Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience

Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures

Representatives from 18 national organizations were convened for a conference to develop recommendations regarding family presence (FP) during pediatric procedures and cardiopulmonary resuscitation. Before the conference, invitees were given a questionnaire and provided with current literature regarding FP. A modified Delphi process was used to develop consensus, including use of multiple questionnaires and breakouts for discussion of specific issues. Participants were encouraged to develop consensus recommendations based on the literature and discussions. Changes in attitude were tracked with repeat questionnaires. Results of the conference were circulated to participants for review and revision. Consensus recommendations include (1) consider FP as an option for families during pediatric procedures and cardiopulmonary resuscitation, (2) offer FP as an option after assessing factors that could adversely affect the interaction, (3) if family is not offered the option for FP, document the reasons why, (4) always consider the safety of the health care team, (5) develop in-hospital transport and transfer policies and procedures for FP, such as family member definition, preparation of the family, handling disagreements, and providing support for the staff, (6) obtain legal review of policies, (7) include education in FP in all core curricula and orientation for health care providers, (8) promote research into best methods for education; effects of FP on patients, family, and staff; best practices for FP; and legal issues regarding FP, among others. These recommendations were approved in concept by the American Academy of Pediatrics and the Ambulatory Pediatrics Association.

Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures

Representatives from 18 national organizations were convened for a conference to develop recommendations regarding family presence (FP) during pediatric procedures and cardiopulmonary resuscitation. Before the conference, invitees were given a questionnaire and provided with current literature regarding FP. A modified Delphi process was used to develop consensus, including use of multiple questionnaires and breakouts for discussion of specific issues. Participants were encouraged to develop consensus recommendations based on the literature and discussions. Changes in attitude were tracked with repeat questionnaires. Results of the conference were circulated to participants for review and revision. Consensus recommendations include (1) consider FP as an option for families during pediatric procedures and cardiopulmonary resuscitation, (2) offer FP as an option after assessing factors that could adversely affect the interaction, (3) if family is not offered the option for FP, document the reasons why, (4) always consider the safety of the health care team, (5) develop in-hospital transport and transfer policies and procedures for FP, such as family member definition, preparation of the family, handling disagreements, and providing support for the staff, (6) obtain legal review of policies, (7) include education in FP in all core curricula and orientation for health care providers, (8) promote research into best methods for education; effects of FP on patients, family, and staff; best practices for FP; and legal issues regarding FP, among others. These recommendations were approved in concept by the American Academy of Pediatrics and the Ambulatory Pediatrics Association.

Family Member Presence for Procedures: The Resident's Perspective

OBJECTIVE

To describe resident acceptance of and comfort with family member presence (FMP) during pediatric invasive procedures and resuscitation in a large, multicenter pediatric residency program. To determine if increased level of training impacts on opinion toward FMP for procedures.

DESIGN AND METHODS

Seventy-six residents of postgraduate levels 1-4 were administered a survey about FMP for procedures. The survey consisted of 4 Likert-scale questions and 1 multiple-choice question of resident acceptance of and comfort with FMP during procedures and cardiopulmonary resuscitation (CPR). Statistical analysis was performed using the Mann-Whitney U test and one-way analysis of variance (ANOVA).

RESULTS

Fifty-three residents (70%) responded. Residents were accepting of FMP during procedures, with a mean score of 3.9/5. However, residents were less accepting of FMP presence during CPR, with a mean score of 2.84/5. There was a trend toward increased comfort and acceptance of FMP with increased level of training; however, this was not statistically significant. In our study, nearly one half of residents (45%) reported that their major reservation toward FMP was that resident anxiety could result in procedure or resuscitation failure.

CONCLUSION

The residents in our pediatric training program generally accept FMP for procedures. Residents were less accepting of FMP for CPR than for procedures. Residents most commonly oppose FMP for procedures because they believe this will make them anxious and lead to failure. This information provides insight into the implementation of FMP for procedures in a medical education setting.

Ethnic differences in parent preference to be present for painful medical procedures

OBJECTIVE

To examine ethnic differences between white, black, and Hispanic (English-speaking and Spanish-speaking) parents in their desire to remain present during their children's painful medical procedures.

METHODS

A convenience sample of parents from each of 4 ethnic groups (black, white, and Hispanic [divided into English-speaking Hispanic and Spanish-speaking Hispanic]) was surveyed regarding their preferences for remaining present for 5 hypothetical painful procedures: venipuncture, laceration repair, lumbar puncture, fracture reduction, and critical resuscitation. For each procedure, a short description of the procedure was read to the parent, and a picture of the procedure was shown. The effect of ethnicity on parental desire to stay was examined by using the chi2 test and multivariate logistic regression.

