Family Presence During Resuscitation and Invasive Procedures

Evidence is mounting that family presence during resuscitation and invasive procedures is beneficial to patients and their families. Meeting psychosocial needs in a time of crisis exemplifies care driven by the needs of patients and their families.

1. Family members of all patients undergoing resuscitation and invasive procedures should be given the option to be present at the bedside per the patient’s wishes. (Family members are those individuals defined by the patient, or in the case of a minor or those without decision-making capacity, by their surrogates. Family members may be relatives or significant others who provide support and with whom the patient shares a significant relationship.¹ ) [level B]

2. All patient-care units should have an approved written practice document (ie, policy, procedure, or standard of care) for presenting the option of family presence during resuscitation and bedside invasive procedures, including the roles and responsibilities of the family presence facilitator. [level D]

Research and public opinion polls indicate that the majority of patients, patients’ families, and consumers believe that patients’ family members should be offered the opportunity to be present during emergency procedures and at the time of their loved one’s death.^2–13 

Despite recommendations from professional organizations, consensus conferences, joint position and policy statements, and clinical practice guidelines regarding family presence during resuscitation,^14–26  only 5% of critical care units in the United States,²⁷  8% in Canada,²⁸  and 7% in Europe²⁹  have written policies that allow family presence. Surveys of nurses’ practice indicate that many, if not most, critical care nurses have been asked by patients’ family members if they could be present during resuscitation and invasive procedures and have brought such families to the bedside, despite the lack of formal written hospital policies.^27–30 

Studies have shown the following benefits of family presence:

1. For patients: Almost all children want their parents present during medical procedures.^31–33  The majority of adult patients want family members to be present during emergency procedures and are comforted and helped by having them there.^{4,10,11,34,35} 

2. For family members: Most family members believe that it is important to be present during their loved one’s emergency procedures and that it is their right, duty, and obligation to be there.^36–39  Their presence at the bedside enables them to understand the severity of their loved one’s condition and helps in removing doubt about the patient’s condition by witnessing that everything possible is being done.^8,35–46  Being present decreases family members’ anxiety and fear about what is happening to their loved one and provides the means to communicate important information about the patient to the health care providers.^{32,35,37,43,47,48}  It facilitates their need to be together and the opportunity to advocate for, comfort, protect, and support their loved one.^{36–39,42–45,47,49,50}  Patients’ families believe that family presence is helpful to the patient and themselves.^{36–38,42,49,51}  Family members’ presence allows them to experience a sense of closure and facilitates the grief process should death occur.^{4,7,8,35,36,39,44–47}  Studies show that 94% to 100% of families present during these events would choose to be present again.^{4,36,37,42,44,47,49,51,52} 

Family presence is reported to improve medical decision making, patient care, and communication with patients’ family members.^36,53 

Studies have shown that family presence results in the following:

1. No patient care disruptions^{36,37,42,49,53–55} 

2. No negative outcomes during family presence events^{8,32,35–37,41,44,45,49,53,56} 

3. No adverse psychological effects reported among family members who participate at the bedside and compared with families not present^{35–37,39,40,42,50,52,56–58} ; signs and symptoms of posttraumatic stress syndrome, depression, and traumatic grief are less frequent when families are permitted to be present during resuscitation than when they are not, both at 3 months and at 1 year after the event, with no medicolegal claims^50,56 

Ensure that your health care facility has written policies and procedures that support family presence during resuscitation and invasive procedures. Create an interdisciplinary task force (ie, nurses, physicians, social workers, pastoral care, respiratory care, child-life specialists, and patient/family advisors) to develop your family presence program.²³  Use recommended guidelines as a template to develop your written policies and procedures.²³ 

Make certain that policies and procedures^15,24,51,59  and educational programs^{24,38,51,59–62}  for providers include the following components:

1. Benefits of family presence for the patient and family^23,63 

2. Presenting family presence as an option and not an expectation or requirement^{23,36,37,53,55,63} 

3. Criteria for assessing family coping to ensure uninterrupted patient care^{23,36,37,53,55,63,64} 

4. Contraindications to family presence (eg, family members who demonstrate combative or violent behaviors; uncontrolled emotional outbursts; behaviors consistent with an altered mental state from drugs or alcohol; or those suspected of abuse)^{22,23,36,37,53,55,62–64} 

5. The role of the family presence facilitator is to consult with the health care team about family presence and prepare families for being at the bedside and to support families before, during, and after the event, including handling the development of untoward family reactions^{23,24,36,37,51,53,55,59,60,62–65} ; family facilitators may be nurses, physicians, social workers, chaplains, child-life specialists, respiratory care practitioners, family therapists, or nursing students^{23,51,63–66} 

6. Support for the patient’s or family members’ decision not to have family members present^23,51,63 

Develop proficiency standards for all staff involved in family presence to ensure patient, family, and staff safety.

Determine your unit’s rate of compliance in offering families the option of family presence during resuscitation and invasive procedures. If compliance is 90% or less, develop a plan to improve compliance:

1. Reeducate staff about family presence; discuss the intervention as a component of patient- and family-centered care and evidence-based practice

2. Incorporate content into orientation programs as well as initial and annual competency verifications

3. Develop a variety of communications strategies to alert and remind staff about the family presence option

Develop documentation standards for family presence; include rationale for when family presence would not be offered as an option to family members.

1. Contact a clinical practice specialist for additional information: go to www.aacn.org/practice-resource-network

2. The third edition of Presenting the Option for Family Presence,²³  developed by the Emergency Nurses Association, offers guidelines that are suitable for adaptation to critical care units and include educational slides and handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, a sample family presence guideline, and other supporting documents. This resource is available at www.ena.org.

3. Institute for Patient- and Family-Centered Care (IPFCC), available at www.ipfcc.org.

4. The DVD Training Parent Facilitators by Martha Curley for the Cardiovascular Critical Care Nursing Program at Children’s Hospital Boston depicts simulations in which staff members support parents whose children are undergoing invasive procedures and CPR. Training materials accompany the DVD and include practice guidelines and a PowerPoint presentation with handouts. This resource (Order No. QA-486) is available at http://fanlight.com/catalog/films/486_tpf.php or by calling (800) 937-4113.

5. Resources for developing a protocol for family presence, including defined team roles and expectations, can be found in Fast Fact #233: Implementation of a Family Presence During Resuscitation Protocol (https://www.capc.org/fast-facts/233-implementation-family-presence-during-resuscitation-protocol/).