Throughout the noisy emergency department, nurses paused at the sound of an ambulance being dispatched to a 4-year-old drowning victim. As charge nurse, Christy knew two things—the patient would arrive in about 7 minutes with cardiopulmonary resuscitation (CPR) in progress, and this emergency would require a family nurse. She glanced quickly at Amanda, who nodded and smiled slightly. Amanda always welcomed the chance to support families in crisis.
By the time the doors of the ambulance bay flew open, Amanda’s team members were covering her patients. As crew members whisked a cyanotic child toward the trauma room, they called out to Amanda, “Grandma is in the front seat!”
In the ambulance, Amanda found an elderly woman who was tearful, uncertain, and frantic. She reached out, and Amanda steadied her. Then she stuttered through an agonizing story of pulling 4-year-old Brett from the pool and holding him until neighbors began CPR. Instinctively, Amanda knew that Brett’s grandmother would want to be by his side while the team fought to save his life.
A conversation about family presence during resuscitation was about to begin.

Offering a choice
Despite the debate about family presence, the risks and benefits aren’t clear. Families overwhelmingly want the option to be present during resuscitation, even if they decline the invitation. Some nurses and physicians express resistance or reluctance, believing that families might experience long-term psychological trauma, sue, or interfere with medical care. Other nurses and physicians believe that families find it easier to accept illness or death when they’re included in the resuscitation. Although several professional health organizations support family presence, few hospitals have policies about it. And research hasn’t defined best practices regarding family presence. With so little clarity and so much at stake, what should Amanda say to Brett’s grandmother?

IN-OR-OUT approach
From reading, attending conferences, talking with experts, and reflecting on her own practice, Amanda has developed a way to offer families a choice about being present during resuscitation. Using a few key principles, Amanda applies the acronym IN-OR-OUT to guide her words. As you read on about the IN-OR-OUT approach, keep in mind that the steps may happen quickly or even simultaneously. With practice comes flexibility in assessing and offering family presence.

I = Introductions
First, introduce yourself as a nurse. Use short sentences. Speak clearly at a moderate pace. Maintain eye contact, with your eyebrows lifted expectantly. Try to adopt a serious but
relaxed facial expression, and occasionally nod your head affirmatively. And be sure to use the patient’s name to personalize the conversation.
“I am Amanda. I am your nurse and will support you while Brett is here in our care.” Allow a moment for the family members to introduce themselves. As they do, quickly assess them for problems, such as
extreme emotional instability, combative behavior, and intoxication. Evaluate whether they pose a threat to the safety of the healthcare team.
Sometimes, family members demand to see their loved one right away. To delay while you assess the family, say, “I need to give you some information before we go into the resuscitation room.”
Family members who are loud and demonstrative, violent, or under the influence of alcohol or drugs can disrupt resuscitation efforts. You can deal with such family members by saying, “I can see that you are very upset. I would be upset, too. Let’s stay together here in this area where I can get frequent updates for you.”
If the patient is a victim of violence, you won’t always know who the perpetrator is or who might still have a weapon. In this situation, say something like, “Sometimes, we invite family members into the room during resuscitation. But my highest priority is your brother’s safety, and I know you share that concern. The police haven’t yet told us how his injuries occurred. Please sit here with me, where I can get minute-by-minute updates for you.” Later, you may offer to take family members to the hallway outside the patient’s room, where they can look in.

N = Now
What is going on right now? Offer simple, basic information: “The resuscitation team is working to save Brett’s life. He’s not breathing on his own, and we are doing CPR. Have you seen CPR?”
You can describe CPR by saying, “We are using our hands to push on Brett’s chest to circulate his blood.” You might add, “His heart is not beating. We are giving medications and putting tubes in his body.”

O = Outcome What are the possible outcomes? Don’t give false hope. Say, “We are doing everything we can to save Brett. We don’t know if he will recover. He still may die.” Use the term “die” so no one can misunderstand this possible outcome. A common question is, “If he lives, will he be a vegetable?” Acknowledge the uncertainty by saying, “We simply don’t know right now.”

