Using Systematic Reviews to Guide Decision Making About Family-Witnessed Resuscitation Susan W. Salmond, EdD, RN, ANEF, FAAN, Lisa M. Paplanus, DNP, RN-C, ACNP-BC, ANP-BC, CCRN, Amita Avadhani, DNP, DCC, ACNP, ANP, CCRN Family-witnessed resuscitation (FWR) allows family members to be present while emergency cardiac life support measures are applied. This article describes the use of systematic reviews to inform best clinical policy on FWR. The authors searched Medline and CINAHL for relevant systematic reviews and retrieved four. The reviews were then tested for rigor and validity using the open source Critical Appraisal Skills Programme from the Institute of Health Science, University of Oxford. The reviews were assessed to be of acceptable quality and therefore good sources of evidence to guide practice and policy development. Two reviews examined FWR of adult patients, one examined FWR of children and adults, and one examined FWR of children. Together, the four reviews covered 83 studies that describe the perspectives of more than 15,000 health care providers; 2,000 family members; and 2,000 patients. The systematic reviews provide clear evidence that both patients and family members want the option to be present during FWR. In contrast, there is significant variability among health care providers, with those in favor ranging from 7% to 96%. This wide range is related to (worldwide) geography and to provider status (eg, Registered Nurse and Medical Doctor). Generally, patients, family, and providers agreed on the benefits of FWR. Barriers to FWR include perceptions of possible performance anxiety and family interruption of care. The authors conclude that institutional settings need to develop a rational policy on FWR, have family support personnel present during FWR, and develop training programs for students and staff on family presence. Keywords: Systematic review, family witnessed resuscitation, evidencebased practice. Ó 2014 by American Society of PeriAnesthesia Nurses
Susan W. Salmond, EdD, RN, ANEF, FAAN, is a Professor and Executive Vice Dean, Rutgers School of Nursing, Newark, NJ; Lisa M. Paplanus, DNP, RN-C, ACNP-BC, ANP-BC, CCRN, NP/ PA, is the Coordinator—Vascular/General/Bariatric Surgery, New York University Hospital, New York, NY; and Amita Avadhani, DNP, DCC, ACNP, ANP, CCRN, is an Assistant Professor, Rutgers School of Nursing, Newark, NJ.
480
Conflict of interest: None to report. Address correspondence to Susan W. Salmond, Rutgers School of Nursing, 65 Bergen Street, Suite 1141, Newark, NJ 07107; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.07.011
Journal of PeriAnesthesia Nursing, Vol 29, No 6 (December), 2014: pp 480-490
GUIDANCE ON FWR
Case Study Scenario 1 JAMES P., AGED 70 YEARS, was admitted for video-assisted thoracic surgery (VATS) for a recently diagnosed advanced adenocarcinoma of the lung. His past history is significant for severe chronic obstructive pulmonary disease (COPD) requiring home oxygen that now limits his functional abilities. He has a 40-year smoking history of one pack a day, but he has not smoked since admission to the hospital for surgery. He had an increased work of breathing from COPD exacerbation on admission; there, he was placed on high-flow oxygen and required steroids as well as antibiotics. James expressed to his nurse that he did not want to undergo this extensive surgery, which will likely require him to be on a ventilator postoperatively. His pulmonary physician and his registered nurse (RN) had a discussion with James’s wife regarding his goals of care as his underlying comorbidities could render him ventilator dependent given the additional extensive stress of surgery. His wife insisted that he undergo the surgery as this was his only chance for an extended life. On being told that her husband wished to decline the surgery, his wife said to him, ‘‘Don’t you want to do this for me? You know I love you.’’ So, James consented to the surgery. The planned VATS approach had to be converted to an open thoracotomy as the tumor could not be accessed using VATS. He was in the operating room (OR) for 8 hours for this extensive resection of his left lower lobe and partial resection of the left upper lobe of the lung. Despite the rough intraoperative course, he remained hemodynamically stable, was extubated in the postanesthesia care unit (PACU), and transferred to the surgical intensive care unit (ICU). Approximately 8 hours after admission to the ICU, he developed dyspnea and hypoxemia and his work of breathing increased progressively, requiring reintubation. Two days after being on the ventilator, James was on a very high concentration of oxygen (100%), requiring high doses of intravenous continuous sedation as he was often restless, agitated, and in pain as per the nonverbal pain assessment. One
481
evening, during a period of agitation, James tried to sit up and remove his endotracheal tube. His heart rate dropped and he went into asystole. His nurse called a Code Blue. James’s wife was very anxious: ‘‘What’s wrong.what’s wrong.is he all right?’’ What should the nurse do with James’ wife as the code team arrives and continues the resuscitative efforts? The hospital has no policy regarding family remaining during resuscitative efforts. Your choices are: A. Ask Mrs. James to leave the room and provide ongoing information on her husband’s status. B. Encourage Mrs. James to stay while resuscitative efforts continue. C. Escort Mrs. James outside of the room and offer to bring her back to witness the resuscitation after explaining to her what happened and after assessment of her emotional status. Scenario 2 Peter S. is a 79-year-old Caucasian man with a history of hypertension, COPD, and non–small-cell lung cancer for which he underwent a right lower lobe resection and pleurectomy for malignant pleural effusions. His postoperative course was unremarkable and he was discharged home 2 days after surgery. He returned to work and was compliant with his treatment. A few weeks ago, Peter experienced new, progressively worsening shortness of breath. His oncologist suspected metastasis to the left lung as well as to other distant organs; this was confirmed on computed tomography scan. Peter was scheduled for a bronchoscopic evaluation and a biopsy of his left lung lesion. He presented to the preanesthesia care unit accompanied by his eldest son Jack and his daughter Jill. Jack, who has power of attorney for his father’s care, was asked to complete the preanesthesia unit form, which included a section on the patient’s advance directive/goals of care/practitioner orders for life-sustaining treatment. Jack tells you that he does not want to complete these forms. He explains that he realizes that his dad is very sick, but their religion does not allow them to cease care for a
SALMOND, PAPLANUS, AND AVADHANI
482
living being. He warned you that the family will not entertain any such discussions. During the procedure, Mr. Peter experienced acute shortness of breath. The procedure was terminated, and he was subsequently intubated and placed on mechanical ventilation. Soon after intubation, he became hypotensive and required vasopressor support. The anesthesia provider started a dopamine infusion. You decided to update Jack and Jill on their father’s status. Shortly thereafter, Peter went into asystole and a Code Blue was called. You relay this information to Jack and Jill, and Jack asks to see his father. The hospital has no policy regarding family presence during resuscitative efforts. What should the nurse do in this situation? A. Bring Jack and Jill into the room where resuscitative efforts are underway. B. Tell them to wait in the waiting room while you check on their father. C. Assess their interest in being present and allow them to witness the resuscitation with you, the nurse, present to interpret events. Scenario 3 Darnell B. is a 2-year-old boy who has an advanced brainstem glioblastoma. He has been treated with both radiation and experimental chemotherapy, which have left him cachectic and debilitated. He completed his last treatment 3 days ago and is scheduled to see his pediatric oncologist in 1 week. He has just arrived in the emergency department (ED) with severe shortness of breath, lethargy, and deteriorating vital signs. He is accompanied by his mother who is at his bedside. He experiences a respiratory arrest 10 minutes after arrival. As soon as the code is called, your colleague wants you to ask Darnell’s mom to wait in the waiting room while James is being resuscitated. What should the nurse do as the code team arrives and continues resuscitative efforts? The hospital has no policy regarding family remaining during resuscitative efforts. Your choices are: A. Request that the mother leave so she is not in the way of resuscitative efforts. B. Have an informed team member remain with the mother and explain what is happening and answer questions.
