1. FAMILY PRESENCE DURING RESUSCITATION IRB 014-138 Pamela Green, APRN, MSN, FNP-C, DNP-S Baylor Medical Center at Carrollton

2. Family Presence during Resuscitation Purpose Statement: To determine if awareness of the benefits of and guidelines for family presence in the resuscitation room has a positive impact on physician opinion. Although CPR forecasts likely poor outcome, less than five percent of acute care facilities across the United States have policies and protocols to allow for family presence in the resuscitation room. (MacLean et al., 2003)

3. Healthcare Provider Perception Family presence would interfere with resuscitation efforts. Resuscitation event would be too stressful for family members. Provider stress and performance anxiety when family present. Provider fear of increased litigation.

4. Guidelines and Position Statements Emergency Nurses Association (ENA) guidelines recommend family members be included during invasive procedures and resuscitation (Emergency Nurses Association [ENA], 2012). The American Heart Association recommended family members be offered the opportunity to be present during resuscitation. (American Heart Association [AHA], 2000) American Association of Critical Care Nurses practice alert in 2010 stated all family members should be given the option of family presence during resuscitation (American Association of Critical Care Nurses [AACN], 2010)

5. Evidence: Delay in Care No significance difference identified in the number of shocks delivered with family present and appropriate protocol in place versus no family presence No significant difference identified in the minutes to first defibrillation shock with family present and appropriate protocol in place versus no family presence ( Fernandez, R., Compton, S., Jones, K. A. & Velilla, M. A. (2009). The presence of a family witness impacts physician performance during simulated medical codes. Critical Care Medicine, 37:6, 1956-1960)

6. Evidence: Family Stress No studies indicated decrease in family member satisfaction or increase in stress when present during resuscitation. Many expressed they not only wanted to be present, but felt it was their right. (Tinsley et al., 2008; Mortelmans et al., 2009; Piira, Sugiura, Champion, Donnelly, & Cole, 2005; Dingeman, Mitchell, Meyer, & Curley, 2007; Dudley et al., 2009; McGahey-Oakland, Lieder, Young, & Jefferson, 2007) Family presence creates transparency. Family members who had witnessed a resuscitation event felt everything had been attempted to save their loved one. (McGahey-Oakland et al., 2007; Tinsley et al., 2008; Emergency Nurses Association [ENA], 2007)

7. Evidence: Provider Stress Providers in the emergency and critical care areas revealed providers were 82% in favor of family presence during resuscitation. (Demir, 2008) Healthcare providers identify family presence allows the family the opportunity to say goodbye when resuscitation efforts are unsuccessful, promotes family acceptance of their loved one’s death, and facilitates grieving. (Dingeman et al., 2007; Demir, 2008; McClement, Fallis, & Pereira, 2009; Walker, 2008).

8. Evidence: Litigation No evidence to support providers fear of increased litigation when family members are present in the resuscitation room. (Walker, 2008; Madden & Condon, 2007; McClement et al., 2009; Dingeman et al., 2007; Demir, 2008; Fernandez et al., 2009)

9. Consumer Opinion Family members perceive the experience to have a positive effect on grieving and adjusting to loss. (Doyle et al., 1987; Meyers et al., 2000; Meyers, Eichhorn, & Guzzetta, 1998) Of those survivors, all were content with family presence during resuscitation. (Robinson, Mackenzie-Ross, Hewson, Egleston, & Prevost, 1998). Hospitalized patients with life threatening illness indicated they would prefer family to be present during CPR. (Mortelmans et al., 2009).

10. Next Steps Baylor Health Care System, like most other acute care facilities, does not have policies in place to support family presence during resuscitation. (MacLean et al., 2003) Three studies indicated hospital policy surrounding family presence would have a positive impact on provider attitude regarding family presence during resuscitation. (Basol et al., 2009; Madden & Condon, 2007; Howlett, Alexander, & Tsuchiya, 2010) ENA recommends that institutional policy should be written to support the recommendation of family presence during resuscitation. (Emergency Nurses Association [ENA], 2012)

11. References Agency for Healthcare Research and Quality. (2001). Translating research into practice (TRIP) - II. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/translating/tripfac/trip2fac.html http://archive.ahrq.gov/research/findings/factsheets/translating/tripfac/trip2fac.html American Association of Critical Care Nurses. (2010). American Association of Critical Care Nurses Practice Alert: Family presence during resuscitation and invasive procedures. Retrieved from http://www.aacn.org/wd/practice/docs/practicealerts/family%20presence%2004-2010%20final.pdf http://www.aacn.org/wd/practice/docs/practicealerts/family%20presence%2004-2010%20final.pdf American Heart Association. (2000). Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care, part 2: ethical aspects of CPR and ECC. Circulation, 102, 112-121. Retrieved from http://circ.ahajournals.org/content/102/suppl_1/I-12.full http://circ.ahajournals.org/content/102/suppl_1/I-12.full Basol, R., Ohman, K., Simones, J., & Skillings, K. (2009). Using research to determine support for a policy on family presence during resuscitation. Dimensions in Critical Care Nursing, 28, 237-247. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19700973 Chelluri, L. P. (2008, April-June). Quality and performance improvement in critical care. Indian Journal of Critical Care, 12, 67- 73. Retrieved from http://www.bioline.org.br/pdf?cm08016http://www.bioline.org.br/pdf?cm08016 Critchell, C. D., & Marik, P. E. (2007). Should family members be present during cardiopulmonary resuscitation? A review of the literature. American Journal of Hospice and Palliative Medicine, 24, 311-317. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17895495 Demir, F. (2008, August). Presence of patients’ families during cardiopulmonary resuscitation: physicians’ and nurses’ opinions. Journal of Advanced Nursing, 63, 409-416. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18727768 Dingeman, R. S., Mitchell, E. A., Meyer, E. C., & Curley, M. A. (2007, October). Parent presence during complex invasive procedures and cardiopulmonary resuscitation: A systematic review of literature. Pediatrics, 120, 842-854. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17908772

