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Old 12-12-2009, 11:42 PM
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Default Family Presence During Cardiopulmonary Resuscitation

Critical care nurses often find themselves in the midst of challenging ethical situations that involve conflict between the needs of critically ill patients and the patients’ family members and the preferences of physicians and other healthcare providers who initiate and manage resuscitation measures. Yet, many critical care nurses have reported that they received little preparation in their basic education programs to deal with these sensitive issues. Because new graduate nurses often choose to specialize in critical care, nurse educators who design and teach undergraduate critical care nursing courses are obligated to address ethical decision making as part of the curriculum. In this article, I present a case study of an ethical issue in critical care and describe a method of clinical ethical analysis that nurse educators can use when teaching students about making ethical decisions in clinical practice.

Case Study

A 40-year-old man lost control of his vehicle and struck a guardrail in a single-car collision. He was not wearing a seat belt and was thrown through the windshield, sustaining a traumatic, closed-head injury. He was brought to the trauma center via helicopter and was admitted to the surgical intensive care unit. The night staff provided support to the patient’s wife during her first visit to see her husband, who was receiving mechanical ventilation and was unresponsive and surrounded by multiple invasive catheters and equipment. The trauma team briefly met with her soon after admission to explain her husband’s grave prognosis.

The patient’s wife came into the unit for her second visit just as the nurse preceptor and the student were preparing the patient for the morning visit. As the patient’s wife approached the bedside, the alarms of the monitors for the cardiac and arterial catheters sounded, indicating a cardiac arrest, and CPR was initiated. The healthcare personnel handling the code situation pulled the privacy curtains around the bed in an attempt to screen the situation from view by the patient’s wife and the other patients and their visitors within the unit. At that moment, the student took the stunned wife into the hallway, and a nursing supervisor arrived to lead the woman into a private waiting room.

The student later reported the events of the morning to her peers at a clinical conference, including the fact that the patient’s wife had arrived just as the code started. The student explained that the patient did not survive despite the team’s efforts and that the patient’s wife did not have the opportunity to see him again before he died. The student’s statement caused the instructor to question the policy in almost all adult critical care units that family members’ access to loved ones during CPR should be restricted. The ethical dilemma that arose in this situation involved the conflict between the desire of the patient’s wife to be present during CPR and the desire of the trauma team to exclude her.

Family presence during CPR is a relatively new issue in healthcare. Students conducting a review of the literature may be surprised to discover that most of the available information has been published within just the past 2 decades. No ethical dilemmas of this type existed before the development of CPR in the late 1950s because family members were present at almost all deaths. A dying person’s last moments were most often controlled by his or her family in the home rather than by medical personnel in a hospital.

The advent of high-tech medical practices moved patients out of homes and into hospital beds. When patients were too sick to be treated on general nursing units, they were moved to critical care units. Even though such a move offered greater proximity to lifesaving equipment, it removed patients from their families.

Advantages and disadvantages of family presence during CPR from the perspectives of patients’ family members and healthcare providers varied slightly. Family members viewed family presence not only as a fundamental right but also as a way of offering support to their loved ones in crisis. However, they also expressed concern about feeling emotionally traumatized and obligated to witness CPR when they might prefer to decline.Patients also thought they had a right to have their families present. Some patients said that they felt safer and less afraid with family members present. However, other patients reported that they preferred to face death alone and did not want estranged relatives allowed to invade their privacy.Healthcare providers viewed family presence as an opportunity to maintain the dignity and personhood of patients but feared physical assault by distraught family members, increased threats of liability and subsequent litigation, and loss of control over the code situation.Interestingly, all parties involved agreed that family presence during CPR could result in subjecting patients to prolonged resuscitations in medically futile situations because the trauma team might be reluctant to "call" the code in the presence of a patient’s family member.

During the past decade, nurses have increasingly advocated for family presence. Nurses generally agree that family presence can be beneficial for both patients and patients’ family members, if patients and their families desire it. Because of this belief, nurses continue to advocate for their patients by attempting to revise policies that restrict family presence in their hospitals. What can nursing students learn from analyzing this case study on family presence? They may realize that situations involving ethical dilemmas in the critical care environment can be resolved in many different ways. Student groups using the case study may gain additional insight by discussing what might have happened if the patient’s wife had been allowed to stay with her husband during CPR. Students may gain a deeper appreciation for the complexity of ethical issues they will face in the critical care environment. They may even begin to question hospital policies that are based on tradition rather than on specific evidence. Providing the opportunity to discuss and debate an ethical issue and to work through a clinical ethical analysis under the guidance of an informed instructor offers students a valuable experience in dealing with the issues they will undoubtedly face as novices in professional nursing practice.
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