In today’s dynamic and ever-changing health care arena, providing care according to current evidence remains the goal of every well-informed advanced practice provider. Using evidence-based practice to define best practice measures is not a new concept. In fact, almost every health care facility uses these terms to define policies and procedures for daily operational procedures. Well-informed advanced practice providers, learn early on in nursing education the importance of first reading, then understanding, and accepting new care standards according to the supporting research. When an advance practice provider is in a situation where personal beliefs are in conflict with current practice recommendations despite evidence pointing to the contrary he or she can experience ethical distress.
The issue of personal beliefs conflicting current practice recommendations is aninfrequently discussed topic among advanced care providers yet; it is defining and shaping how care is delivered. One such issue in today’s emergency departments is the concept of family presence during cardio-pulmonary resuscitation (CPR), (Duran,Oman, Jordan Abel, Koziel, & Szymanski, 2007), (MacLean et al. 2003), (Mason, 2003), (McLaughlin & Gillespie, 2007), (Sanford, Pugh, & Warren, 2002). While it appears that evidence clearly indicates positive outcomes from family witnessed resuscitation (FWR), a majority of emergency departments fail to effectively implement or even institute policies regarding FWR , (MacLean et al. 2003).
So what is the reason for the discrepancy between recommended practice and actual practice? In order to accurately answer that question, one must understand the history and controversy surrounding FWR. The first published article regarding FWR was in 1987 (Doyle, et al 1987), which was, a descriptive survey used to determine attitudes of staff and patients’ families that had participated in FWR. The study concluded that 94% of family members would want to be present again for the resuscitation of a loved one, 76% of family members felt that adjusting to the loss of a loved one was easier, and 64% felt their presence was beneficial to their dying family member. (Doyle, et al 1987)
A descriptive survey conducted in 2000 (Myers, et al 2000) investigated attitudes and beliefs of patients’ families and ER staff members about FWR. The survey reported that 98% of patients’ families indicated that they had a right to be present and would do it and would participate in FWR again; 100% of family members said that FWR was helpful to them, and 95% said it was helpful for the patient. It also showed that 70% of professionals surveyed after their participation in FWR actually produced a higher level of “professional” behavior along with a more “professional” bedside dialog amongst the health care team. The survey also indicated that having the family in the resuscitation room prompted the staff to take the patient’s dignity, privacy, and need for pain management into greater consideration when compared to an un-witnessed resuscitation effort. (Myers, et al 2000)
A descriptive survey of US and international critical care professionals (McClenathan,Torrington, & Uyehara, 2002) found that attitudes toward FWR were in strong opposition. According to the survey, 78% of health care professionals surveyed (physicians, nurses, allied health-care providers) reported being opposed to FWR for adults. In a further analysis of the data, it was found that a greater percentage of physicians (80%) then nurses (57%) were opposed to FWR. Participants of the survey indicated in the short answer section of the survey that, FWR would violate patient confidentiality, distract staff members from performing their jobs, evoke performance anxiety, and expose family to unnecessary psychological trauma. (McClenathan, Torrington, & Uyehara, 2002)
While this survey indicates that more nurses then physicians have a positive attitude toward FWR, a majority of emergency departments do not have written guidelines or an established policy regarding FWR. A 30-item descriptive survey (MacLean et al, 2003) of randomly selected registered members of the American Association of Critical-Care Nurses (AACN) and the Emergency Nurses Association (ENA), in regards to policy and procedure practices involving FWR demonstrated that only 5% of 984 respondents worked on a unit with an established policy. The survey also found that 37% of respondents preferred to have a written policy in support of FWR, though 45% of respondents reported they have participated in a FWR without a written policy. Of the respondents that supplied their personal experiences with FWR, their comments indicated the following benefits of family presence; provides emotional support for the patient, allows staff to provide guidance and increase family understanding of the patient’s situation, helps patient’s families know that everything was done to save their loved one, and it facilitated closure and healing. (MacLean et al, 2003)
Opponents of FWR also state that FWR may be in violation of a patient’s right to privacy. While protection of a patient’s privacy is important, health care professionals must also take into consideration that the patient is part of a greater whole- the family, which arguably also suffers when the opportunity for them to provide support to a loved-one in their greatest time of need is denied. Life and death situations are special circumstances in which not all patient rights may be honored. Having the family at the bedside may also serve as a resource to help guide how aggressive resuscitation efforts should be according to what the family feels the patient may have wanted. This is a simple way to allow the patient to express what they would have wanted for themselves, through their family.
Another reason facilities are reluctant to allow FWR is the concern of increased litigation. Advocates of FWR state the risk of litigation will actually decrease for several reasons; firstly the family will develop a bond with staff members as they support one another through the resuscitation, and secondly, the family will gain insight and increased education regarding the resuscitation process, which is generally accepted as a way to decrease risk of litigation. (Duran, Oman, Jordan Abel, Koziel, & Szymanski, 2007), (MacLean, et al.,2003)
A family members perception of the quality of bedside manner of the health care team is a big determinant in whether or not litigation will occur. Developing a relationship, or bonding-moment with the family is essential for a successful, potentially litigation free FWR experience. By having staff actively explaining procedures and involving the family, they develop the feeling of actually being part of the team, with every member working toward the common goal of caring for the patient or their loved one respectively. This also allows the family to see that everything possible was done for their loved one, which will help bring a sense of closure with the termination of resuscitation efforts. (MacLean et al., 2003), (Mason, 2003), (McLaughin, 2007), (Sanford, 2002).