C. Escort the mother to the waiting room and have someone provide updates of the status so that his mom remains well informed. The patients described are all in end stages of illness and have had an event necessitating cardiopulmonary resuscitation (CPR). The differences are contextual: the setting (ICU, PACU, and ED), the treatment, and the age (older adult and toddler). The issue that the nurse is faced with is the same: whether to allow the family to be present during resuscitation because there is no formal organizational policy. Family-witnessed resuscitation (FWR) allows for family members to be present during the process of basic CPR and/or advanced cardiac life support techniques. Despite guidelines promulgated by many professional health care organizations calling for FWR, there remains significant opposition by health care providers.1,2 Kissoon3 highlights that proponents and opponents ‘‘share equally passionate and entrenched views.’’p.488 How should this issue of FWR be handled? Is it reasonable to allow the decision to be based on the passions of the provider (for or against) or the passions of the family? Should there be some standardized approach used to answer questions regarding family presence to guide hospital policy? This article will describe how systematic reviews can be used to answer this clinical question and provide the necessary evidence to support policy or best practice.
Using Systematic Reviews to Answer Clinical Questions and Guide Practice Amidst this debate on whether to allow family members to be present during resuscitation where there are differing opinions, perceptions, anxieties, and attitudes from family members and providers, it is important to turn to science to answer the question and use this evidence to frame policy and practice. From an evidence-based perspective, systematic reviews are the highest level of evidence from which to guide practice and should be the first source clinicians turn to in searching for answers to clinical questions.4 A systematic review is a form of research that aims to find, evaluate, and synthesize high quality research evidence on a given question. It collapses
GUIDANCE ON FWR
483
large amounts of information that has been appraised to be of high quality and provides a reliable evidential summary of research that has been done on the question. The busy clinician can be more confident in the conclusions of this pooled data as compared with data from a single study, thereby increasing the strength and generalizability/transferability of the findings. To answer questions about the case scenarios presented, the practitioner should turn to systematic reviews on FWR. A search of two databases, Medline and CINAHL, using the terms ‘‘systematic review,’’ ‘‘family witnessed resuscitation,’’ and ‘‘family witnessed cardiac arrest’’ was done. Four relevant systematic reviews were found as indicated in Table 1. After retrieving the systematic reviews and before using the evidence to inform practice, the clinician must be assured that the review itself was rigorous and valid. The mere presence or publication of a review in a journal does not guarantee the quality of the scientific work. It is incumbent on the clinician before using any form of research to critically appraise the article to ensure it is of high quality. There are several open source systematic review critical appraisal tools available. One commonly used appraisal tool is the Critical Appraisal Skills Programme tool from the Institute of Health Science in Oxford and is available at http://www.gla. ac.uk/media/media_64047_en.pdf.5 Table 2 displays the 10 appraisal criteria that are included in this tool along with an assessment of each of the four systematic reviews on FWR. The appraiser determines whether each of the criteria were present (yes), absent (no), or whether it cannot be determined (cannot tell). As can be seen from the
appraisal, the reviews were generally of high quality. The Dingeman systematic review had limitations as it did not do an extensive search of the literature and critical appraisal was not performed on the original studies. Recognizing these limitations, the study did search two major databases and findings were congruent with the other three systematic reviews, which were assessed to be of high quality. Consequently, the results of all four systematic reviews are deemed appropriate to guide practice and will be incorporated into this article on using systematic reviews to inform practice. Table 3 provides an evidence table summarizing the four reviews. Two of the reviews examined FWR of adult patients, one looked at both FWR of children and adults, and one looked at FWR of children. Three of the reviews were quantitative and one examined qualitative studies on the phenomenon of FWR. The reviews covered the perspectives of patients, family members, and health care providers. Moreover, the results provide data from those who have participated in FWR as well as from those who have not. The samples were drawn from acute care environments, predominantly ICUs and EDs as well as from the general public and professional organization memberships. Together, the four reviews cover 83 studies that describe the perspectives of more than 15,000 health care providers; 2,000 family members; and 2,000 patients. The evidence is primarily Level III evidence (ie, drawn from cross-sectional descriptive surveys), although there is both Level I (randomized controlled trials) and Level II (matched cohort designs) evidence included as well. To present the information from the four reviews, a series
Table 1. Retrieved Systematic Reviews Dingeman RS, Mitchell EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: A systematic review of the literature. Pediatrics. 2007;120:842-854. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part I: Perspectives of patients and families. JBI Libr Syst Rev. 2012;10:1883-2017. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part II: Perspectives of healthcare providers. JBI Libr Syst Rev. 2012;10:2018-2294. Rittenmeyer L, Huffman D. How families and health care practitioners experience family presence during resuscitation and invasive procedures. JBI Libr Syst Rev. 2012;10:1785-1882.
SALMOND, PAPLANUS, AND AVADHANI
484
Table 2. Critical Appraisal of Systematic Reviews Using Critical Appraisal Skills Programme Tool Parameters
Paplanus Paplanus Rittenmeyer Dingeman et al8 et al7 (Part I) et al10 (Part II) and Huffman9
Did the review address a clear question? Did the authors look for the right type of articles? Do you think the important, relevant articles were included? Did the review authors do enough to assess the quality of the studies? If the results of the reviews have been combined, was it reasonable to do so? What are the overall results of the review? How precise are the results? Can the results be applied to the local population? Were all important outcomes considered? Are the benefits worth the harm and the costs?
Y Y Y
Y Y Y
Y Y Y
Y Y N
Y
Y
Y
N
Y
Y
Y
Y
Y NA Y Y Y
Y NA Y Y Y
Y NA Y Y Y
Y NA Y Y Y
Source: Critical Appraisal Skills Programme (CASP). 2014. CASP Checklists (http://media.wix.com/ugd/dded87_ ebad01cd736c4b868abe4b10e7c2ef23.pdf) Oxford. Used under Creative Common License (http://www.caspuk.net/#!creative-commons/cd2g).
of questions will be answered using the evidence from the systematic reviews.
in favor of FWR as opposed to the public support of 50.6%.