RESULTS

Complete data on 300 parents, 72 to 79 from each ethnic group, were obtained. There were no significant demographic differences between groups except that English-speaking Hispanic parents were younger, and black parents were relatively well educated, whereas Spanish-speaking Hispanic parents were relatively less well educated. Overall, the percentages of those who would wish to remain with their child during the procedures were 94% (venipuncture), 88% (laceration repair), 81% (lumbar puncture), 81% (fracture reduction), and 81% (critical resuscitation). The only significant ethnic difference was that English-speaking Hispanic parents were less likely to want to remain present during a critical resuscitation (P = .01). Black parents were less likely, and English-speaking Hispanic parents were more likely, to want physicians to decide for them whether they should remain present. Parents generally preferred to actively participate during the procedure by coaching and soothing their child rather than to just observe.

CONCLUSIONS

We found few ethnic differences in parents' desire to be present during their child's painful medical procedures. Overall, the vast majority of parents would prefer to remain present even for highly invasive procedures.

Witnessing invasive paediatric procedures, including resuscitation, in the emergency department: A parental perspective

OBJECTIVE

To determine whether parents prefer to be present during invasive procedures performed on their children in the ED.

METHODS

A prospective study using a written survey was carried out in the ED of a secondary level regional hospital in south-east Queensland. The survey conducted between August 2003 and November 2003 consisted of parental demographics, seven theoretical paediatric procedural scenarios with increasing level of procedural invasiveness (including resuscitation) and reasons for the decisions of parents to either stay with the child or leave the room. Parents of children with Australasian Triage Scale (ATS) triage category 3, 4 and 5 were surveyed.

RESULTS

Of 573 surveys collected, 553 (96.5%) were completed correctly. The number of parents expressing a desire to be present during a procedure performed on their child was 519 (93.9%) for phlebotomy or i.v. cannulation of an extremity, 485 (87.7%) for nasogastric tube insertion, 461 (83.4%) for lumbar puncture, 464 (83.9%) for urinary catheter insertion, 430 (77.8%) for suprapubic bladder aspiration, 519 (93.4%) during procedural sedation and 470 (85%) during a resuscitation where the possibility existed that their child may die. The most common reason for wanting to be present was to provide comfort to their child (542/98%). The most common reason for not wanting to be present was a parental concern of getting in the way (181/33%).

CONCLUSION

Most parents surveyed would want to be present when invasive procedures are performed on their children in the ED. With increasing invasiveness, parental desire to be present decreased. However, the overwhelming majority of parents would want to be in attendance during procedural sedation or resuscitation.

Family presence during cardiopulmonary resuscitation

A recent phenomenon in emergency and critical care settings is the presence of family members during resuscitation events. It remains controversial in most institutions, but evidence is increasing that the experience has positive benefits for family members. In this article, the origin of family presence is described and research evidence about the experience is presented. Three case studies are presented to illustrate typical events, including the potential role of the hospital chaplain. Recommendations for implementation are included.

A national survey of Turkish emergency physicians perspectives regarding family witnessed cardiopulmonary resuscitation

We investigated Turkish emergency physicians' views regarding family witnessed resuscitation (FWR) and to determine the current practice in Turkish academic emergency departments with regard to family members during resuscitation. A national cross-sectional, anonymous survey of emergency physicians working in academic emergency departments was conducted. Nineteen of the 23 university-based emergency medicine programs participated in the study. Two hundred and thirty-nine physicians completed the survey. Of the respondents, 83% did not endorse FWR. The most common reasons for not endorsing FWR was reported as higher stress levels of the resuscitation team and fear of causing physiological trauma to family members. Previous experience, previous knowledge in FWR, higher level of training and the acceptance of FWR in the institution where the participant works were associated with higher rates of FWR endorsement for this practice among emergency physicians.

Family presence during pediatric resuscitation: an integrative review for evidence-based practice

Many pediatric health care institutions lack guidelines to address the presence of family members during resuscitation activities. This integrative literature review was used to establish an evidence-based approach that would compliment our institution's philosophy of "family centered care." The evidence supports a partnering with the families: Hospital staff ask families whether they want to be present during life-saving interventions by health care professions. Families want to make the choice, and when they are present during resuscitation efforts, there is less litigation, anxiety, and second-guessing regarding the efforts and competence of the staff providing that care. No literature was found to support beliefs that family member presence is harmful to the family or the institution. A practice policy is provided that respects family choice and presence during life-saving measures in pediatric care facilities.

