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Jese Broersma
Family presence during resuscitation (FPDR) is a growing topic of interest, and there is
variation in the way hospitals handle this sensitive situation. Many hospitals have generated
policies surrounding FPDR in order to adhere to patient- and family-centered care models.
Despite having established policies in place, hospitals are not consistently implementing FPDR;
however, family- and patient-centered care practice models reveal family grieving is positively
impacted when FPDR is implemented because families are able to be part of the resuscitation
(Leske, McAndrew, & Brasel, 2013). Nurses play a key role in the successful implementation of
this practice (Jensen, & Kosowan, 2011). The perceived barriers among health care professionals
and psychological benefit for families have been investigated in depth in order to fully
understand this dynamic topic. This paper will critique and synthesize the information in the
several pieces of literature surrounding family presence during resuscitation in the critical care
setting in order to gain a greater understanding of the issue. This paper will address methods,
Background
The idea of having family present during resuscitation (FPDR) in the critical care setting
was introduced in 1982 after family members refused to leave the bedside of their loved ones on
two separate occasions at Foote Hospital in Jackson, MI (Boehm, 2008). Family presence during
resuscitation is defined as one or more family member present in the care area during
cardiopulmonary resuscitation where they have visual or physical contact with their family
member (Boehm, 2008). Research has been conducted addressing the perceptions of health care
providers and family members, along with the psychological benefits afforded to family in FPDR
situations. There is a lack of consistency in practice of FPDR in the critical care setting (Jensen,
FAMILY PRESENCE DURING RESUSCITATION 3
& Kosowan, 201; Wolf, Storer, & Brim, 2012). There are multiple professional nursing
organizations that support the concept of FPDR such as Emergency Nurses Association (ENA),
American Heart Association (AHA), and American Academy of Critical-Care Nurses (AACN).
The ENA released a position statement in 2009 indicating that there are no apparent detrimental
effects to the patient, family, or health care team when the family is present during resuscitation
(ENA, 2012). The ENA recommends policies be created to allow for families to have the option
of being present (ENA, 2012). Literature will be investigated and analyzed to answer the
question: In the family of patients undergoing resuscitation in the critical care setting, does being
present during resuscitation compared to not being present, result in more family members
stating they were glad they were present when attempts were unsuccessful 3-months post-
resuscitation?
Literature Review
Methods
Research design. The quantitative data is primarily non-nursing research which allows
for a multidisciplinary assessment of the topic. Jabre et al. (2014) conducted a prospective,
randomized control study that assessed psychological effects one-year after witnessing
resuscitation. Goldberger, et al. (2015) conducted a cohort study that focused on the impact of a
written FPDR policy on resuscitation outcomes. Despite there being limited quantitative data
available, it is an important to consider the data when analyzing the depth of the topic because
this provides a quantifiable strength that qualitative data is unable to produce. The available
qualitative data primarily addresses the effects of witnessing resuscitation on family and staff
perception of having family present through surveys, interviews, and field notes taken by the
researchers (Leske, McAndrew, & Brasel, 2013; Powers, & Candela, 2017; Davidson et al.,
FAMILY PRESENCE DURING RESUSCITATION 4
2011; Lowry, 2012; Jensen, & Kosowan, 2011). The considerable amount of qualitative data,
along with recurrent themes amongst available sources, provides strength to the suggestion of the
gathering data in the descriptive studies is multi-dimensional surveys, questionnaires, and direct
interviews (Leske, McAndrew, & Brasel, 2013; Powers, & Candela, 2017; Davidson et al., 2011;
Lowry, 2012; Jensen, & Kosowan, 2011). The ENA explored and analyzed qualitative and