How Is ‘‘Family’’ Defined in the Context of FWR?
Data from Dingeman et al8 are even more compelling. All studies included in the review of Dingeman et al8 found that the parents want to be able to choose to remain at their child’s side during resuscitation. Most parents would want to be present during CPR, and 86% believed that it was their right to be present. Both Dingeman et al8 and Paplanus et al7 (Part I) reported on those who had actually witnessed resuscitation, and 94% from both reviews would opt to be present again. Rittenmeyer and Huffman9 concluded that there was ‘‘conditional acceptance’’ explaining that family members generally accept the practice of family presence during resuscitation, but that some express ambivalence.p.1829 Dingeman et al8 found that parents do not want clinicians making the decision for them as to whether they can remain present at their child’s bedside.
The FWR is the presence of a family member in a patient care area where the family member(s) have visual and/or physical contact with the patient during a resuscitation event.6 Family was defined similarly in three of the systematic reviews to include ‘‘direct family members or significant others identified as family;’’ and in the parental presence review, parent was defined as either the biological parent or legal guardian. Do Patients and Family Members Want the Option to be Present During Resuscitation? The evidence is clear from the systematic reviews that both patients and family members want the option to be present during FWR. Paplanus et al7 (Part I) concluded that ‘‘a substantial percentage of patients are in favor of FWR and believe it is their right. Moreover, family had even stronger feelings of wanting to be present.’’p.1908 Paplanus et al7 separated out those studies that looked specifically at perceptions surrounding individuals being cared for in a health care facility compared with those perceptions from the general public. Family members of hospitalized patients reported 76.4%
Do Health Care Providers Want to Embed the Practice of FWR? There is significant variability among health care providers regarding FWR. In Paplanus, Part II, findings from 22 of the 28 studies indicated percentages of favor or disfavor for FWR.10 These percentages ranged from 7% to 96% in favor. Rittenmeyer and Huffman9 concluded that there
Paplanus et al7 (Part I)
Dingeman et al8
Review
Four primary research questions: 1. What is the current practice of parent presence during invasive pediatric procedures and resuscitation 2. What behaviors do parents demon strate at the bedside during their child’s invasive procedure or resuscitation 3. What are the benefits and risks to children, parents, and clinicians of parent presence? 4. Is there evidence to support interventions to facilitate parent presence during invasive pediatric procedures and resuscitations? To examine the evidence on FWR in adults from the perspective of patients and family members.
Purpose
Quantitative systematic review of 15 studies including RCTs (2), prospective cohort studies (1), and survey evaluation (12).
Quantitative systematic review included 13 studies addressing family-witnessed resuscitation (FWR). Study type included RCTs (1), prospective cohort studies (3), and survey evaluation (9) 13 Studies examined clinician’s perspectives and 5 examined parental perspectives. Limited database search (2 databases) No critical appraisal. Data extraction tool not described
Methodology
Studies involved adult patients (7) and their relatives (10)* Of the 7 patient studies, 1 was of patients who had a resuscitative event (match-control
Parents (5 studies) and clinicians (10 studies). For clinicians was not a requirement to have participated in witnessed invasive procedures or resuscitation. Drawn from settings of ER, PICU, and organizational meetings
Participants
Table 3. Evidence Table
Meta-analysis was not possible owing to heterogeneity; narrative analysis used.
Narrative synthesis shaped around 4 research questions
Analysis
(Continued )
There exists strong support/preference for FWR among patients and families across the 5 countries in the included studies with
Parents prefer to have a choice about whether they remain at their child’s side during resuscitation. There remains apprehension and controversy among clinicians regarding their presence.
Conclusion
GUIDANCE ON FWR 485
Paplanus et al10 (Part II)
Review
To examine the evidence on FWR of adult patients from the perspective of health care providers
Purpose study). The remaining 6 captured patients’ perceptions of patients with acute illness via survey design. Of the 10 family member studies, 4 captured family members who had actual experience with FWR and the remaining 6 captured perceptions of family members. All family studies were crosssectional survey designs. Sites included EDs, ICUs, and acute care units. Studies involved health care practitioners, predominantly RNs and MDs. Of the 28 studies, 5 studies were of actual witness experiences and 23 studies were perceptions of FWR Sites included EDs, ICUs, and general acute care hospital units as well as data collected from
9 Databases searched along with gray literature. 38 retrieved articles assessed for methodological quality independently by 2 reviewers. About 23 studies excluded based on appraisal Findings were extracted using researcherdeveloped de novo tools
Quantitative systematic review of 28 studies including RCTs, prospective cohort studies, and survey evaluation research. A total of 8 databases were searched along with gray literature Retrieved articles assessed for methodological quality independently by 2 reviewers.
Participants
Methodology
Table 3. Continued
Meta-analysis was not possible owing to heterogeneity; narrative analysis used.
Analysis
There is mixed support for FWR among health care providers. Factors such as duration of clinical practice in nursing, the study setting, and the presence of a formal institutional policy all appear to play an important role in the perspectives of health care providers
the belief that FWR is a right. Patients/families should be given the choice for FWR.
Conclusion
486
SALMOND, PAPLANUS, AND AVADHANI
To synthesize the best available research evidence on how families and health care practitioners experience family presence during resuscitation and invasive procedures Qualitative systematic review of 25 studies—4 phenomenology, 6 mixed methods, and 15 qualitative descriptive studies 12 Databases and 14 sources of gray literature 30 articles critically appraised and 5 were excluded.
health care providers attending international and national meetings. A total of 8 countries represented in the studies including: USA, UK, Ireland, Belgium, Turkey, Canada, Australia, and Singapore. Family members and health care practitioners who experienced the phenomena of family presence during resuscitation or invasive procedures Three studies examined patient perspectives, 5 family perspectives, 5 parent perspective, and 16 provider perspectives Meta-synthesis using a meta-aggregation approach. A total of 154 findings were extracted and collapsed into 14 categories and 5 metasynthesis statements
A tension is created between the belief of most family members that being present is a right and health care practitioners who believe they should have control over the circumstances of the practice. Although health care practitioners express concern that the practice will cause the family to experience psychological trauma, the data do not suggest that this is the case. Most family members describe their presence as an opportunity to comfort and to gain closure.
FWR, family-witnessed resuscitation, RCT, randomized controlled trial, ER, emergency room, PICU, pediatric intensive care unit, ED, emergency department, ICU, intensive care unit, RN, registered nurse, MD, medical doctor. *Some studies looked at both patient and family member perceptions.