Family member presence during resuscitation in the emergency department: An Australian perspective

OBJECTIVE

The practice of family member presence during resuscitation in the ED has attracted widespread attention over the last few decades. Despite the recommendations of international organizations, clinical staff remain reluctant to engage in this practice in many EDs. This paper separates the evidence from opinion to determine the current state of knowledge about this practice.

METHODS

A search strategy was developed and used to locate research based publications, which were subsequently reviewed for the strength of evidence providing the basis for recommendations.

RESULTS

The literature was examined to reveal what patients and their family members want; the outcomes of family presence during resuscitation for patients and their family members; staff views and practices regarding family presence during resuscitation. Findings suggest that providing the opportunity to be with their critically ill family member is both important to and beneficial for families, however, disparity in staff views has been identified as a major obstacle to family presence during resuscitation. Examination of published guidelines and staff practices described in the literature revealed consistent elements.

CONCLUSION

Although critics point to the lack of rigour in this body of literature, the current state of knowledge suggests merit in pursuing future research to examine and measure effects of family member presence during resuscitation on patients, family members and healthcare providers.

Medical staff attitudes toward family presence during pediatric procedures

OBJECTIVE

Investigate health care providers' perceived advantages and disadvantages of family member presence (FMP) for a wide spectrum of procedures in the pediatric emergency department.

SETTING

Urban tertiary care children's hospital.

PARTICIPANTS

Pediatric emergency department faculty and nurses, pediatric residents.

METHODS

In a written survey, participants rated approval of FMP for 9 procedures: intravenous (IV) placement, urinary catheterization, suturing, lumbar puncture, fracture reduction, chest tube placement, endotracheal intubation, medical resuscitation, and trauma resuscitation. Respondents listed advantages and disadvantages of FMP for patients, families, and staff.

RESULTS

71% (104/146) of the surveys were completed. Attending physicians and nurses provided similarly high approval rating for less invasive procedures, with a decrement in approval for more invasive or life-threatening situations. Attending physicians and nurses were more likely than residents to approve FMP for all procedures except IV placement, suturing, and urinary catheterization, which had similar approval rates for all respondents. Commonly expressed potential advantages were ability to calm the patient, decreased parental "helplessness," and increased parental knowledge that everything was done. Disadvantages included higher anxiety in room, disturbing parental memories, and detriment to success of the procedure. Medical-legal concerns, mistrust of providers, and more difficult teaching environment were uncommonly listed as disadvantages.

CONCLUSIONS

Emergency department staff support FMP for minor procedures, yet express concern regarding the effects of this practice on the family and the success of the procedure. Most attending physicians and nurses support FMP during highly invasive procedures and resuscitations, whereas residents do not. This information provides insight into the educational and systematic requirements of implementation of FMP.

Families' needs in emergency departments: instrument development

BACKGROUND

Families who accompany critically ill relatives in emergency departments (EDs) are an integral part of the care unit. However, there are few empirical data on their needs during this phase of care. In order to guide quality care, general and specific needs of families accompanying these critically ill relatives should be systematically examined.

AIM

The aim of this pilot project was to test the tool, methods and analysis plan for a study to examine the perceived needs of family members accompanying critically ill patients in EDs and their perceptions of ED staff's ability to meet these needs.

METHOD

Over a 6-week period in 1996, 84 relatives who met the inclusion criteria were recruited to the study. A postal questionnaire, to uncover the needs of family members, was pilot tested. The questionnaire consisted of 40 need statements reflecting five major themes: meaning, proximity, communication, comfort and support. Of the 84 relatives selected for the study, 73% returned completed questionnaires.

RESULTS

The findings of this pilot study suggest that the questionnaire is a valid and reliable tool for researchers wishing to examine and rank the needs of family members who accompany critically ill people in EDs. In addition, the analysis plan was found to be appropriate.

CONCLUSIONS

This pilot study provides both a method and a tool for further research into family needs. Examination of the pilot data supported the reliability and validity of the tool and produced findings that challenge nurses to move beyond traditional practice that has excluded families from being an integral part of caring for critically ill patients in EDs.

Family member presence in the pediatric emergency department

Traditionally, family members were excluded from viewing invasive procedures and cardiopulmonary resuscitation in the pediatric emergency department. The concept of family-centered care in the emergency department has now become more widespread. Consequently, family member presence during routine invasive procedures such as venipuncture, intravenous cannulation, urethral catheterization, and lumbar puncture has become more accepted. Survey evidence indicates parents' overwhelming desire to be present for invasive procedures and cardiopulmonary resuscitation. Healthcare provider opinions about family witnessed resuscitation lack similar uniformity. Variations in approval of witnessed resuscitation are influenced by occupation, level of training and experience, and prior exposure to family member presence practices. Although several organizations formally support family presence policies, citing benefits for grieving relatives, critics point to a lack of rigor in a large body of the research cited to underpin these endorsements. We review the literature from the perspective of pediatric emergency physicians, offer suggestions for family member presence, and provide directions for future study.

