CASAMBROS; CASTRENCE; CHAVEZ; CIPRIANO 4DCN AUGUST 31, 2011 EFFECTS OF FAMILY PRESENCE DURING RESUSCITATION AND INVASIVE

PROCEDURES IN A PEDIATRIC EMERGENCY DEPARTMENT INTRODUCTION Traditionally, when a patient arrests in a hospital the family is guided away from their loved one into a waiting room while life-saving measures are initiated. As a nurse is able to break away from the resuscitation, she updates the family on the patient s status. But the scene is changing as families exercise their right to be present during resuscitation in the same way they once did in the delivery

room. Allowing family members to be present at the bedside during cardiopulmonary resuscitation (CPR) and invasive procedures is a contentious issue and has stimulated widespread debate. However, the movement to allow family presence (FP) has steadily evolved because of support from professional organizations, attention from the media, and research on the topic. The purpose of this study is to evaluate the effectiveness of family presence in facilitating care. Harmful external events like serious illness can provoke stress-reactions which both the patient and the patient s family need to cope with. However, family presence can reduce such psychological distress and lower the likelihood of illness. Family presence is considered the most important form of support when coping with stressful experiences. Family support is often divided into emotional and informational support; emotional support reassures a person that he or she is a valuable individual about who people care. Informational support can help a person to understand a stressful event better and determine what resources and strategies are required in the particular situation. However, sometimes family members may fail to understand what kind of support is actually needed. Too much or too insistent family support may increase the stress experience. Those providing support may also be affected negatively by the stressful event.

BACKGROUND OF THE STUDY Increasingly, patients families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. Recent research and public opinion polls revealed that most consumers think that patients family members would want to be and should be allowed to be present while emergency procedures were performed on the patients and at the time of death. Several studies indicated the multiple benefits of this practice for patients family members: It removes doubt about what is happening to the patient and reinforces that everything possible was done; it reduces anxiety and fear; it engenders feelings of supporting and helping the patient; it sustains patient-family connectedness and bonding; it provides a sense of closure on a life shared together; it facilitates the grief process; and it engenders feelings of being helpful to healthcare staff. Nearly all families involved in such an experience reported that they would make the same choice again. Despite the fears of healthcare providers that patients families might become emotionally upset and interfere with care, researchers found no disruptions in the operations of the healthcare team, no adverse outcomes during events at which patients families were present, and no adverse psychological effects among family members who participated at the bedside.

SUMMARY To sum it all up, the study revealed in more than 100 Family Presence Cases, family members din not intervene with patient care or delay the tasks of the health care team. The results highly suggest that family presence is effective in the assistance of uninterrupted patient care. Another important role for the health care provider is to choose a family member who is stable emotionally and setting aside family members who would likely be unable to cope or adjust while at the bedside. Parents and the patient stated that it was beneficial for them, they reacted positively about family presence and majority of the respondents showed the same reactions. Parents stated that they would be at the bedside again given a similar situation. And even though not all of the family members want to witness the resuscitation or invasive procedure, but most of them wants to participate and be a part of the process. Thus, this kind of approach provides patient-family centered-care. In the study, parents described family presence as a helpful way in supporting, relaxing, soothing and talking to their child. This redefined the definition of family support as an active participation of the event.

The value of parent presence on pediatric patients has not been well studied or addressed with direct measurement of child discomfort, ease, personal preference, or sense of humanity. Although comparable data do not exist in children, reported that adult resuscitation survivors did not believe their confidentiality or dignity was compromised by family-member presence. These adult patients also expressed that their family members' presence made them feel less alone and that they were content that the family member was present. Most parents believed that their presence during invasive procedures and resuscitations helped their child or helped them. Parents agreed or strongly agreed that being able to be present provided them peace of mind, allowed them to let their child know they loved him or her, and helped them know that everything possible had been done to treat their child.

CONCLUSION & RECOMMENDATION Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended. The review revealed that the debate among health care providers regarding parent presence at the bedside during complex invasive procedures and resuscitations. Parents, on the other hand, clearly prefer to have the choice about whether they remain at their child's bedside during these events. Despite the endorsement of some associations, few pediatric institutions have drafted guidelines, conducted clinical education, or committed sufficient staff resources to fully support the practice. Additional research into the practice is needed to determine the best methods of educating and debriefing health care providers so that the practice of parent presence can benefit both the clinicians and the parents. Further study of the use, role, and cost of additional staff to support the parents would provide health care providers with a better understanding of how we can best assist parents who remain present. Last, a more thorough investigation into the perspective of children who undergo complex invasive procedures and resuscitations would help both parents and clinicians gain more insight and skill when they provide emotional and psychological support.

Because the results indicate that nearly all critical care and emergency departments have no written policies or guidelines for family presence, research is needed to explore the implications of these findings. For example, studies are needed to compare institutions with and without formal, written policies on family presence to determine differences in provider support for family presence, how often patients families are brought to the bedside, and desired outcomes of family presence such as uninterrupted care for patients and meeting the needs of patients families (satisfaction, comfort, and closure). Practitioners need to consider and researchers need to explore differences between formal and informal policies in promoting a family-centered care environment or in supporting a delivery of care that focuses on what works best for the institution. Up to this moment, we do not know if formal or informal policies provide stability to work units and promote consistent approaches in carrying out family presence practices. For example, what are the effects of informal versus formal policies on both staff and patients families? IMPLICATION OF THE NURSING PRACTICE The findings in the journal have several important implications for practice and research. Because many nurses receive requests from patients families to be present during CPR and invasive procedures and because nurses often facilitate the families presence, critical care units and emergency departments need to decide where they stand on the issue. Most units probably do not have formal policies on family presence because it is a controversial practice and historically families have always been banned from the bedside during such events. Soon, however, other professional organizations most likely will recommend family presence during CPR and invasive procedures. After we end our journal review, we would like to finish it with a quote that inspired us about family presence: Relatives must not be viewed as an added complication but as a direct extension and reflection of the patient s life. The need to say good-bye before it is too late should be regarded as an innate response to the death of a family member. Resuscitation teams seem to take for granted that they are often the last people to be in the presence of a dying person. Being present during these final moments is a privilege, not a side effect of an arrest protocol. Sharing this privilege may be the greatest comfort the medical profession can offer a grieving relative.