Rittenmeyer and Huffman9
Findings were extracted using researcherdeveloped de novo tool
GUIDANCE ON FWR 487
488
was conditional acceptance among providers, although some believe that family should not be allowed to be present under any circumstances. There was a geographic variation with more disfavor occurring in studies from Belgium, Germany, Singapore, and Turkey, and favor in studies from the United Kingdom, Ireland, Australia, and the United States. These differences may be attributable to cultural differences as well as the structure of health care delivery. Looking at the eight studies from the United States, RNs were more supportive of FWR than physicians, although there was great variability in RN support ranging from a low of 36% to a high of 96%. Dingeman et al8 report similar variability and cites discipline, geographical region, and hospital department as factors influencing favor or disfavor. Nurses were more in favor than physician colleagues, and those working in inpatient settings were more in favor than those in outpatient settings. Both reviews found that those practitioners who had participated in FWR had more favorable views than those who did not. Paplanus et al7 (Part I) and Rittenmeyer and Huffman9 found that practitioners want to decide about FWR. They wish to have ‘‘control over the practice and have final say about when or when not to allow it.’’p.1829 This can create a possible strain as the perceptions of family and provider may differ. Rittenmeyer and Huffman9 termed this ‘‘conditional acceptance’’ in which it was stated that ‘‘a tension is created between the belief of most family members that being present is a right and health care practitioners who believe that they should have control over the circumstances of the practice.’’p.1829 What are the Perceived Advantages and Disadvantages of FWR? Table 4 summarizes the perceived advantages and disadvantages found in these reviews. Generally, there was agreement among patients, family, and providers as to the benefits of FWR. A consistently mentioned advantage was that FWR helped the family understand both the seriousness of the situation as well as comforted them that all was done that could be done. Being present, although stressful, provided comfort and an opportunity for the family member to express love, facilitated coming
SALMOND, PAPLANUS, AND AVADHANI
to terms with a loved one’s death, and eased the grief and adjustment process. Rittenmeyer and Huffman9 found the value of FWR to be that it helped the family confront reality. Being present leads to better ‘‘understanding of the context of the situation and therefore facilitates better decisions on behalf of their family member.’’ p.1832 Despite this advantage, Rittenmeyer and Huffman9 describes a ‘‘hovering uneasiness,’’ such that practitioners express concerns regarding performance anxiety and curtailing of coping strategies used by the team. These concerns revolve around the potential for the family to interfere with care, and the negative impact that family presence could have on staff performance anxiety. Paplanus (Part I and II) and Dingeman et al8 report that in studies of actual witness, it was found that families generally do not interfere with their loved one’s care during resuscitation, and those providers participating in FWR indicated that their performance was not affected. It was noted, however, that novice practitioners may be anxious with the practice. What Specific Interventions Were Used in Implementing FWR? Although no studies tested specific interventions in a clinical trial format, most studies reporting on actual FWR used an assigned support person to be with the family member during the event. The support person was also called a chaperone, facilitator, or family coordinator. The role of this individual was to assess the appropriateness of the family member being present, invite the family member to witness, and be present to explain what was happening and provide emotional support. This intervention has been incorporated into clinical guidelines on FWR promulgated from most nursing and medical organizations. How Should the Evidence Support Clinical Decision Making? Is the Evidence Transferable to My Practice Setting? The evidence presented should guide decision making not only of the introductory scenarios but also in real-life practice. Based on the data that have been presented, there is strong evidence that patients and family members support the option to be present during resuscitation of both
GUIDANCE ON FWR
489
Table 4. Advantages and Disadvantages of Family Witnessed Resuscitation Advantages Ability to get history quickly Presence facilitates understanding of the seriousness of the condition with recognition that all that could be done was done Families comforted by presence, being able to be with the person Provides an opportunity to be with/see loved one for last time, gives an opportunity to say goodbye Gave opportunity to express their love Presence facilitates emotional and spiritual needs of family Supports families in making decisions about treatment withdrawal Facilitates coming to terms with loved ones death Eases grief and facilitates adjustment
children and adult family members. The evidence of actual witness experiences has shown that family presence is not detrimental to the plan of care and may facilitate understanding and emotional adjustment with the situation. Although most studies of actual witness were in EDs and ICUs, this evidence appears transferrable to other practice settings including PACUs. With the move toward patient- and family-centered care, it is time for the practitioners to drop paternalistic views on what is best for the family and let the family member be the decision maker as to whether they prefer to be present or not. Both academic settings and practice settings must prepare the practitioner for resuscitative experiences in the presence of a family member. What Clinical Implications Emerge From This Examination of FWR Evidence? Three main recommendations emerge for practice. First, all institutional settings need to develop an institutional policy on FWR to provide a clear decision path and minimize idiosyncratic decision making by providers. Staff from multiple disciplines should be involved, and guidelines from professional associations such as the Emergency Nurses Association can serve as a starting point for the discussion.6 Once developed, the policy needs active dissemination and discussion to assist practitioners in understanding the value of family presence.
Disadvantages Potential to interfere with care Emotionally too upsetting for family
Negative impact on staff performance (performance anxiety)—feeling judged and curtailing normal staff coping mechanisms such as joking Potential for litigation
Furthermore, the policy should be described in information about patient and family rights, so that the families are aware of the option for presence. The second recommendation is for institutions to develop family support personnel or advocates to accompany the family during FWR. These advocates may be personnel from nursing, the clergy, social service, and even from volunteer staff who have been appropriately trained. The key is that there must be advocates available on all shifts on all days of the week. The final recommendation is to develop training programs for students and staff on family presence. This would include communication, mutual respect, and performance of CPR in the presence of family. Evidence from these systematic reviews should be presented to support the need for the change and to discuss the evidence on the patient and family perspective. Frank discussions of the role changes needed to accommodate FWR need to be held. Training in communication, mutual respect and performance of CPR in the presence of family should occur.
Conclusion Applying the evidence to the case scenarios at the beginning of the article, the evidence is clear. Whether the patient is an adult or child, or whether the crisis occurs in ICU, PACU, or the
SALMOND, PAPLANUS, AND AVADHANI
490
ED, the evidence points to a common approach. The family should receive an explanation of what is happening and be assessed for their emotional state and interest in FWR. If the family member opts to remain, then a family support person/
chaperone should be present to provide information and emotional support during the witness. The evidence on FWR is clear; the responsibility for its actualization resides with informed, courageous, health care professionals.
References 1. Mortelmans LJ, VanBroeckhoven V, Van Boxstael S, et al. Patients’ and relatives’ view on witnessed resuscitation in the department: A prospective study. Eur J Emerg Med. 2010;17:203-207. 2. Wendover N. Changing staff attitudes towards familywitnessed resuscitation. Emerg Nurse. 2012;20:21-24. 3. Kissoon N. Family presence during cardiopulmonary resuscitation: Our anxiety versus their needs. Pediatr Crit Care Med. 2006;7:488-490. 4. Holly C, Salmond S, Saimbert M. Comprehensive Systematic Review for Advance Practice. New York, NY: Springer; 2011. 5. CASP, Critical Appraisal Skills Programme. Available at: http://www.casp-uk.net/#!casp-tools-checklists/c18f8. Accessed January 16, 2014. 6. Emergency Nurses Association. Position Statement: Family Presence at the Bedside During Invasive Procedures and Cardiopulmonary Resuscitation. 2005. Available at: https:// www.ena.org/SiteCollectionDocuments/Position%20Statements/ FamilyPresence.pdf. Accessed January 16, 2014.
7. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part I: Perspectives of patients and families. JBI Libr Syst Rev. 2012;10:1883-2017. 8. Dingeman RS, Mitchell EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: A systematic review of the literature. Pediatrics. 2007;120:842-854. 9. Rittenmeyer L, Huffman D. How families and health care practitioners experience family presence during resuscitation and invasive procedures. JBI Libr Syst Rev. 2012;10: 1785-1882. 10. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part II: Perspectives of healthcare providers. JBI Libr Syst Rev. 2012;10:2018-2294.
Susan W. Salmond, EdD, RN, ANEF, FAAN, is a Professor and Executive Vice Dean, Rutgers School of Nursing, Newark, NJ; Lisa M. Paplanus, DNP, RN-C, ACNP-BC, ANP-BC, CCRN, NP/ PA, is the Coordinator—Vascular/General/Bariatric Surgery, New York University Hospital, New York, NY; and Amita Avadhani, DNP, DCC, ACNP, ANP, CCRN, is an Assistant Professor, Rutgers School of Nursing, Newark, NJ.
480
Conflict of interest: None to report. Address correspondence to Susan W. Salmond, Rutgers School of Nursing, 65 Bergen Street, Suite 1141, Newark, NJ 07107; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.07.011
Journal of PeriAnesthesia Nursing, Vol 29, No 6 (December), 2014: pp 480-490
GUIDANCE ON FWR
Case Study Scenario 1 JAMES P., AGED 70 YEARS, was admitted for video-assisted thoracic surgery (VATS) for a recently diagnosed advanced adenocarcinoma of the lung. His past history is significant for severe chronic obstructive pulmonary disease (COPD) requiring home oxygen that now limits his functional abilities. He has a 40-year smoking history of one pack a day, but he has not smoked since admission to the hospital for surgery. He had an increased work of breathing from COPD exacerbation on admission; there, he was placed on high-flow oxygen and required steroids as well as antibiotics. James expressed to his nurse that he did not want to undergo this extensive surgery, which will likely require him to be on a ventilator postoperatively. His pulmonary physician and his registered nurse (RN) had a discussion with James’s wife regarding his goals of care as his underlying comorbidities could render him ventilator dependent given the additional extensive stress of surgery. His wife insisted that he undergo the surgery as this was his only chance for an extended life. On being told that her husband wished to decline the surgery, his wife said to him, ‘‘Don’t you want to do this for me? You know I love you.’’ So, James consented to the surgery. The planned VATS approach had to be converted to an open thoracotomy as the tumor could not be accessed using VATS. He was in the operating room (OR) for 8 hours for this extensive resection of his left lower lobe and partial resection of the left upper lobe of the lung. Despite the rough intraoperative course, he remained hemodynamically stable, was extubated in the postanesthesia care unit (PACU), and transferred to the surgical intensive care unit (ICU). Approximately 8 hours after admission to the ICU, he developed dyspnea and hypoxemia and his work of breathing increased progressively, requiring reintubation. Two days after being on the ventilator, James was on a very high concentration of oxygen (100%), requiring high doses of intravenous continuous sedation as he was often restless, agitated, and in pain as per the nonverbal pain assessment. One
481
evening, during a period of agitation, James tried to sit up and remove his endotracheal tube. His heart rate dropped and he went into asystole. His nurse called a Code Blue. James’s wife was very anxious: ‘‘What’s wrong.what’s wrong.is he all right?’’ What should the nurse do with James’ wife as the code team arrives and continues the resuscitative efforts? The hospital has no policy regarding family remaining during resuscitative efforts. Your choices are: A. Ask Mrs. James to leave the room and provide ongoing information on her husband’s status. B. Encourage Mrs. James to stay while resuscitative efforts continue. C. Escort Mrs. James outside of the room and offer to bring her back to witness the resuscitation after explaining to her what happened and after assessment of her emotional status. Scenario 2 Peter S. is a 79-year-old Caucasian man with a history of hypertension, COPD, and non–small-cell lung cancer for which he underwent a right lower lobe resection and pleurectomy for malignant pleural effusions. His postoperative course was unremarkable and he was discharged home 2 days after surgery. He returned to work and was compliant with his treatment. A few weeks ago, Peter experienced new, progressively worsening shortness of breath. His oncologist suspected metastasis to the left lung as well as to other distant organs; this was confirmed on computed tomography scan. Peter was scheduled for a bronchoscopic evaluation and a biopsy of his left lung lesion. He presented to the preanesthesia care unit accompanied by his eldest son Jack and his daughter Jill. Jack, who has power of attorney for his father’s care, was asked to complete the preanesthesia unit form, which included a section on the patient’s advance directive/goals of care/practitioner orders for life-sustaining treatment. Jack tells you that he does not want to complete these forms. He explains that he realizes that his dad is very sick, but their religion does not allow them to cease care for a
SALMOND, PAPLANUS, AND AVADHANI
482
living being. He warned you that the family will not entertain any such discussions. During the procedure, Mr. Peter experienced acute shortness of breath. The procedure was terminated, and he was subsequently intubated and placed on mechanical ventilation. Soon after intubation, he became hypotensive and required vasopressor support. The anesthesia provider started a dopamine infusion. You decided to update Jack and Jill on their father’s status. Shortly thereafter, Peter went into asystole and a Code Blue was called. You relay this information to Jack and Jill, and Jack asks to see his father. The hospital has no policy regarding family presence during resuscitative efforts. What should the nurse do in this situation? A. Bring Jack and Jill into the room where resuscitative efforts are underway. B. Tell them to wait in the waiting room while you check on their father. C. Assess their interest in being present and allow them to witness the resuscitation with you, the nurse, present to interpret events. Scenario 3 Darnell B. is a 2-year-old boy who has an advanced brainstem glioblastoma. He has been treated with both radiation and experimental chemotherapy, which have left him cachectic and debilitated. He completed his last treatment 3 days ago and is scheduled to see his pediatric oncologist in 1 week. He has just arrived in the emergency department (ED) with severe shortness of breath, lethargy, and deteriorating vital signs. He is accompanied by his mother who is at his bedside. He experiences a respiratory arrest 10 minutes after arrival. As soon as the code is called, your colleague wants you to ask Darnell’s mom to wait in the waiting room while James is being resuscitated. What should the nurse do as the code team arrives and continues resuscitative efforts? The hospital has no policy regarding family remaining during resuscitative efforts. Your choices are: A. Request that the mother leave so she is not in the way of resuscitative efforts. B. Have an informed team member remain with the mother and explain what is happening and answer questions.
