Should the family be present during resuscitation?

Nursing, Oct 2003 by Marrone, Lauren, Fogg, Catherine

Are policies allowing family into the trauma room humane and necessary-or just asking for trouble?

During a resuscitation effort in most emergency departments, the patient is wheeled into the trauma room and the family is escorted into the family crisis room. While we work desperately to resuscitate the patient, a social worker updates the family on our progress. If the patient dies, we make him as presentable as we can, quickly put the room in order, and then invite the family in to say goodbye to their loved one. The social worker supports the family during this difficult time, and we, the code team, return to our other patients.

For decades, this approach seemed to work well. We feared that if we did let the family in during the code, they'd either get in the way or become so distraught that we'd have more patients on our hands. We felt we were doing the family a greater service by letting them see their loved one only after we'd removed tubes and lines, even though the calm scene we produced was in total contradiction to actual events.

But recently, this traditional approach has sparked controversy. Many family members want to be present during resuscitation efforts. Health care professionals are divided on whether families should be present, but most agree the issue must be addressed.

As nurses, our primary question about any policy change must be: Will this benefit the patient above all? Here, we'll discuss the pros and cons of family presence during a code and let you decide.

How family presence can help...

Hearing is the last sense to cease, and many seemingly unconscious patients may have some awareness of their surroundings. Aware of his family's presence and hearing their encouraging, loving words, a patient may find the strength to survive or take great comfort if he's dying. A family's support can help a patient feel less alone and vulnerable among strangers. If he's dying, he may well prefer to see loved ones' faces than those of the code team.

Allowing family to be present carries some obvious benefits for family members too: This may be their last chance to see their loved one and to say good-bye while he's alive. And although witnessing a failed resuscitation is a severely traumatic event for a family, seeing the extraordinary effort put forth by the code team gives real meaning to the words "We did everything we could."

Being shut out of the resuscitation process can increase family members' feelings of helplessness, anxiety, panic, and guilt. But being able to care for a loved one during his final moments, even in small ways, and to say good-bye can reduce those feelings and help family members through the grieving process.

A family's presence can't help but increase the staff's emotional vulnerability, yet even this can benefit the family, according to research. The code team may want to be strong for the family, but families seem touched when physicians or nurses show their own grief over a patients death.

...and how it can hinder

Family presence during resuscitation also has some serious drawbacks. Resuscitation is an intense situation; every second is critical. What if distressed family members interfere with resuscitation efforts? And how can staff continue to work effectively in the midst of a frightened, grieving family? If family members are present, will they distract attention from the patient and the care he needs?

Furthermore, resuscitation isn't pretty. How many families can handle watching someone they love undergo such aggressive measures as chest compression and intubation?

The potentially long-term mental anguish families can suffer in response to watching a resuscitation has legal as well as ethical implications. Things can go wrong during any medical procedure; the presence of family members could easily increase staff anxiety and make matters worse. Family members could sue the staff or facility for negligence or for shock caused by seeing the resuscitation. However, one study points out that angry family members who are shut out of the resuscitation effort are more likely to bring a lawsuit and that providing the right kind of support may actually reduce legal risks.

And, most important, what about the patient's wishes? 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 cardiopulmonary resuscitation. He might want to face his death alone. How do we know whose wishes we're fulfilling when we allow family into the trauma room?

Weighing the pros and cons

Clearly, trying to meet all the needs of everyone involved in a resuscitation attempt would be difficult at best. We must prioritize those needs-and the patient's needs come first.

Overall, most of those who've studied this issue believe that despite the frightening and potentially traumatizing aspects of a resuscitation effort, the benefits of family presence outweigh the negatives. The patient always takes top priority, but in the broader view, the family is part of the patient. Truly holistic care takes into account not only the patient, but also his family during an event as crucial as resuscitation. Even though the patient can't be consulted during resuscitation, he's more likely to feel comforted hearing the voice of his spouse or his child than just staff members shouting to each other over his bed. And the clear benefits to family members-a chance to say good-bye, reduced guilt and anxiety, firsthand knowledge of the staff's effort to resuscitate, and possibly a more straightforward grieving process-outweigh the potential emotional trauma.