quantitative data to create a Clinical Practice Guideline that focused on the practice of FPDR and
Sample. The samples and inclusion/exclusion criteria varied among all literature
reviewed. Small sample sizes that ranged between 14 and 124 were used and were primarily
convenience samples (Leske, McAndrew, & Brasel, 2013; Powers, & Candela, 2017; Davidson
et al., 2011; Lowry, 2012; Jensen, & Kosowan, 2011). The effects of a small sample size and
convenience sampling are: lack of diversity (gender, age, ethnicity/racial) and potential threats to
transferability and generalizability (Leske, McAndrew, & Brasel, 2013; Powers, & Candela,
2017; Davidson et al., 2011; Lowry, 2012; Jensen, & Kosowan, 2011). The qualitative data had
clearly defined inclusion/exclusion criteria which refined the results and narrowed the focus of
the studies. Inclusion criteria utilized were: nurses that had previous experience with FPDR
practices (Lowry, 2012) and patients 18 and older admitted to the SICU requiring resuscitation
(Leske, McAndrew, & Brasel, 2013). Reasons for exclusion from the sample included: patients
under 18 years old, a fatality in the same accident, multiple family members as patients in a
critical care setting (Leske, McAndrew, & Brasel, 2013) and families that didn't answer the
phone for follow-up interview after 15 attempts (Jabre et al., 2014). The quantitative data yielded
a significantly larger sample sizes (4,608 family members and 41,568 patients) that allow for
FAMILY PRESENCE DURING RESUSCITATION 5
more practical and realistic generalizability and transferability of themes (Wolf, Storer, & Brim,
2012; Jabre et al., 2014; Goldberger et al., 2015). Because of the larger sample sizes, the
quantitative studies were able to analyze the impact of a FPDR policy on resuscitation outcomes
(Goldberger et al., 2015) and the long-term impact of implementing FPDR practices on families
(Jabre et al., 2014) because their result are easily generalized and transferred.
Findings
Family and patient perceptions. The findings revealed commonalities that included:
family member is part of the team or a voice for the patient (Lowry, 2012; Davidson et al., 2011;
Leske, McAndrew, & Brasel, 2013; Wolf, Storer, & Brim, 2012), sense of comfort for the family
members (Powers, & Candela, 2017; Jabre et al., 2014; Leske, McAndrew, & Brasel, 2013;
Wolf, Storer, & Brim, 2012; Lowry, 2012; Jensen, & Kosowan, 2011), and increased sense of
closure (Powers, & Candela, 2017; Wolf, Storer, & Brim, 2012; Jensen, & Kosowan, 2011; Jabre
et al., 2014; Davidson et al., 2011 Lowry, 2012). These themes reflect the importance and
satisfaction with the care their loved one received and decreased distress when they were present
during resuscitation which had positive psychological benefits and facilitated grieving (Wolf,
Storer, & Brim, 2012). An increased sense of closure was conveyed in family members that were
able to view and participate in the resuscitation efforts which is an important component of the
grieving process (Jabre et al., 2014; Powers, & Candela, 2017; Jensen, & Kosowan, 2011;
Lowry, 2012). Current promotion of a patient and family centered models care suggest that
family should be a critical decision maker and an active member of the health care team (Jabre et
al., 2014; Powers, & Candela, 2017; Jensen, & Kosowan, 2011; Lowry, 2012). Critical events,
FAMILY PRESENCE DURING RESUSCITATION 6
like resuscitation, can be challenging for all parties involved but it is important to evaluate and
consider the benefits of FPDR to the family when considering resuscitating a patient.
Staff perceptions and perceived barriers. Staff perceptions and perceived barriers
were other areas addressed in the literature that provided insight as to why FPDR is not
commonly practiced. Family interfering with efforts was a commonality revealed that is
important because families may not be offered the option to be present if they interrupt the
efforts of the health care team (Jensen, & Kosowan, 2011; Goldberger et al., 2015; Goldberger et
al., 2015; Wolf, Storer, & Brim, 2012). Another commonality was health care providers feeling
uneasy with family present which may impact the effectiveness of their treatments and
interventions (Jensen, & Kosowan, 2011; Davidson et al., 2011; Wolf, Storer, & Brim, 2012).