C. Escort the mother to the waiting room and have someone provide updates of the status so that his mom remains well informed. The patients described are all in end stages of illness and have had an event necessitating cardiopulmonary resuscitation (CPR). The differences are contextual: the setting (ICU, PACU, and ED), the treatment, and the age (older adult and toddler). The issue that the nurse is faced with is the same: whether to allow the family to be present during resuscitation because there is no formal organizational policy. Family-witnessed resuscitation (FWR) allows for family members to be present during the process of basic CPR and/or advanced cardiac life support techniques. Despite guidelines promulgated by many professional health care organizations calling for FWR, there remains significant opposition by health care providers.1,2 Kissoon3 highlights that proponents and opponents ‘‘share equally passionate and entrenched views.’’p.488 How should this issue of FWR be handled? Is it reasonable to allow the decision to be based on the passions of the provider (for or against) or the passions of the family? Should there be some standardized approach used to answer questions regarding family presence to guide hospital policy? This article will describe how systematic reviews can be used to answer this clinical question and provide the necessary evidence to support policy or best practice.
Using Systematic Reviews to Answer Clinical Questions and Guide Practice Amidst this debate on whether to allow family members to be present during resuscitation where there are differing opinions, perceptions, anxieties, and attitudes from family members and providers, it is important to turn to science to answer the question and use this evidence to frame policy and practice. From an evidence-based perspective, systematic reviews are the highest level of evidence from which to guide practice and should be the first source clinicians turn to in searching for answers to clinical questions.4 A systematic review is a form of research that aims to find, evaluate, and synthesize high quality research evidence on a given question. It collapses
GUIDANCE ON FWR
483
large amounts of information that has been appraised to be of high quality and provides a reliable evidential summary of research that has been done on the question. The busy clinician can be more confident in the conclusions of this pooled data as compared with data from a single study, thereby increasing the strength and generalizability/transferability of the findings. To answer questions about the case scenarios presented, the practitioner should turn to systematic reviews on FWR. A search of two databases, Medline and CINAHL, using the terms ‘‘systematic review,’’ ‘‘family witnessed resuscitation,’’ and ‘‘family witnessed cardiac arrest’’ was done. Four relevant systematic reviews were found as indicated in Table 1. After retrieving the systematic reviews and before using the evidence to inform practice, the clinician must be assured that the review itself was rigorous and valid. The mere presence or publication of a review in a journal does not guarantee the quality of the scientific work. It is incumbent on the clinician before using any form of research to critically appraise the article to ensure it is of high quality. There are several open source systematic review critical appraisal tools available. One commonly used appraisal tool is the Critical Appraisal Skills Programme tool from the Institute of Health Science in Oxford and is available at http://www.gla. ac.uk/media/media_64047_en.pdf.5 Table 2 displays the 10 appraisal criteria that are included in this tool along with an assessment of each of the four systematic reviews on FWR. The appraiser determines whether each of the criteria were present (yes), absent (no), or whether it cannot be determined (cannot tell). As can be seen from the
appraisal, the reviews were generally of high quality. The Dingeman systematic review had limitations as it did not do an extensive search of the literature and critical appraisal was not performed on the original studies. Recognizing these limitations, the study did search two major databases and findings were congruent with the other three systematic reviews, which were assessed to be of high quality. Consequently, the results of all four systematic reviews are deemed appropriate to guide practice and will be incorporated into this article on using systematic reviews to inform practice. Table 3 provides an evidence table summarizing the four reviews. Two of the reviews examined FWR of adult patients, one looked at both FWR of children and adults, and one looked at FWR of children. Three of the reviews were quantitative and one examined qualitative studies on the phenomenon of FWR. The reviews covered the perspectives of patients, family members, and health care providers. Moreover, the results provide data from those who have participated in FWR as well as from those who have not. The samples were drawn from acute care environments, predominantly ICUs and EDs as well as from the general public and professional organization memberships. Together, the four reviews cover 83 studies that describe the perspectives of more than 15,000 health care providers; 2,000 family members; and 2,000 patients. The evidence is primarily Level III evidence (ie, drawn from cross-sectional descriptive surveys), although there is both Level I (randomized controlled trials) and Level II (matched cohort designs) evidence included as well. To present the information from the four reviews, a series
Table 1. Retrieved Systematic Reviews Dingeman RS, Mitchell EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: A systematic review of the literature. Pediatrics. 2007;120:842-854. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part I: Perspectives of patients and families. JBI Libr Syst Rev. 2012;10:1883-2017. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part II: Perspectives of healthcare providers. JBI Libr Syst Rev. 2012;10:2018-2294. Rittenmeyer L, Huffman D. How families and health care practitioners experience family presence during resuscitation and invasive procedures. JBI Libr Syst Rev. 2012;10:1785-1882.
SALMOND, PAPLANUS, AND AVADHANI
484
Table 2. Critical Appraisal of Systematic Reviews Using Critical Appraisal Skills Programme Tool Parameters
Paplanus Paplanus Rittenmeyer Dingeman et al8 et al7 (Part I) et al10 (Part II) and Huffman9
Did the review address a clear question? Did the authors look for the right type of articles? Do you think the important, relevant articles were included? Did the review authors do enough to assess the quality of the studies? If the results of the reviews have been combined, was it reasonable to do so? What are the overall results of the review? How precise are the results? Can the results be applied to the local population? Were all important outcomes considered? Are the benefits worth the harm and the costs?
Y Y Y
Y Y Y
Y Y Y
Y Y N
Y
Y
Y
N
Y
Y
Y
Y
Y NA Y Y Y
Y NA Y Y Y
Y NA Y Y Y
Y NA Y Y Y
Source: Critical Appraisal Skills Programme (CASP). 2014. CASP Checklists (http://media.wix.com/ugd/dded87_ ebad01cd736c4b868abe4b10e7c2ef23.pdf) Oxford. Used under Creative Common License (http://www.caspuk.net/#!creative-commons/cd2g).
of questions will be answered using the evidence from the systematic reviews.
in favor of FWR as opposed to the public support of 50.6%.
How Is ‘‘Family’’ Defined in the Context of FWR?
Data from Dingeman et al8 are even more compelling. All studies included in the review of Dingeman et al8 found that the parents want to be able to choose to remain at their child’s side during resuscitation. Most parents would want to be present during CPR, and 86% believed that it was their right to be present. Both Dingeman et al8 and Paplanus et al7 (Part I) reported on those who had actually witnessed resuscitation, and 94% from both reviews would opt to be present again. Rittenmeyer and Huffman9 concluded that there was ‘‘conditional acceptance’’ explaining that family members generally accept the practice of family presence during resuscitation, but that some express ambivalence.p.1829 Dingeman et al8 found that parents do not want clinicians making the decision for them as to whether they can remain present at their child’s bedside.
