time of invasive procedures and cardiopulmonary resuscitation while being done to them.  Not only the medical staff but also the family members had the same view. This attitude on the part of both the medical staff and family members has been changing, though there are reservations on both sides even today. Medical Staff is now in favor of some reasons and family members for different reasons which will be discussed in the succeeding paragraphs. Traditionally the reasons behind this are imaginary fears on both sides without scientific reasoning. Children while undergoing invasive procedures would like their parents to be near them. Parents also want to be present as they think the children will not cooperate during the procedures. The most compelling reason is that both the parents and patients want to be near each other when the end comes to the patients because both invasive procedures and resuscitation are resorted to only in life-threatening situations and invariably chances of survival in resuscitation attempts have been only minimal. This paper will discuss the reasons for and against family presence during invasive procedures and cardiopulmonary resuscitation. The impact of family presence during resuscitation on patients, patients’ family members, and staff will be reviewed. For this purpose, there will be a detailed literature review of the researches done on the subject to arrive at a realistic conclusion.

    Literature Review

    Ten years ago Emergency Nurses Association (ENA) made its position known on the presence of patients’ family members at the time of resuscitation and invasive procedures. (ena.org) Due to the increase in the education levels and promotion of consumerism at the same time, families have started questioning the wisdom behind the prevention of their presence at the time some of the thing very critical is happening to their loved ones.  Halm. A ( 2005) reports that the families who have expressed their interest to be present, would reiterate it in future also as found by him in the studies of the past years in 2000, 1997, 1992, 1987 by Meyers T.A.et al, Belanger J Reed S, Hanson C & Strawser, Doyle C et al respectively as reported in Medline. The imaginations that it will be in violation of medical codes and that family members cannot tolerate witnessing the procedures have all been dismissed by the above-cited studies. American Heart Association in its Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care changed the standards for resuscitation by incorporating the choice of family members being present at the time of Cardio Pulmonary Resuscitation (CPR). Nurses as part of their obligation to put the family members and patients at a comfort level in their health care delivery, also are morally compelled to support Family Presence During Resuscitation(FPDR). There is no question of trauma being undergone by the family members as they are already used to seeing such invasive procedures being telecast these days. Pro-FPDR activists feel that it is the fundamental right of both patients and their family members to access to witnessing the CPR. Halm’s critical review covered 28 studies on FPDR of which 24 were quantitative and 4 were qualitative. The study revealed however lack of consistency and the knowledge development in this area is still not mature. Most of the samples used were of convenience. The studies reviewed did not have the patients’ opinions.

    Mac Lean et al (2003) state that 984 respondents out of 1500 members each randomly selected from the American Association of Critical Care Nurses and Emergency Nurses Association to a questionnaire of 30 queries have informed that though their institutions have no written policies on the subject, they welcome the idea of family members being present. The authors have recommended written policies of the hospitals should be available. Only 5% of the respondent worked in places having written policies that allowed the presence. Many of them, say 36% and 44% did take the family members for witnessing resuscitation and invasive procedures respectively. Family members asked to be present were 31 % for resuscitation and 44% invasive procedures. They opine allowing the presence is still a sticky issue in the United States through the issue has been gaining momentum for the past decade due to support from professionals, media, and topical research. Researches cited by McLean et al are reported be stating that allowing the Family’s presence allays fears about what is happening to the patients and it serves to reassure them that all possible is being done to save the patient thus mitigating the stress and strain they undergo when not permitted to see their patients in their fight for survival.

    If the patients die, the presence serves to assuage the feelings of grief to the family members.  The research has also found that family members did not interfere with the care delivery and no adverse outcome came about because of their presence and most importantly family members did not suffer from psychological trauma after witnessing. The child-patients’ attitude reveals that they felt safe in the presence of their family members during their painful and stressful procedures. Adult patients also felt it would be of comfort to them if their family members were present and this helped improve bondage between the patient and family.