R = Relationships
How are the people at the hospital related to the patient? Many families are complex, and it’s hard to know who is who. Generally speaking, if “family” members came to the hospital with the patient, they are probably “family” in some sense.
Ask, “How are you related to Brett?” If someone becomes defensive, explain your need for facts. Say something like, “I know you’re close to Brett, or you wouldn’t be here. I just want to clarify who everyone is.” You can follow up with, “Who is making healthcare decisions for Brett?” Or, “Who is his next-of-kin?” Don’t assume that someone is the custodial parent. Ask who would know about advance directives. Usually, families respond to a no-nonsense approach.
Use your communication skills to quickly develop an effective working relationship with the family. Learn family members’ names. Hold out your hands to them, palms up, elbows close to your body. If they reach out and initiate touch, then use touch throughout the experience, if culturally appropriate.

O = Option
Offer family presence as an option. Say, “I know this is a very difficult situation for you. In a few minutes, you will need to make a choice about going into the resuscitation room or staying here where I can bring you frequent updates. Either choice is a good one. Go in or stay out. You can change your mind later.”
Make sure the family members understand that you’ll escort them and stay with them throughout the experience. If appropriate, let them know that the hospital chaplain is also available.

U = Understanding
If family members do want to go in, make sure they understand the resuscitation scene. Say, “What you see and hear may be unpleasant or upsetting. There will be a lot of activity around Brett, and you may see some blood. I will be right beside you. You can ask me questions. If you want to leave, I will bring you out at any time.”
Try not to overwhelm them with details about what they will see. Give them a general sense, noting that it may be traumatic. Ask if there’s anything that the family doesn’t want to see, such as defibrillation. You can strategically position yourself to temporarily block their view or take them out of the room during the procedure.

T = Time
It’s time to go in. Let the healthcare team know who is entering the room: “Dr. Ritchey, Brett’s grandmother, Emma, is coming in now. She has been with him since the accident. Her daughter Susan is Brett’s custodial parent, and she will arrive shortly.” Or you might say, “I will be rotating Brett’s family in and out of the room. His parents are next-of-kin, and they are coming in first.”
If the family becomes disruptive, use a firm voice and direct eye contact: “Look at me. Your voice is louder than you realize, making it hard for the medical team to do their best work. Do you want to slip out of the room with me for a few moments, or do you want to stay here and lower your voice? You can tell me quietly what you are feeling.”

Being Present
Brett’s grandmother chose to be present. From the foot of his stretcher, she rubbed his feet, whispered to him, and prayed while the team worked. She asked very few questions, wiped a few tears, and leaned on Amanda. She was there when Brett’s heart started a slow sinus rhythm and he took a sudden, shallow breath. Then he took another and another. He was on his way back.
Of course, not all families in the resuscitation room witness a recovery. When the resuscitation team is ready to stop efforts, give the family a few moments’ warning. Say, “Our best efforts are not enough. Your son is not coming back to life. When we stop our efforts in a moment, he will die.” Ask if they have questions about stopping the interventions. Encourage them to touch, talk to, hug, or pray for the patient, as efforts cease. Affirm that it was valuable to have them present. Give them plenty of time with their deceased relative, even if you have to move the group to a less acute area of the hospital. Obtain contact information for follow-up in a few days. During your follow-up contact, ask about the effectiveness of family presence from their perspective.
Later in the day of Brett’s near-death experience, Amanda commented to several colleagues, “I think we do better resuscitation work with families present.” No one responded. It isn’t always easy to have families present. But Amanda believes that when nurses care for the heart and spirit of families in crisis, good things happen. Families grieve better. Nurses give better care. Physicians practice in family-centered ways. And patients, whether they recover or die, are connected to someone close to them.
Brett never remembered anything about his near-death experience. His grandmother can only recall bits and pieces. Mostly, she remembers Amanda.

Selected references
Boudreaux E, Francis J, Loyacano T. Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research. Ann Emerg Med. 2002;40:193-205.
Ellison S. Nurses’ attitudes toward family presence during resuscitative efforts and invasive procedures. J Emerg Nurs. 2003;29:515-521.
Halm M. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005;14:494-513.
Henderson DP, Knapp JF. Report of the National Consensus Conference on family presence during pediatric cardiopulmonary resuscitation and procedures. J Emerg Nurs. 2006;32(1):23-29.
McClenathan B, Torrington, K, Uyehara C. Family members’ presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.

Cheryl Riwitis, RN, BSN, CEN, EMT-B, is a Staff Nurse, Emergency Medicine and Trauma Center
at Clarian Health, Methodist Hospital in Indianapolis and an Executive Board Member of Albany EMS in Albany, Indiana. Renee Samples Twibell, RN, DNS, is an Associate Professor, School of Nursing, at Ball State University and a Nurse
Researcher at Ball Memorial Hospital in Muncie, Indiana.