“Hold CPR.” “No pulse.” “Resume CPR. Give epi 1 mg now.”
Erin, an RN, taps a key on the computer in the resuscitation room and glances at the information: Devon, 22-year-old male, motor vehicle trauma, massive blood loss, shocked three times in transport, mother and brother on the way.
She sees the patient’s family in the hallway and steps out to meet them. Returning to the resuscitation room, she notes the ominous waveform on the monitor, interrupted only by the rhythm of chest compressions.
Dr. Garber’s orders are curt. “His family is here,” Erin interjects, “I’ll bring them in.” “Not now,” Dr. Garber erupts, “Can’t you see we have to concentrate here?”
Erin returns to the family and says, “Let me update you on the seriousness of Devon’s condition.” As she comforts family members, she debates how to proceed.
Erin isn’t alone. Every day, healthcare teams wrestle with the issue of whether to allow the family to be present during resuscitation attempts.
Differences of opinion
Nurses and physicians from many clinical specialties in one Midwestern hospital responded to a survey about family presence during resuscitation. Most nurses supported family presence, especially because the family would be able to see that all efforts were made. Yet, many also expressed concern that the resuscitation team might be distracted and the family might experience additional emotional trauma.
The views of physicians varied greatly. Those who didn’t work in the emergency department were more resistant, believing family presence reduced the resuscitation team’s effectiveness and created legal liability.
Nurses and physicians were more likely to favor family presence if a healthcare provider was assigned to focus solely on the family. But nurses and physicians disagreed about who should make the decision on family presence. Physicians thought physicians should decide, and if the patient was capable of giving an opinion, the patient’s wishes should be a secondary consideration. Less than one-third of physicians thought the family should decide. More than two-thirds of nurses thought so.
Negotiating the family’s way in
As a nurse, what can you do when the family insists on being at the bedside during resuscitation but the physician says no? First, assess family members. Look for signs of substance abuse or disruptive behavior. If the family seems capable of conducting themselves appropriately but the physician refuses to let them in, think of his or her stance as temporary. Use “not yet” language to create more time for negotiating. For example, you might say to the doctor, “I’ll ask the family to wait a few moments.” Or, “The team is working hard to stabilize your mother. I’ll watch closely for the right time to bring you in.”
Clearly express the stakes, risks, and benefits to the physician, using short sentences in the “I do/I don’t” format. (See Finding the right words by clicking on the pdf button above.) State that you will manage the family in the resuscitation room and take responsibility. If negotiations fail, contact a supervisor to secure support for a possible customer service crisis. Provide frequent updates to the family, stay with them, and develop a trusting relationship.
Afterward, discuss communication and decision making regarding family presence with the physician. Listen actively and nondefensively. State a common goal; for example: “Even though we are looking at things differently, we both want what’s best for the patient and family. And I also want to work well with you, now and in the future.” Thank the physician for considering a new idea, even if only for a moment. As new opportunities arise, commit to ongoing negotiations with the physician.
What can you do to prepare for the next time you disagree with a physician about family presence? Determine your view of your responsibility to patients and families in end-of-life situations and the extent to which you are committed to family presence.
Arrange discussions among physicians and nurses about the barriers to and benefits of allowing the family in. Note that letting the family in the resuscitation room is the best practice based on research evidence, expert opinion, and recommendations from medical and nursing organizations. Also, note that healthcare providers nationwide recognize that families belong together during crises.
Respect everyone’s concerns and choose your words carefully to create a collaborative climate. If discussions don’t yield a consensus, suggest allowing families into the resuscitation room on a trial basis for 1 month. Collect data on family and staff satisfaction and outcomes, such as length of resuscitation and any legal challenges.
Enlist nurse and physician opinion leaders to help shift cultural norms toward family-centered care. Offer information about how family presence can be effective, using guidelines from professional organizations. Include role playing and scripting to build confidence. Health team members who are confident of their skills are more likely to invite families in.
Immediately after a family witnesses a resuscitation attempt, the staff should talk. Huddle in a quiet corner. Or if the situation was intense, engage a facilitator and meet off the unit. Focus on the decisions made as well as the fears, concerns, and outcomes. If the discussion is painful for some participants, agree to reconvene in 48 hours when emotions are less raw.
After Devon is resuscitated successfully, Dr. Garber and Erin have the following exchange:
Dr. Garber: “Erin, I didn’t appreciate your interrupting me during the code. It was unprofessional.”
Erin: “Dr. Garber, I want to work well with you; I think you know that. I also want to honor family requests to be together. Although we may disagree, I’d like to hear your thoughts on this matter so we can be ready next time.”
With effective communication, you can lead a healthcare team to confidently negotiate collaborative decisions when stakes are high and second chances are rare.
Patterson K, Grenny J, McMillan R, Switzler A, Covey S. Crucial Conversations: Tools for Talking When Stakes are High. New York, NY: McGraw-Hill; 2002.
Riwitis C, Twibell R. Family presence during resuscitation: the in’s and out’s. Am Nurse Today. 2006;1(2):12-15.
Twibell R, Siela D, Neal A, et al. Family presence during resuscitation: who decides? Paper presented at: 34th Annual Nursing Research Conference, Methodist Hospital, Clarian Health System; December 2008; Indianapolis, IN.
Twibell R, Siela D, Riwitis C, et al. Nurses’ perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. Am J Crit Care. 2008;17(2):101-112.
Visit www.AmericanNurseToday.com/Archives.aspx for a complete list of selected references.
Renee Twibell is an associate professor at Ball State University School of Nursing and a nurse researcher at Ball Memorial Hospital in Muncie, Indiana. Debra Siela is an assistant nursing professor at Ball State University. Cheryl Riwitis is a staff nurse in the Emergency Department of Methodist Hospital, Indianapolis, Indiana. Joe Wheatley is prospective payment services coordinator at the Physical Rehabilitation Center at Ball Memorial Hospital. Tina Riegle is a staff nurse in the Emergency Department at Community Hospital in Anderson, Indiana. Doreen Johnson is chief nursing officer at Ball Memorial Hospital. Alexis Neal is senior administrative director of women’s and children’s services at Ball Memorial Hospital. Denise Bousman is a flight nurse for PHI Air Medical in Phoenix, Arizona. Sandra Cable and Pam Caudill are nursing instructors at Ball Memorial Hospital.