Concern for misinterpretation of interventions resulting in legal action was a common finding
that could create significant financial cost to the hospital or physician (Jensen, & Kosowan,
2011; Lowry, 2012; Wolf, Storer, & Brim, 2012). Understanding barriers to implementation will
Discussion
Limitations. Limitations in the literature are sample size and a limited amount of
quantitative data surrounding the topic because. Opportunities to obtain relevant data may be
affected if the physician is not experienced with FPDR because family presence is ultimately the
physician's decision. With the expanded practice of FPDR, sufficient data may be available to
strengthen the driving forces behind creation and implementation of policies. Due to the sensitive
nature surrounding FPDR, quantitative data is often difficult to obtain (Leske, McAndrew, &
Brasel, 2013; Lowry, 2013; Jensen, & Kosowan, 2011). This may require nurses to develop
FAMILY PRESENCE DURING RESUSCITATION 7
additional intervention-based studies to gather data that supports the implementation of FPDR
Gaps in the literature. Gaps in the literature are evident when analyzing reliability,
validity, and trustworthiness of the study designs and results. The majority of the literature fails
to comment on measures taken to ensure reliability, validity, and trustworthiness are met. This
creates challenges and uncertainty surrounding the strength, usefulness, and generalizability of
the results and preceding recommendations. Leske, McAndrew, & Brasel (2013) addressed these
measures by indicating researchers provided a thorough description about the setting and
analysis of findings, practiced peer debriefings, utilized a systematic approach to data analysis,
and maintained an adult trial. Lowry (2012) also comments on having data analyzed and cross-
throughout the literature and focuses on addressing barriers, gaining quantitative data, and
understanding long-term benefits of FPDR (Leske, McAndrew, & Brasel, 2013; Jensen, &
Kosowan, 2011; Lowry, 2012; Wolf, Storer, & Brim, 2012; Davidson et al., 2011; Goldberger et
al., 2015). Additional research is needed to understand the acceptance of FPDR policies, staffs
Powers, & Candela, 2017) Additional educational efforts are also proposed in an attempt to
bridge the gap between acceptance of FPDR and its practice. Recommendations include:
education provided to staff surrounding policies, the practice of FPDR, and psychological effects
on family (Powers, & Candela, 2017; Lowry, 2012; Leske, McAndrew, & Brasel, 2013).
Professional organizations like ENA, AACN, and AHA have created clinical practice guidelines
FAMILY PRESENCE DURING RESUSCITATION 8
that should be used as a framework for the implementation FPDR (Leske, McAndrew, & Brasel,
Conclusion
This paper sought to critique and synthesize information from several pieces of literature
surrounding family presence during resuscitation in the critical care setting. Areas addressed
were methods, findings, areas for change, and future research. Additional research is needed to
answer the question: In the family of patients undergoing resuscitation in the critical care setting,
does being present during resuscitation compared to not being present, result in more family
members stating they were glad they were present when attempts were unsuccessful 3-months
post-resuscitation? Collaborating findings and suggestions from all sources will add to the data
Clinical Implications
This section will discuss clinical implications related to the PICOT question: In the
family of patients undergoing resuscitation in the critical care setting, does being present during
resuscitation compared to not being present, result in more family members stating they were
glad they were present when attempts were unsuccessful 3-months post-resuscitation?