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses

BACKGROUND

Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence.

OBJECTIVE

To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures.

METHODS

A 30-item survey was mailed to a random sample of 1500 members of the American Association Of Critical-Care Nurses and 1500 members of the Emergency Nurses Association.

RESULTS

Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedures) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures).

CONCLUSIONS

Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.

Family Presence During Cardiopulmonary Resuscitation and Invasive Procedures: Practices of Critical Care and Emergency Nurses

• Background Increasingly, patients’ families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence.

• Objective To identify the policies, preferences, and practices of critical care and emergency nurses for having patients’ families present during resuscitation and invasive procedures.

• Methods A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association.

• Results Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures).

• Conclusions Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.

Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals

OBJECTIVE

Recent international emergency cardiovascular care (ECC) and cardiopulmonary resuscitation (CPR) guidelines have recommended that health-care professionals allow family members to be present during resuscitation attempts. To assess whether critical care professionals support these recommendations, we surveyed health-care professionals for their opinions regarding family-witnessed resuscitation (FWR).

METHODS

We surveyed health-care professionals attending the International Meeting of the American College of Chest Physicians in San Francisco, CA, from October 23 to 26, 2000, about their CPR experience, their opinions on FWR, and demographic characteristics. The opinions of physicians, nurses, and other allied health professionals were compared, and differences in opinions based on demographics were examined.

RESULTS

Five hundred ninety-two professionals were surveyed. Fewer physicians (20%) than nurses and allied health-care workers combined (39%) would allow family member presence during adult CPR (p = 0.0037 [chi(2) test]). Fourteen percent of physicians and 17% of nurses would allow a family presence during pediatric CPR. There was a significant difference among the opinions of US professionals, based on regional location. Professionals practicing in the northeastern states were less likely than other US professionals to allow FWR during adult or pediatric resuscitations (p = 0.016 and p < 0.001, respectively [chi(2) test]). Midwestern professionals were more likely than others to allow family members to be present during an adult resuscitation, when compared to professional in the rest of the nation (p = 0.002 [chi(2) test]). Health-care professionals disapproving of family member presence during CPR did so because of the fear of psychological trauma to family members, performance anxiety affecting the CPR team, medicolegal concerns, and a fear of distraction to the resuscitation team.

CONCLUSIONS

Our evaluation indicated that the majority of critical care professionals surveyed do not support the current recommendations provided by the ECC and CPR guidelines of 2000.

Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research

STUDY OBJECTIVE

We examine the literature relating to family presence in the emergency department, with a specific emphasis on parental experiences and presence during invasive procedures and family presence during cardiopulmonary resuscitation and resuscitation.

METHODS

An electronic search and examination of resulting references was conducted using the words, "family centered care," "parent participation," "parent presence," "family presence," and "emergency department," "accident and emergency department," "procedure," "invasive procedure," and "resuscitation." Articles related to out-of-hospital emergency medical services were excluded. Also, articles were included only if the manuscript was based on an empirical study and if the manuscript was published in a peer-reviewed journal.

RESULTS

Twenty articles, primarily composed of survey research, were included in this review. Research suggests that families want to be given the option and, when given the option, often choose to remain during invasive procedures and resuscitations. Those who remain generally report favorable experiences and feel it is beneficial to the patient and themselves. Providers, however, have mixed opinions regarding family presence. Nurses may have a more favorable view toward family presence during invasive procedures than physicians. Among physicians, it appears that greater age and experience may be associated with more favorable opinions of family presence. Randomized controlled trials are mixed regarding whether family presence actually helps the patient.

CONCLUSION

Despite what appear to be promising data regarding the benefits of family presence, this area of research is in the initial phases of development with many limitations that are discussed. Recommendations for future research are presented.

Family presence during resuscitation: to see or not to see?

Encouraging family presence during resuscitation is controversial. Health care providers should use evidence-based practice to review this issue and be open to the idea of allowing the family to be present. The literature supports family presence during resuscitation and there is insufficient research in opposition to family presence. Health care institutions should revise their practices to coincide with the wants and needs of their patients and families. Nurses have an ethical obligation to intervene and create family presence programs.