    The health care professionals considered the new development as a paradigm shift in their outlook. Apart from the concerns that the presence will disrupt the procedures by their getting emotionally upset which however is no more an issue, lack of staff to manage them and extra space to accommodate can not be ignored. Many respondents have also expressed concerns about possible litigation, hurdles to giving training to the interns, violation of patients’ privacy, and possible real and psychological disturbance to the service providers on being watched by the family members. The same study also gives an account of what service providers feel in terms of their getting an opportunity to educate the family members about the patients’ critical conditions and mostly serving as a prelude to mitigate shock and grief in case of patients’ loss.

     American Association of Critical Care-Nurses in its issue of 11/2004 has echoed the findings of researches such as above and exhorted its members to have written policies on the family members’ presence and stipulated that the guidelines under the policies should mention the benefits that accrue to the family members, have the criteria to evaluate the family before being allowed to be present, have facilitators who can be nurses, and other health care workers including social workers for the family to keep them well prepared to brace any eventuality that may befall the patients, and have also a policy to support should the patients or their family members who decide against. It has advocated the development of proficiency standards for those involved to ensure safety to patients, family members, and staff during the resuscitation and invasive procedure and maintain a record of compliance with the request of family members to be present and to improve the same if compliance is less than 90 percent. (AACCN 2004)

     Australia-based three years Research conducted by Holzhauser et al (2006) confirms that their literature review also revealed a positive stance of the family members about being present at the time of invasive procedures and CPR. The objective of the research was (a) to ascertain whether there is a change in the attitude of the staff towards family members after policy implementation to permit their presence, (b) how the staff behaved towards relatives after the resuscitation, and (c) to ascertain how the relatives felt about being present. This study mostly covered the third objective The authors of the study originally planned for 12 months but got extended to three years discuss that few family members expressed their gratitude at being allowed to be present. The extension to three years was mainly due to the majority of the patients expressing their attitude against their family members’ presence. The relatives were found to be health care workers but without any experience in resuscitation. Although the staff expressed apprehensions about the relatives’ adverse remarks of staff performance during resuscitation, the study revealed that relatives actually focused on the support provided rather than on procedures resorted to. Besides the study adopted the guideline of the USA-based Emergency Nurses Association which it has acknowledged as having been most useful to conduct the study. The study finally, after a lot of distorting eliminations, has concluded that relatives are positive about their presence and they have not expressed adversely about the staff performance. They did report that their presence was useful and helped communication between the staff and family which facilitated coping with the disturbing outcomes.

    Discussion

     While the permission to be present facilitates to witness mostly the last moments of the patients never to be witnessed again, the traumatic memories do not last for more than three or four months in the minds of the relatives. Care providers also reported no adverse impact on their care performance. (Schott SS et al 2006) If the patients do survive, it is all the better as memories turn out is pleasant ones. However, there has not been documentation on the subject specifically covering the following areas. Techniques should be identified to assess the ability of family members to cope with the witnessing of the invasive procedures (IP) and resuscitation. Benefits that are likely to accrue to the family as a result. What are the real barriers to the family presence weighing against?

    What the attitudes of the family members towards their presence are, though this has been already covered considerably. And finally what are the most important needs named by the family members of the critically ill patients. The underlying undeniable concerns still lingering are the prospects of clinical activities being compromised and increasing liability risks by allowing the presence which will give rise to adverse comments on unintended actions or inactions not directly related to the outcomes of the invasive procedures and CPR. (King A 2001) The concept of family members’ desire to be present is probably an extension of their presence during labor and delivery. Preoperative Implications notwithstanding, the family members consider it their right to be present as a part of the care delivery team. Regardless of the patients’ survival or otherwise, it would go a long way in mitigating the effects of the patients’ and relatives’ adverse feelings. The presence of the husband at the time of labor and delivery does have a positive effect on the ability of wife patients ability to deliver without much trauma. If the same equation is applied, it is certainly going to minimize the physical and psychological trauma of the patients with their family member’s presence. About the preoperative implications, carers must ensure cleanliness and sterile conditions are not compromised as a result of family members’ presence and aggravate patients’ conditions. It can be safely argued that family members have the inherent right to be present in the case of pediatric resuscitations which physicians themselves welcome through their presence in adult resuscitations, nurses welcome rather than physicians. It shows nurses are more driven by emotions than doctors who perceive a real positive impact on children than on adults. (Gold J et al)  Dr. Guzzetta reports that a nurse at Parkland, Theresa A. Meyers nearly lost her job after permitting a couple to witness the resuscitation of their 14-year-old son. This came naturally to her driven by natural emotions. It was this incident that triggered a series of discussions on allowing family presence during  CPR initiated by Dr. Guzzetta. in 1994. ( Spittler 2006).