12. References Doyle, C. J., Post, H., Burney, R. E., Maino, J., Keefe, M., & Rhee, K. J. (1987, February 3). Family participation during resuscitation: an option. Annals of Emergency Medicine, 16:6, 673-675. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3578974 Dudley, N. C., Hansen, K. W., Furnival, R. A., Donaldson, A. E., Van Wagenen, K. L., & Scaife, E. R. (2009). The effect of family presence on the efficiency of pediatric trauma resuscitations. Annals of Emergency Medicine, 53, 777-784. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19013688 Emergency Nurses Association. (2007). Presenting the Option for Family Presence. Des Plains, IL: Emergency Nurse Association. Retrieved from http://rn-aim.org/docs/MuldoonChapter%206%20slides%20ppt%20%20nsg%20retr.pdf Emergency Nurses Association. (2012). Clinical Practice Guideline: Family presence during invasive procedures and resuscitation. Retrieved from https://www.ena.org/practice-research/research/CPG/Documents/FamilyPresenceCPG.pdfhttps://www.ena.org/practice-research/research/CPG/Documents/FamilyPresenceCPG.pdf Feagan, L. M., & Fisher, N. J. (2011, May). The impact of education on provider attitudes toward family witnessed resuscitation. Journal of Emergency Nursing, 37, 231-239. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21550455 Fernandez, R., Compton, S., Jones, K. A., & Vilella, M. A. (2009). The presence of a family witness impacts physician performance during simulated medical codes. Critical Care Medicine, 37, 1956-1960. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19384215

13. References Howlett, M. S., Alexander, G. A., & Tsuchiya, B. (2010). Health care providers’ attitudes regarding family presence during resuscitation of adults: An integrated review of the Literature. Clinical Nurse Specialist, 24, 161-174. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20404625 Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7, 149-158. Retrieved from http://qualitysafety.bmj.com/content/7/3/149.full.pdf+htmlhttp://qualitysafety.bmj.com/content/7/3/149.full.pdf+html Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass. MacLean, S. L., Guzzetta, C. E., White, C., Fontaine, D., Eichhorn, D. J., Meyers, T. A., & Desy, P. (2003, June). Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. Journal of Emergency Nursing, 29:3, 208-221. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12751400 Madden, E., & Condon, C. (2007). Emergency nurses’ current practices and understanding of family presence during CPR. Journal of Emergency Nursing, 33, 433-440. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17884472 McClement, S. E., Fallis, W. M., & Pereira, A. (2009). Family presence during resuscitation: Canadian critical care nurses perspectives. Journal of Nursing Scholarship, 41, 233-240. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19723271 McGahey-Oakland, P. R., Lieder, H. S., Young, A., & Jefferson, L. S. (2007). Family experiences during resuscitation at a children’s hospital emergency department. Journal of Pediatric Health Care, 21, 217-225. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17606158

14. References Meyers, T. A., Eichhorn, D. J., & Guzzetta, C. E. (1998, October). Do families want to be present during CPR? A retrospective survey. Journal of Emergency Nursing, 24:5, 400-405. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9814254 Meyers, T. A., Eichhorn, D. J., Guzzetta, C. E., Clark, A. P., Taliaferro, E., Klein, J. D., & Calvin, A. (2000). Family presence during invasive procedures and resuscitation. American Journal of Nursing, 100:2, 32-42. Retrieved from http://journals.lww.com/ajnonline/Abstract/2000/02000/Family_Presence_During_Invasive_Procedures_and.43.aspx Mortelmans, L. J., VanBroeckhoven, V., Van Boxstael, S., De Cauwer, H. G., Verfaillie, L., Van Hellemond, P. L.,... Cas, W. M. (2009, August). Patients’ and relatives’ view on witnessed resuscitation in the emergency department: A prospective study. European Journal of Emergency Medicine, 17, 203-207. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19734795 Peberdy, M. A., Kaye, W., Ornato, J. P., Larkin, G. L., Nadkami, V., & Mancini, M. E. (2003). Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation, 58 (3), 297-308. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12969608 Piira, T., Sugiura, T., Champion, G. D., Donnelly, N., & Cole, A. S. (2005). The role of parental presence in the context of children’s medical procedures: A systematic review. Child: Care, Health & Development, 31, 233-243. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15715702 Robinson, S. M., Mackenzie-Ross, S., Hewson, G. L., Egleston, C. V., & Prevost, A. T. (1998). Psychological effects of witnessed resuscitation on bereaved relatives. Lancet, 352, 614-619. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9746023 Rycroft-Malone, J. (2004). The PARIHS framework - A framework for guiding the implementation of evidence based practice. Journal of Nursing Care Quality, 19, 297-304. Retrieved from http://journals.lww.com/jncqjournal/Citation/2004/10000/The_PARIHS_Framework_A_Framework_for_Guiding_the.2.aspx