Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6
Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7
Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.
In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9
Positive family member comments included the following:
- “I couldn’t imagine not being a part of it”;
- “I saw that everything was done for him”;
- “I felt he knew that I was there”; and
- “Seeing and touching helped relieve the stress I felt weeks later.”5
Negative comments included:
- “ … Very unpleasant, haunting, and constant memory”;
- “ … Staff seemed too coldly professional”; and
- “I can still see him with all those needles.”
Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.
Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11
In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.