Key Findings
Despite hospitals having policies surrounding FPDR, the practice is inconsistent (Jensen,
& Kosowan, 201; Wolf, Storer, & Brim, 2012). Multiple professional nursing organizations such
as the Emergency Nurses Association (ENA), American Heart Association (AHA), and
American Academy of Critical-Care Nurses (AACN) recommend the creation of a FPDR policy
and offering family members the option of being present during resuscitation (AACN, 2016;
AHA, 2010; ENA, 2012). Having a family member act as a voice for the patient and active
member of the health care team during resuscitation efforts was a commonality amongst the
research (Lowry, 2012; Davidson et al., 2011; Leske, McAndrew, & Brasel, 2013; Wolf, Storer,
& Brim, 2012). Research also showed an increased sense of closure when families were present
(Powers, & Candela, 2017; Wolf, Storer, & Brim, 2012; Jensen, & Kosowan, 2011; Jabre et al.,
2014; Davidson et al., 2011; Lowry, 2012). Families reported an increased level of satisfaction
with the care their loved one received and decreased distress when present during resuscitation
which facilitated grieving (Wolf, Storer, & Brim, 2012). Research indicates that implementation
of policies, a family facilitator, and education programs will help with implementing the practice
of FPDR (Powers, & Candela, 2017; Wolf, Storer, & Brim, 2012; Jensen, & Kosowan, 2011;
Implementation Plan
FAMILY PRESENCE DURING RESUSCITATION 10
The research evaluated to determine the implementation process was primarily level VI
according to the Hierarchy of Evidence for Interventional Studies adopted from Bernadette
Melnyk (Stillwell, et al., 2010). The proposed practice change will occur at Sharp Memorial
Policy and procedure. SMHED has a policy and procedure titled Family Presence
During Resuscitation (Appendix A) that was written in 2011 and revised in 2015 (SMMC, 2012).
This policy has as a framework for implementation but is infrequently practiced. This policy
defines the terms: family, resuscitation, family facilitator (FF), family presence, acute phase, and
transition phase in order to establish guidelines for the implementation of the practice. Family is
defined as a relative, significant other, or any person the patient has an established relationship
The family facilitator is a member of the health care team that facilitates family presence,
remains with family for the duration of their presence, answers questions, and provides support
(SMMC, 2012). During the acute phase, the time where the patient is undergoing life-saving
treatment, the FF will be a registered nurse who is familiar with the progression of resuscitation
(SMMC, 2012). During the transition phase, the time where the patient has been stabilized or
has expired, the FF can be a chaplain, social worker, or any other support person that can
advocate for and provide assistance to the family (SMMC, 2012). The policy outlines family
expectations (Appendix B) that will be reviewed with the family prior to being escorted to the
The proposed change will be as follows: When radio room notifies Charge RN that CPR
is inbound, the resuscitation team will gather in trauma/resuscitation room and a pre-brief will be
initiated. During the pre-brief, the charge nurse will delegate one bedside RN to act as the
FAMILY PRESENCE DURING RESUSCITATION 11
FF. Once family arrives in the ED lobby, they will be escorted to a private area where the charge
nurse and assigned FF will greet family. At this time, guidelines and behavior expectations will
be discussed with the family and they will be escorted to the treatment area, if indicated and
appropriate. The rest of the procedure will be followed as outlined by the policy. If nursing staff
is unavailable, the Administrative Liaison (AL) may fill the role of FF (SMMC, 2012). The FF
will accompany the family to the patient care area and remain with them until the resuscitation is
complete (SMMC, 2012). Finally, the family will be escorted to an area of the ED where they
can discuss the events and be supported. At this time, the family will be informed of what to
expect and the decisions they will make in the near future (SMMC, 2012).
Data collection and evaluation. The charts of all patients who received cardiopulmonary
retrospectively. Internal data will be accessed in order to determine the current level of
compliance with practicing FPDR. Provider education will be presented to all nursing staff
during the annual skills and competency testing and to physicians during their monthly meeting.
Once all staff has received the education, FPDR practice change will be initiated. Families
invited to be present during resuscitation and those not present will all be included to ensure both
groups are represented. All of the charts of patients who receive cardiopulmonary resuscitation
between August 2017 and December 2017 we be included. The emotional status will be
evaluated in the families that were present and will be compared to those not present during the
same time period. Methods used by Jabre et al. (2014) will be utilized to evaluate familys
emotional status. Families of all resuscitations will be contacted at the 3-month mark and
questioned by a trained psychologist to complete the complete the impact of event scale (IES),
the hospital anxiety and depression scale (HADS), the inventory of complicated grief (ICG), and
FAMILY PRESENCE DURING RESUSCITATION 12
the structured diagnosis of a major depressive episode (MINI) to determine if they fall within the
DSM-IV criteria for major depressive episode. These tools have been used internationally and
have been validated and compared to tools used for DSM criteria in the US (Jabre et al., 2014).