    Conclusion

    The concept of family members’ presence (FMP) is now decades old. (Sacchetti D et al 2003)  But the documentation on the same has not to gown as much. Serous discussion and researches on FMP have begun only in the 1990s when care providers were confronted with growing consumerism and relatives’ persistence on being present during the emergencies faced by the patients. Loss of life for the patients has serious implications for the relatives as well, as such loss of beloved ones and earning members of the family would leave much to be desired. The caregivers’ reservation on the policy relates to the prospect of adverse consequences on the procedures whether family members are going to complain or not and on the possible avoidable litigation in respect of unintended and unavoidable outcomes. If only the Government and/or the professional associations would deliberate on giving them protection in any such eventuality, there is nothing that can prevent family members’ presence during the invasive procedures and Cardio Pulmonary Resuscitation. Family members’ presence should not be regarded as the one touching upon the caregivers’ and physicians’ integrity. Many a time, caregivers and physicians turn out to be patients in which situations Family Members are being allowed as their privilege in some quarters though this is not documented. Though the concept now studied is not quite old, there is not much to be researched about and it is the physicians and other caregivers who should come to terms with reality and encourage even legislation on the issue so that it will improve the Health Care Institutions’ efficiency as an incidental benefit.

    References

    1. AACN 2004, “Family Presence during CPR and Invasive Procedures” American          Association of Critical –Care Nurses Practice Alert 11/2004
    2. Ena.org Family presence at the bedside during invasive procedures and resuscitation.     Emergency Nurses Association Position Statement; 2001. Available at:             http://www.ena.org/about/position/PDFs/FamilyPresence.PDF. Accessed   September 29, 2007.
    3. Gold J Katherine, Gorenflo W.Daniel, Schwenk L. Thomas, and Bratton L. Susan          “Physician experience with family presence during cardiopulmonary resuscitation in children” Pediatric Crit care Med 2006 Vol 7, No 5, 428-433
    4. Halm A Margo 2005 ‘Family Presence During Resuscitation: A Critical Review of the    Literature’ American Journal of Critical Care, 2005, 14 (6): 494-511
    5. Holzhauer Kerri, Finucane Julie, De Vries M.Susan (2006) “Family Presence During  Resuscitation: A Randomised Controlled Trial Of The Impact Of Family     Presence” Australasian Emergency Nursing Journal (2006) 8 (4): 139-147.
    6. King A. Cecil (2001) “Family Presence During Invasive Procedures And Resuscitation –           positives dominate survey results – Statistical Data Included” AORN Journal,        May 2001
    7. MacLean L.Susan, Guzzetta E. Cathie, White Cherri, Fontaine Dorrie, Eichhorn J. Dezra,          Meyers A.Theresa, and Desy Pierre 2003 “Family Presence During            Cardiopulmonary Resuscitation and Invasive Procedures: Practices of Critical     Care and Emergency Nurses” American Journal of Critical care 2003; 12:246-257
    8. Sacchetti D. Alfred, Guzzetta E. Cathie, Harris H.Russel “Family Presence During
    9. Resuscitation Attempts and Invasive Procedures: Is There Science Behind the  Emotion?” Clin Ped Emerg Med 4:292-296. © 2003 Elsevier Inc.
    10. Scott SH Mangurten J,   CE Guzzetta, AP Clark, L.Vinson, J Sperry, B.Hicks,    W.Voelmeck (2006) “Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department” Journal of Emergency             Nursing 2006 Jun, 32(3): 225-33
    11. Spittler L.Karen March 2006 “Family Presence During CPR and Invasive Procedures”   Vol 11, No 3 <www.Pulmonary Reviews.Com> accessed September 29, 2007

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