Family in the resuscitation room

Sandra M. Schneider, MD FACEP, Chair, Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry; Member, New York ACEP Board of Directors

Back in the late 90’s, a series of articles introduced the concept of allowing families to be present during resuscitations. These articles clearly showed that families wanted to be present and that the physicians and nurses did not want them there. Debate raged for several months in both the UK and US journals; then quieted. A few institutions changed their policies and permitted families in the resuscitation bay. Several practitioners tried unsuccessfully to effect this change. But most just continued with the status quo. So here we are, 5-10 years later, and once again the concept has emerged in the literature. A recent Pediatric article (1) describes the positive aspects of allowing family to be present in the resuscitation bay. It’s time again to examine our own practice and perhaps, once again, try to change our system.

Many of the arguments against family presence are misfounded.

Concern: Families will sue. They will gather information during the resuscitation to use against us. Families are in a time of crisis. Their focus is not on what the team is doing, but how their loved one is doing. Around their focus, care is simply activity, a type of controlled chaos. They lose time perspective, and realize it. They rarely process individual events, even when the family is medically trained. More suits arise out of ignorance of the event, or poor documentation, than out of perceptions at the bedside.

Concern: Families will not want the team to stop efforts. It is true that the media has built unrealistic expectations about cardiac arrests. On TV most patients not only survive but often begin to talk within seconds after an arrest! Families in the waiting room cling to the hope that their loved one will recover. Families in the resuscitation room see the reality of the situation. When the resuscitation is prolonged, it is often the family request that it stop.

Concern: Families will become emotional. Most patients in cardiac arrest come in by EMS. The family has already faced the event and has had a few moments to adjust. A nurse, social worker or chaplain should accompany families; in some small hospitals this is obviously not feasible.
My own belief about family presence crystallized during an arrest of the father of a member of the medical staff. The family had witnessed the intubation, starting of an IV and cardiac compressions on the living room floor. Asking them to leave while we continued compressions and pushed drugs seemed quite absurd.
The reality is that most cardiac arrest victims are not successfully resuscitated. You will do more for the family than you will for the patient in asystole. Family presence appears to help with the grieving process. It helps families bring closure. “I wanted him to know that I was close to him in his time of need and would have liked to have held his hand, but didn’t dare ask.” (2)

Some important considerations:
1. Educate the staff BEFORE you allow families in the resuscitation area. While 70% of families surveyed wished to be involved, only 30% of nurses and physicians felt they should be allowed. (3) Recognize that family presence may not be comfortable for all staff and all families. One way to introduce this concept to the staff is to ask where they would want to be if their closest loved one was dying.

2. Ask the family members if they wish to be present. Although 70% of surveyed families wanted to be asked, fewer wanted to actually view the resuscitation.
3. Families that have already viewed the resuscitative efforts at home are likely to want to view the hospital care.

4. Have a nurse/social worker/chaplain stay with the family in the resuscitation room

5. Holding and touching the body will help in the grieving process. This may need to be limited when there is violence involved.

6. Keep the family informed of the progress, or the lack there of. “He simply is not responding to our efforts.” “No one like this has survived without serious brain damage.” Families adjust to the situation. Often they suggest withdrawing efforts.

7. Consider setting up a contact with the family after the event. A contact by phone or having them visit during a slow time in the ED will give an opportunity for questions and concerns that have arisen since the time.

“It is a very frightening experience to someone who does not understand what is going on in front of them, but the overwhelming desire is to stay close to the injured person.” (2)

1. Eppich WJ. Current Opinion in Pediatrics 2003; 15:294.
2. Adams S. BMJ 1994; 308: 1687.
3. Doyle CJ. Annals Emergency Medicine 1987; 16:673.