Families that refuse to complete the follow-up interview and/or are unreachable after five
Barriers to implementation. Family interfering with efforts was a commonality that was
revealed and is important because families are less likely to be offered the option of being
present during resuscitation if the staff feels they may interfere with care (Jensen, & Kosowan,
2011; Goldberger et al., 2015; Wolf, Storer, & Brim, 2012). Another barrier to implementation
is the concern that having family present may increase stress and anxiety among health care
providers (Jensen, & Kosowan, 2011; Wolf, Storer, & Brim, 2012). Providing education to the
health care team on the benefits of FPDR for the family is a way to overcome these barriers
(Davidson et al., 2011; Jensen, & Kosowan, 2011). Implementing a policy surrounding FPDR
will create structure and a framework for implementing the practice (Leske, McAndrew, &
Brasel, 2013; Jensen, & Kosowan, 2011; Lowry, 2012; Wolf, Storer, & Brim, 2012; Davidson et
Though grief and bereavement are universal, some cultural differences and preferences
may be factors in families and health care providers practicing FPDR (Jabre et al., 2014; Wolf,
Storer, & Brim, 2012). Studies conducted in Turkey, Germany, and Hong Kong revealed that
there was a guarded attitude toward FPDR among health care providers despite family members
being in favor of the practice (Wolf, Storer, & Brim, 2012). Nurses indicate that providing
emotional, psycho-social, and spiritual support to patients and family members is an important
FAMILY PRESENCE DURING RESUSCITATION 13
aspect of their job and most feel comfortable in doing so (Jensen, & Kosowan, 2011). A
benefits to others (Beauchamp & Childress, 2013). FPDR has the ability to fulfill the principle of
beneficence by reassuring family that everything is being done and to facilitate closure if
Powers, & Candela, 2017). Educational efforts are also proposed in an attempt to bridge the gap
between acceptance of FPDR and its practice. Recommendations include: education provided to
staff surrounding policies, the practice of FPDR, and psychological effects on family (Powers, &
Candela, 2017; Lowry, 2012; Leske, McAndrew, & Brasel, 2013). Due to the sensitive nature
surrounding FPDR, quantitative data is often difficult to obtain (Leske, McAndrew, & Brasel,
Conclusion
Framework has been created to aid in the implementation and consistent FPDR practice.
Minimal additional cost will be endured by the ED to create a team to include a family
facilitator, a psychologist to conduct follow-up interviews, a data collector and analyzers, and
suggestions from all sources will add to the data encouraging development and wide-spread
implementation of FPDR policies (Powers, & Candela, 2017; Wolf, Storer, & Brim, 2012;
References
American Association of Critical-Care Nurses (2016). Family presence during resuscitation and
website/clincial-resources/practice-alerts/fampresresuscpafeb2016ccnpages.pdf
American Heart Association (2010). Family presence during resuscitation. Retrieved from:
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-12-
pediatric-advanced-life-support/intra-arrest-care-updates/family-presence-during-
resuscitation/
Retrieved from:
http://www.zoll.com/CodeCommunicationsNewsletter/CCNL05_08/CodeCommunicatio
ns05_08.pd
Beauchamp, T., & Childress, J. F. (2013). Principles of biomedical ethics. Oxford University
Press, USA.
Davidson, J., Buenavista, R., Hobbs, K., & Kracht, K. (2011). Identifying factors inhibiting or
Emergency Nurses Association (2012). Emergency nursing resource: Family presence during
http://ena.org/IENR/ENR/Documents/FamilyPresneceENR.pdf
Goldberger, Z., Nallamothu, B., Nichol, G., Chan, P., Curtis, J., & Cooke, C. (2015). Policies
allowing family presence during resuscitation and patterns of care during in-hospital
Jabre, P., Tazarourte, K., Azoulay, E., Borron, S. W., Belpomme, V., Jacob, L., & ... Adnet, F.
doi:10.1007/s00134-014-3337-1
Jensen, L., & Kosowan, S. (2011). Family presence during cardiopulmonary resuscitation:
Leske, J. S., McAndrew, N. S., & Brasel, K. J. (2013). Experiences of families when present
Lowry, E. (2012). It's Just What We Do: A qualitative study of emergency nurses working
329-334. doi:10.1016/j.jen.2010.12.016
Powers, K. A., & Candela, L. (2017). Nursing practices and policies related to family presence
Sharp Metropolitan Medical Campus. 2012. Family presence during resuscitation, 35091.99.