When addressing the aspect of life and death, particularly in regards to the affected family members, several ethical principals must be considered. According to the American Heart Association (AHA), the goal of any resuscitation is to preserve life, restore health, relieve suffering, limit disability, and reverse clinical death (American Heart Association, 2005). Due to the acuity of the patient in cardiac or respiratory arrest, decisions are made as quickly as possible in order to adequately restore life with the best possible chance of a full recovery. It is in this instance that choices are made for the patient because they cannot verbalize their own wishes, as a result, some decisions may be in conflict with what the patient actually desires. Patient autonomy is generally respected ethically and legally, assuming the patient possesses decision-making capability and cannot be declared incompetent in a court of law (American Heart Association, 2005). In a situation where the patient cannot make decisions due to the acuity of their illness and their preferences cannot be clarified, all emergency conditions should be treated accordingly. Involving family in the resuscitation efforts can allow for patient autonomy to be maintained as family can express what the patient would have wanted. Ideally, using the patient’s advance directive or living will along with family input.
The principal of beneficence and nonmalefiecence apply, as it is understood as a holistic advanced care provider one must do good, avoid evil, and do no harm. These principals are often translated to mean that if one cannot do good without also causing harm, then one should not act at all in that particular circumstance (Ascension, n.d.) This becomes impossible with the acutely ill patient, as taking no action would also cause harm. It must also be considered that the patient’s family may also suffer harm by not allowing them to be at the bedside with their loved one. If family is not allowed to be involved during resuscitation efforts and the resuscitation is unsuccessful as most resuscitation attempts are, then that patient has essentially died alone.
The principle of human dignity, or the intrinsic worth that is inherent in every human being is the conceptual basis for human rights (Ascension, n.d.). Every human being is an inherently valuable member of the human community as a unique expression of life deserving of respect (Ascension, n.d.). Patients with reduced autonomy are entitled to appropriate protection of both their bodily person as well as their spiritual person (Ascension, n.d.). This can be achieved by not performing unnecessarily long resuscitation efforts, not subjecting the patient to unnecessary procedures, and allowing family to be present to support the patient.
While it cannot be denied that further research is needed in the area of FWR, several recommendations can be made from results of previously conducted studies. Because research indicates that nurses are generally more open to the idea of FWR, it then becomes our responsibility to lead the way for policy development in our own institutions. Under provision 6 in the American Nurses Association (ANA) Code of Ethics, “the nurse participates in establishing, marinating, and improving health care environments and conditions of employment conducive to the provisions of quality health care and consistent with the values of the profession through individual and collective action” (ANA, 2001). While not every physician supports FWR, it can also be said that not every physician opposes it; therefore presenting the evidence and reasoning for the development of a FWR policy to staff in a logical, appropriate, manner will inhibit potential disagreement or argument. Indicating that while individual healthcare teams may have personal reasons for opposition of FWR, in the end we need to do what produces the best outcomes for families and patients, which is not necessarily what is most convenient or comfortable for the health care team.
Currently, the ENA, the AHA, the AACN, the American Academy of Pediatrics (AAP), the National Association of Emergency Medical Technicians (NAEMT), and the National Association of Social Workers (NASW) support FWR and have implemented specific guideline recommendations (Durina,Oman, Jordan-Able, Koziel, Szymanski, 2007). All of the above mentioned organizations recommend the development of facility-specific policies and procedures to ensure a positive FWR experience for the patient, family, and staff.
Any policy regarding FWR should include several key components; first each family is unique and therefore must be treated as such. A designated member of the resuscitation team must assess each family before deciding weather or not FWR would be of benefit. Time is of the essence for most resuscitations, so this screening process must be fast and effective. If it is found that FWR is of interest to the family, the staff member must clearly verbalize that the family is not to hinder or distract the resuscitation team intentionally.
The designated staff member must also remain with the family at all times, to both provide emotional support and to explain each step and procedure that the family is witnessing. This allows the family a reliable resource for information as well as an opportunity to develop a bond with staff. Detailed and education appropriate level explanations of procedures also helps the family to feel that everything is being done to save their loved one.
In addition to a designated healthcare team member assigned to the family, an effective policy should include how to properly obtain and implement care according to the family’s religious or cultural background. This will further allow the family to feel as though their presence is making a positive impact as well as allowing them to feel like a part of the resuscitation effort. Respect for cultural differences and religious preferences is considered for all other aspects of care, therefore it is only a natural transition that advanced care professionals also start applying this to resuscitation efforts.
Providing comprehensive education as well as yearly competency training for all emergency staff members will create a greater awareness of their own actions, and promote an environment that is conducive to allowing family at the bedside of the critically ill patient. Promotion of a holistic care approach with inclusion of the family may be difficult to initiate, however with time and practice, the emergency department will be providing an experience that is will equate to the greatest good for all.
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