Family Presence During Resuscitation in the Emergency Department

Does One Size Fit All?

What is it?

This?

What is it?

Or This?

Definitions Family presence during resuscitation (FDPR) is defined as ‘the presence of family in the patient care area, in a location that affords visual or physical contact with the patient during…resuscitation events’. Source: Clark AP, Aldridge MD, Guzzetta CE, et al. Family presence during cardiopulmonary resuscitation. Crit Care Nurse Clin N Am. 2005; 17:23-32.

Definitions Family presence during resuscitation should be viewed as being part of a spectrum of family participation during the delivery of patient centered care in the ED.

Patient centered care : "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." Institute on Medicine. "Crossing the Quality Chasm: A New Health System for the 21st Century". 26 November 2012.

Spectrum Minimally Invasive - Throat Swab Medium - Urinary catheter insertion Highly Invasive – CPR, Cardiac massage, etc.

Roughly correlate to risk, prognosis, emotional response, AND controversy.

Definitions Family : A person or group with a continuing, established legal, genetic, and/or emotional relationship with the patient (relative, caregiver, significant other, etc.).

Source: Children's Hospital of Philadelphia Revised EMERGENCY DEPARTMENT GUIDELINES

Definitions Resuscitation : A sequence of events, including invasive procedures, which are initiated to sustain life and/or prevent further deterioration of the patient’s condition.

Invasive Procedure : Any intervention that involves manipulation of the body and/or penetration of the body’s natural barriers to the external environment. This even includes “minor” procedures such as IV placement, urinary catheterization, suturing, fracture reduction, lumbar punctures, etc.

Source: Children's Hospital of Philadelphia Revised EMERGENCY DEPARTMENT GUIDELINES

Proponents for Family Presence American Heart Association American Academy of Pediatrics Ambulatory Pediatric Association Emergency Nurses Association Emergency Medical Services for Children Published guidelines/courses EMSC FCC Guidelines (2000) AHA CPR Guidelines (2000, 2005) Pediatric Advanced Life Support (2002) Advanced Pediatric Life Support (2004) Emergency Nursing Pediatric Course (2004) Trauma Nursing Core Course (2002) Emergency Medical Services for Children. Guidelines for providing family-centered care. 2000.

Proponents for Family Presence To enhance EOL care in the Emergency Department, the American College of Emergency Physicians believes that emergency physicians should “Encourage the presence of family and friends at the patient’s bedside near the end of life, if desired by the patient. (1) Family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members and should be based on written institution policy developed in cooperation with departments such as, but not limited to social services, pastoral care, risk management, nursing and medical staff. (2) Source: (1) ACEP Board of Directors, "Ethical Issues at the End of Life" (2)Position Statement - Emergency Nurses Association

Supporters Say Helped for family to see that everything had been done Positive experience for the family Enhanced communication - provide history for nonverbal patients Facilitated education Facilitated grief process Source: 2012 ENA Emergency Nursing Resources Development Committee

Studies Show 94 to 100 percent of families [who asked to be] involved in family presence events would do so again.

A majority of adult patients indicated that would be their preference despite believing it may be traumatic for the family.

A majority of family members believed their presence during resuscitation was comforting to their child.

Source: 2012 ENA Emergency Nursing Resources Development Committee

Non-Supporters Say possibility of families interfering with the process and disrupting care increased performance anxiety and stress on the part of clinicians interference with the process of teaching may be too traumatic for families misinterpretation of procedure increased risk of litigation

Challenges to Consensus Evidence is based on surveys and expert opinion NOT controlled studies Objections are based on anecdotal and theoretical concerns Controlled studies cannot be blinded and are either unethical or irrelevant (use mannequins, simulations, family surrogates, etc.).

Even the surveys have selection or cultural bias.

Family Presence During Invasive Procedures and Resuscitation

Literature base consists primarily of surveys of provider beliefs & practices 60 to 80% of families believe they want to be present during ED care Providers are somewhat less supportive RNs generally more supportive than Physicians Senior Physicians more supportive than trainees Support decreases with increasing acuity and/or intensity of the procedure Source: Eppich WJ, Arnold LD. Family member presence in the pediatric emergency department. Current Opinion in Pediatrics 2003; 15:294-8.

Do These Factors Sound Familiar?

ACEP: Factors Placing Providers and Patients at Risk in the ED

Overcrowding Complexity of emergency patient and family needs Shortage of healthcare workers Uncontrollable nature of workflow Declining health status of patient populations Language barriers Limited access to primary and specialty care providers Lack of established relationships between ED staff and patients Source: American College of Emergency Physicians. Patient safety in the emergency department environment report, 2001. Available at: http://www.acep.org.

Policy for Family Presence?

Who will be the family advocate during resuscitation efforts How many family members (and which ones) can be present in the room at one time When family will be allowed into the resuscitation room What the family's responsibilities will be Where family can be in the room Under what circumstances to make exceptions Who will write the policy

Family Facilitator • • • • • The option of family presence should NOT be offered without someone serving in this role. Family Facilitator (AKA “Family Support Person”) is trained to: Provide support Prepare the family regarding what to expect Provide rationale for any procedures Remain with the family at all times as there can be highly emotional moments

Family Facilitator Family Facilitator has NO direct patient care responsibility, and is assigned exclusively to assist the family.

What Not To Do

Things to Consider Size of the ER and number of staff Physician experience and comfort level (beware Emperor's New Clothes Syndrome) Cultural differences – likelihood of interference or hysteria “Cell Phone Phenomenon” - ANY level of interaction with family WILL take cognition Team communication must NOT be impaired

Things to Consider Moral hazard - that we will tend to create policies that emphasize “positive outcomes” in terms of survivor satisfaction instead of patient outcome Blanket policies which automatically exclude or include family members from being present during resuscitation or invasive procedures will inevitably cause harm Knowledge/experience/training of the relative

Things to Consider Patient preference and confidentiality Emotional connection and actual relationship to the patient Emotional reaction of relative in dynamic situation Written policies will either recognize the physician's role as “captain of the ship” or run the risk of unintended consequences

Main Points The option of family member presence should be encouraged for all aspects of emergency care.

Family presence should never be forced on a family or the emergency staff.

Relatives who remain with loved ones who are in critical condition often express appreciation for the efforts of emergency teams.

Providing the best care for patients is the primary goal of emergency physicians and nurses.

Source: American College of Emergency Physicians Policy Statement. “Patient- and Family-Centered Care and the Role of the Emergency Physician Providing Care to a Child in the Emergency Department.”2012.

Main Points Any written policy should be tailored to a hospital's specific circumstance ED physicians should not be forced to practice outside of their comfort zone simply to satisfy the terms of an FPDR policy or staff expectations No FPDR policy can or should replace a physician who is using clinical judgment, common sense, and the “golden rule”

Questions and Discussion