Wolf, L., Storer, A., & Brim, C., (2012). Clinical practice guideline: Family presence during
Appendix A
PAGE 16 OF 4 REFERENCE
TITLE:
[ ] POLICY
[ ] PROCEDURE
FAMILY PRESENCE DURING RESUSCITATION
[X] POLICY & PROCEDURE
[ ] PLAN
SUBJECT:
Patient Care
KEYWORD(S): CPR
.[ ] All Sharp HealthCare AFFECTED DEPARTMENTS: ACCREDITATION:
I. PURPOSE:
The purpose of this document is to outline and explain the process of Family Presence During Resuscitation.
This process will be followed when appropriate based on staffing and patient circumstances.
II. DEFINITIONS:
A. Family: A relative or significant other with whom the patient shares an established relationship.
C. Family Facilitator (FF): A member of the healthcare team who facilitates family presence while offering
support and supervision of the family before, during, and after resuscitation. The FF shall assess the
family for appropriateness prior to their invitation into the patient care area and during resuscitation,
answer questions during resuscitation, and offer support for the family. The FF is a vital role and should
be this team members only responsibility during resuscitation. During the acute phase (see below) the
FF will be an experienced emergency department registered nurse (RN) so that questions about the
patients medical care can be answered. Family members will not be present without escort by the FF.
D. Family Presence: The presence of one or more family members in the patient care area.
E. Acute Phase: The phase of resuscitation in which the patient is undergoing life-saving treatment.
F. Transition Phase: The phase of resuscitation in which the patient has been stabilized or has expired.
During this phase the FF can be a chaplain or other support staff to advocate and provide assistance for
the family.
FAMILY PRESENCE DURING RESUSCITATION 17
III. TEXT:
Family Presence During Resuscitation has been shown to allow for the following:
A. Enhanced family understanding of patient condition
B. Opportunities for family members to support the patient or obtain closure in case of death
C. Family appreciation of resuscitation efforts
D. Staff attention to dignity of the patient
E. Enhanced professional behavior among staff members
F. A more holistic approach to care, utilizing medical, nursing, auxiliary, and chaplain staff to ensure
maximum quality in patient care
The FF shall prepare the family for what they are about to see,
where they should sit in the room, and how they should behave.
The FF may review the Family Expectations During
Resuscitation agreement prior to entering the patient care area
(refer to Attachment A herein).
Transition phase:
Once acute measures have been discontinued (expiration or return
of stability), a FF remains to aid the family in the transition period
until the patient is moved to the ICU or the expired patient is
moved to its destination. During this time, the role of FF may be
delegated to the hospital staff chaplain.
V. REFERENCES:
Basol, R., Ohman, K., Simones, J., & Skillings, K. (2009). Using research to determine
support for a policy on family presence during resuscitation. Dimensions of Critical Care
Nursing, 28(5), 237-247.
Meyers, T., Eichhorn, D., Guzzetta, C., Clark, A., & Taliaferro, E. (2004). Family
presence during invasive procedures and resuscitation: the experience of family
members, nurses, and physicians. Topics in Emergency Medicine, 26(1), 61-73.
Mian, P., Warchal, S., Whitney, S., Fitzmaurice, J., & Tancredi, D. (2007). Impact of a
multifaceted intervention on nurses' and physicians' attitudes and behaviors
toward family presence during resuscitation. Critical Care Nurse, 27(1), 52-61.
Oman, K., & Duran, C. (2010). Health care providers' evaluations of family presence
during resuscitation. Journal of Emergency Nursing, 36(6), 524-533.
Appendix B
Someone will stay with you the entire time you are in
the treatment area.