The FWR is the presence of a family member in a patient care area where the family member(s) have visual and/or physical contact with the patient during a resuscitation event.6 Family was defined similarly in three of the systematic reviews to include ‘‘direct family members or significant others identified as family;’’ and in the parental presence review, parent was defined as either the biological parent or legal guardian. Do Patients and Family Members Want the Option to be Present During Resuscitation? The evidence is clear from the systematic reviews that both patients and family members want the option to be present during FWR. Paplanus et al7 (Part I) concluded that ‘‘a substantial percentage of patients are in favor of FWR and believe it is their right. Moreover, family had even stronger feelings of wanting to be present.’’p.1908 Paplanus et al7 separated out those studies that looked specifically at perceptions surrounding individuals being cared for in a health care facility compared with those perceptions from the general public. Family members of hospitalized patients reported 76.4%
Do Health Care Providers Want to Embed the Practice of FWR? There is significant variability among health care providers regarding FWR. In Paplanus, Part II, findings from 22 of the 28 studies indicated percentages of favor or disfavor for FWR.10 These percentages ranged from 7% to 96% in favor. Rittenmeyer and Huffman9 concluded that there
Paplanus et al7 (Part I)
Dingeman et al8
Review
Four primary research questions: 1. What is the current practice of parent presence during invasive pediatric procedures and resuscitation 2. What behaviors do parents demon strate at the bedside during their child’s invasive procedure or resuscitation 3. What are the benefits and risks to children, parents, and clinicians of parent presence? 4. Is there evidence to support interventions to facilitate parent presence during invasive pediatric procedures and resuscitations? To examine the evidence on FWR in adults from the perspective of patients and family members.
Purpose
Quantitative systematic review of 15 studies including RCTs (2), prospective cohort studies (1), and survey evaluation (12).
Quantitative systematic review included 13 studies addressing family-witnessed resuscitation (FWR). Study type included RCTs (1), prospective cohort studies (3), and survey evaluation (9) 13 Studies examined clinician’s perspectives and 5 examined parental perspectives. Limited database search (2 databases) No critical appraisal. Data extraction tool not described
Methodology
Studies involved adult patients (7) and their relatives (10)* Of the 7 patient studies, 1 was of patients who had a resuscitative event (match-control
Parents (5 studies) and clinicians (10 studies). For clinicians was not a requirement to have participated in witnessed invasive procedures or resuscitation. Drawn from settings of ER, PICU, and organizational meetings
Participants
Table 3. Evidence Table
Meta-analysis was not possible owing to heterogeneity; narrative analysis used.
Narrative synthesis shaped around 4 research questions
Analysis
(Continued )
There exists strong support/preference for FWR among patients and families across the 5 countries in the included studies with
Parents prefer to have a choice about whether they remain at their child’s side during resuscitation. There remains apprehension and controversy among clinicians regarding their presence.
Conclusion
GUIDANCE ON FWR 485
Paplanus et al10 (Part II)
Review
To examine the evidence on FWR of adult patients from the perspective of health care providers
Purpose study). The remaining 6 captured patients’ perceptions of patients with acute illness via survey design. Of the 10 family member studies, 4 captured family members who had actual experience with FWR and the remaining 6 captured perceptions of family members. All family studies were crosssectional survey designs. Sites included EDs, ICUs, and acute care units. Studies involved health care practitioners, predominantly RNs and MDs. Of the 28 studies, 5 studies were of actual witness experiences and 23 studies were perceptions of FWR Sites included EDs, ICUs, and general acute care hospital units as well as data collected from
9 Databases searched along with gray literature. 38 retrieved articles assessed for methodological quality independently by 2 reviewers. About 23 studies excluded based on appraisal Findings were extracted using researcherdeveloped de novo tools
Quantitative systematic review of 28 studies including RCTs, prospective cohort studies, and survey evaluation research. A total of 8 databases were searched along with gray literature Retrieved articles assessed for methodological quality independently by 2 reviewers.
Participants
Methodology
Table 3. Continued
Meta-analysis was not possible owing to heterogeneity; narrative analysis used.
Analysis
There is mixed support for FWR among health care providers. Factors such as duration of clinical practice in nursing, the study setting, and the presence of a formal institutional policy all appear to play an important role in the perspectives of health care providers
the belief that FWR is a right. Patients/families should be given the choice for FWR.
Conclusion
486
SALMOND, PAPLANUS, AND AVADHANI
To synthesize the best available research evidence on how families and health care practitioners experience family presence during resuscitation and invasive procedures Qualitative systematic review of 25 studies—4 phenomenology, 6 mixed methods, and 15 qualitative descriptive studies 12 Databases and 14 sources of gray literature 30 articles critically appraised and 5 were excluded.
health care providers attending international and national meetings. A total of 8 countries represented in the studies including: USA, UK, Ireland, Belgium, Turkey, Canada, Australia, and Singapore. Family members and health care practitioners who experienced the phenomena of family presence during resuscitation or invasive procedures Three studies examined patient perspectives, 5 family perspectives, 5 parent perspective, and 16 provider perspectives Meta-synthesis using a meta-aggregation approach. A total of 154 findings were extracted and collapsed into 14 categories and 5 metasynthesis statements
A tension is created between the belief of most family members that being present is a right and health care practitioners who believe they should have control over the circumstances of the practice. Although health care practitioners express concern that the practice will cause the family to experience psychological trauma, the data do not suggest that this is the case. Most family members describe their presence as an opportunity to comfort and to gain closure.
FWR, family-witnessed resuscitation, RCT, randomized controlled trial, ER, emergency room, PICU, pediatric intensive care unit, ED, emergency department, ICU, intensive care unit, RN, registered nurse, MD, medical doctor. *Some studies looked at both patient and family member perceptions.
