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Resuscitation and Invasive Procedures

New guidelines help clarify released this year rules on family presence at the bedside.

One Mother's Memories

Twenty-two years later. I think back on that painful morning, when my beautiful, charismatic, and loving 14-year old son, my first-born, breathed his last breath. Donnie's heart ceased to beat and I would never hear the sound of his voice again. I would never know him as an adult. He would never go the prom, college, or marry and have children. 

Months later, in my grief, I shared my story with my friend, a nurse. She insisted that my memory was inaccurate - I simply could not have been in the room. "They just do not allow that!" I realized I had been given a "gift" of something I thought was practiced routinely.

Theresa was at our side as this compassionate team of nurses and physicians worked feverishly, holding out hope for the slightest chance of a miracle, that they might breathe new life into our son. Despite being the most painful moments of my life, when I faced the grim reality that Donnie may not survive, despite those heroic efforts, I would not trade that experience and I would choose to do so again without hesitation. In those moments, I witnessed surreal details in a very real venue, with details I might have doubted if doors had closed, leaving me only to wonder, fret, and conjure up even worse details in a cold waiting room. I birthed my precious baby boy into this world and could not bear thinking of Donnie left alone with strangers during this traumatic time. He needed to hear our lovingly familiar voices. Maybe hearing us encourage and plead with him could help him stay. His father needed the chance to apologize for words they had with each other only hours earlier. There were things that could not be left unsaid! I believe that Donnie heard and felt our love, along with permission to go if that is what he needed. This unfinished business would not be the same if left for a time at the morgue. This experience helped me with my grief, especially with my anger. I was allowed to experience Donnie's last moments and let him go.

Now, as a grandmother of five, and mother of three, I think back with gratitude for this courageous team of medical professionals who realized MY needs were so much greater than their fears, and that we all wanted the same outcome..life.

I'm amazed at the progress that has been made in support of family presence, yet surprised that there is still work to be done, eyes and hearts to be opened to the benefits for  patients and their families in times of trauma.

I met mom, Susie, and Theresa, an expert trauma nurse who brought Susie and her husband into the resuscitation long ago. When Theresa was grilled about why she did that (with threats that she might lose her job), she replied, "It was the right thing to do for this family." This event also caused Theresa to question clinical practice. She asked that critical question: "Why do we ban all families from the bedside during resuscitation?" We came to learn this "unwritten" hospital rule was based on tradition and fear - and not on any clinical or research-based evidence.

Family Member Benefits

Over the years, our research teams have interviewed hundreds of family members regarding their family presence experiences. We learned that although not all families want to be at the bedside, the majority do. Our research combined with the findings of others has demonstrated consistent evidence about the many benefits for family members. Families believe it is their right, obligation and duty to be there. They have related stunning statements about their need: "Wild horses couldn't have dragged me away," "I would have handcuffed myself to the bedside if they made me leave," and "It was one of the hardest things I've ever done, but I didn't want to be anywhere else." Families have explained their need to comfort, protect, advocate for, and communicate critical information about their loved one. They needed to see what was happening, understand their loved one's condition, and know everything possible was done. Being there also brought a sense of reality, helped them adjust to death, and made grieving easier.

Healthcare Provider Benefits

We and others also have surveyed healthcare providers. When comparing providers who have not been involved in family presence, the majority of those who have experienced actual family presence events support the practice. Studies have found that providers' anxiety and stress levels are not increased when families are there. Providers believe having families present facilitates behavior that is more professional and diminishes extraneous conversations. During the event, quality provider communication with the family also is enhanced as families become a part of the patient-family-provider team and the decision making process. The primary provider fear about family presence is that family members will disrupt patient care. To date, there is no evidence family presence has caused patient care disruptions, negative patient outcomes or adverse psychological family effects.

Facts You Need to Know

If you are considering supporting family presence, there are many resources to help you get started. Here are seven facts you need to know:

1.      Put it in writing. If you are thinking about setting up a family presence program (or informally doing it), develop a written practice guideline (i.e., policy, procedure, clinical practice guideline, standard of care) to protect the safety of patients, family members and healthcare providers involved.

2.      Don't do it alone. Identify a few nurses, physicians or others who will champion the practice. Then establish an interdisciplinary team including family members to develop, implement and evaluate a process to support the option of family presence.

3.      Recognize family presence is an option - not an expectation - but should be available to all who want to be offered that choice.

4.      Create a family presence facilitator role for providers who are assigned to families to guide them before, during, and after the family presence event. Facilitators can include nurses, physicians, social workers, child life specialists, chaplains, volunteers and others trained in the role.

5.      Communicate that patient care is the priority. It is recommended families be assessed to determine their level of coping before offering family presence. Families are not offered the option if they demonstrate combative or threatening behavior, extreme emotional instability, or behaviors consistent with an altered mental state.

6.      Educate staff about the benefits of family presence, written practice guidelines, criteria to assess family coping, contraindications to family presence, and the facilitator role. 

7.      Evaluate family presence from the perspective of patients, families and providers to identify concerns, problems, needed revisions and outcomes.

Professional Organization Recommendations

When Theresa made the decision to bring Susie in during resuscitation two decades ago, she had never done anything like that. She was challenged to defend her decision and her job. There was little evidence or professional support for the practice. But things have changed! Because of the mounting evidence of family presence benefits and the push to provide patient-family-centered care, professional nursing and medical organizations have developed position statements, guidelines, and recommendations supporting family presence as the standard of care.

In 1993, the Emergency Nurses Association developed a resolution supporting family presence. They then developed national guidelines for assessing, implementing, and evaluating family presence programs in their publication Presenting the Option for Family Presence, which was endorsed by the American Association of Critical-Care Nurses (AACN) in 2007. Likewise, AACN has developed a Practice Alert for Family Presence during Resuscitation and Invasive Procedures (updated 2016) that is intended to be a succinct directive, supported by authoritative evidence, to ensure excellence in practice and a safe and humane work environment.1

Moreover, other professional organizations have weighed in to support family presence including the Society of Critical Care Medicine, the American College of Emergency Physicians, National Association of Social Workers, American Heart Association and American Academy of Pediatrics.

 

Reference
1.AACN Practice Act. "Family Presence During Resuscitation and Invasive Procedures.http://www.aacn.org/wd/practice/docs/practicealerts/
fam-pres-resusc-pa-feb2016ccn-pages.pdf
Accessibility verified May 16, 2016.

Cathie E Guzzetta is nursing research consultant and clinical professor at George Washington University School of Nursing in Washington, DC. Susan Hott is family member consultant at Dallas Family Presence Team in Dallas.



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