Rittenmeyer and Huffman9
Findings were extracted using researcherdeveloped de novo tool
GUIDANCE ON FWR 487
488
was conditional acceptance among providers, although some believe that family should not be allowed to be present under any circumstances. There was a geographic variation with more disfavor occurring in studies from Belgium, Germany, Singapore, and Turkey, and favor in studies from the United Kingdom, Ireland, Australia, and the United States. These differences may be attributable to cultural differences as well as the structure of health care delivery. Looking at the eight studies from the United States, RNs were more supportive of FWR than physicians, although there was great variability in RN support ranging from a low of 36% to a high of 96%. Dingeman et al8 report similar variability and cites discipline, geographical region, and hospital department as factors influencing favor or disfavor. Nurses were more in favor than physician colleagues, and those working in inpatient settings were more in favor than those in outpatient settings. Both reviews found that those practitioners who had participated in FWR had more favorable views than those who did not. Paplanus et al7 (Part I) and Rittenmeyer and Huffman9 found that practitioners want to decide about FWR. They wish to have ‘‘control over the practice and have final say about when or when not to allow it.’’p.1829 This can create a possible strain as the perceptions of family and provider may differ. Rittenmeyer and Huffman9 termed this ‘‘conditional acceptance’’ in which it was stated that ‘‘a tension is created between the belief of most family members that being present is a right and health care practitioners who believe that they should have control over the circumstances of the practice.’’p.1829 What are the Perceived Advantages and Disadvantages of FWR? Table 4 summarizes the perceived advantages and disadvantages found in these reviews. Generally, there was agreement among patients, family, and providers as to the benefits of FWR. A consistently mentioned advantage was that FWR helped the family understand both the seriousness of the situation as well as comforted them that all was done that could be done. Being present, although stressful, provided comfort and an opportunity for the family member to express love, facilitated coming
SALMOND, PAPLANUS, AND AVADHANI
to terms with a loved one’s death, and eased the grief and adjustment process. Rittenmeyer and Huffman9 found the value of FWR to be that it helped the family confront reality. Being present leads to better ‘‘understanding of the context of the situation and therefore facilitates better decisions on behalf of their family member.’’ p.1832 Despite this advantage, Rittenmeyer and Huffman9 describes a ‘‘hovering uneasiness,’’ such that practitioners express concerns regarding performance anxiety and curtailing of coping strategies used by the team. These concerns revolve around the potential for the family to interfere with care, and the negative impact that family presence could have on staff performance anxiety. Paplanus (Part I and II) and Dingeman et al8 report that in studies of actual witness, it was found that families generally do not interfere with their loved one’s care during resuscitation, and those providers participating in FWR indicated that their performance was not affected. It was noted, however, that novice practitioners may be anxious with the practice. What Specific Interventions Were Used in Implementing FWR? Although no studies tested specific interventions in a clinical trial format, most studies reporting on actual FWR used an assigned support person to be with the family member during the event. The support person was also called a chaperone, facilitator, or family coordinator. The role of this individual was to assess the appropriateness of the family member being present, invite the family member to witness, and be present to explain what was happening and provide emotional support. This intervention has been incorporated into clinical guidelines on FWR promulgated from most nursing and medical organizations. How Should the Evidence Support Clinical Decision Making? Is the Evidence Transferable to My Practice Setting? The evidence presented should guide decision making not only of the introductory scenarios but also in real-life practice. Based on the data that have been presented, there is strong evidence that patients and family members support the option to be present during resuscitation of both
GUIDANCE ON FWR
489
Table 4. Advantages and Disadvantages of Family Witnessed Resuscitation Advantages Ability to get history quickly Presence facilitates understanding of the seriousness of the condition with recognition that all that could be done was done Families comforted by presence, being able to be with the person Provides an opportunity to be with/see loved one for last time, gives an opportunity to say goodbye Gave opportunity to express their love Presence facilitates emotional and spiritual needs of family Supports families in making decisions about treatment withdrawal Facilitates coming to terms with loved ones death Eases grief and facilitates adjustment
children and adult family members. The evidence of actual witness experiences has shown that family presence is not detrimental to the plan of care and may facilitate understanding and emotional adjustment with the situation. Although most studies of actual witness were in EDs and ICUs, this evidence appears transferrable to other practice settings including PACUs. With the move toward patient- and family-centered care, it is time for the practitioners to drop paternalistic views on what is best for the family and let the family member be the decision maker as to whether they prefer to be present or not. Both academic settings and practice settings must prepare the practitioner for resuscitative experiences in the presence of a family member. What Clinical Implications Emerge From This Examination of FWR Evidence? Three main recommendations emerge for practice. First, all institutional settings need to develop an institutional policy on FWR to provide a clear decision path and minimize idiosyncratic decision making by providers. Staff from multiple disciplines should be involved, and guidelines from professional associations such as the Emergency Nurses Association can serve as a starting point for the discussion.6 Once developed, the policy needs active dissemination and discussion to assist practitioners in understanding the value of family presence.
Disadvantages Potential to interfere with care Emotionally too upsetting for family
Negative impact on staff performance (performance anxiety)—feeling judged and curtailing normal staff coping mechanisms such as joking Potential for litigation
Furthermore, the policy should be described in information about patient and family rights, so that the families are aware of the option for presence. The second recommendation is for institutions to develop family support personnel or advocates to accompany the family during FWR. These advocates may be personnel from nursing, the clergy, social service, and even from volunteer staff who have been appropriately trained. The key is that there must be advocates available on all shifts on all days of the week. The final recommendation is to develop training programs for students and staff on family presence. This would include communication, mutual respect, and performance of CPR in the presence of family. Evidence from these systematic reviews should be presented to support the need for the change and to discuss the evidence on the patient and family perspective. Frank discussions of the role changes needed to accommodate FWR need to be held. Training in communication, mutual respect and performance of CPR in the presence of family should occur.
Conclusion Applying the evidence to the case scenarios at the beginning of the article, the evidence is clear. Whether the patient is an adult or child, or whether the crisis occurs in ICU, PACU, or the
SALMOND, PAPLANUS, AND AVADHANI
490
ED, the evidence points to a common approach. The family should receive an explanation of what is happening and be assessed for their emotional state and interest in FWR. If the family member opts to remain, then a family support person/
chaperone should be present to provide information and emotional support during the witness. The evidence on FWR is clear; the responsibility for its actualization resides with informed, courageous, health care professionals.
References 1. Mortelmans LJ, VanBroeckhoven V, Van Boxstael S, et al. Patients’ and relatives’ view on witnessed resuscitation in the department: A prospective study. Eur J Emerg Med. 2010;17:203-207. 2. Wendover N. Changing staff attitudes towards familywitnessed resuscitation. Emerg Nurse. 2012;20:21-24. 3. Kissoon N. Family presence during cardiopulmonary resuscitation: Our anxiety versus their needs. Pediatr Crit Care Med. 2006;7:488-490. 4. Holly C, Salmond S, Saimbert M. Comprehensive Systematic Review for Advance Practice. New York, NY: Springer; 2011. 5. CASP, Critical Appraisal Skills Programme. Available at: http://www.casp-uk.net/#!casp-tools-checklists/c18f8. Accessed January 16, 2014. 6. Emergency Nurses Association. Position Statement: Family Presence at the Bedside During Invasive Procedures and Cardiopulmonary Resuscitation. 2005. Available at: https:// www.ena.org/SiteCollectionDocuments/Position%20Statements/ FamilyPresence.pdf. Accessed January 16, 2014.
7. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part I: Perspectives of patients and families. JBI Libr Syst Rev. 2012;10:1883-2017. 8. Dingeman RS, Mitchell EA, Meyer EC, Curley MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: A systematic review of the literature. Pediatrics. 2007;120:842-854. 9. Rittenmeyer L, Huffman D. How families and health care practitioners experience family presence during resuscitation and invasive procedures. JBI Libr Syst Rev. 2012;10: 1785-1882. 10. Paplanus LM, Salmond SW, Jadotte YT, Viera DL. A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally—Part II: Perspectives of healthcare providers. JBI Libr Syst Rev. 2012;10:2018-2294.
