The attempted resuscitation of a hospitalized patient is an emotionally charged event where a family must confront the possibility of a loved one’s death. In the hope of addressing the needs of family members during resuscitation, many institutions have adopted policies that allow for family presence during resuscitation (FPDR).
Why is it important to involve the family in patient care?
[ 1] Involving the family in patient's care is critical as it has multiple benefits for the patients themselves, staff, and the organization [ Table 1 ].
Is it better to treat the whole family or the patient?
Treating the whole family tends to be more effective and less burdensome for the psychiatrist, as well as the patient. Gabor I. Keitner, MD, is a professor of psychiatry and human behavior at Brown University in Providence, Rhode Island.
Should patients be involved with family members in making decisions?
Some choose to involve family members, even sometimes allowing the family’s desires to supersede their own. Respecting autonomy necessarily means respecting patients’ decisions.
Are family members adequately informed of potential risks associated with healthcare?
Health care providers accept this risk, but family members have not been adequately informed of potential risks, do not have the requisite knowledge to protect themselves, and may be at higher risk for exposure as a result.
Why is it important for families to be involved in patient care?
Active participation of patients in their own care and decision-making is associated with positive results, including: higher quality, fewer errors, more positive views of the health care system, improved patient confidence- both in their ability to manage and control their own health conditions and also in the ability ...
Why is it important to communicate with the patient's family?
Effective communication and collaboration with patients and family members affects patient outcomes, patient safety, and perceptions of quality. If patients feel involved in their care, they will be more likely to follow their treatment plans and may experience better clinical outcomes.
Why is patient and family-centered care so important in the hospital setting?
Patient- and family-centered care leads to better health outcomes, improved patient and family experience of care, better clinician and staff satisfaction, and wiser allocation of resources.
Is it ethical for a doctor to treat a family member?
In general, physicians should not treat themselves or members of their own families. However, it may be acceptable to do so in limited circumstances: (a) In emergency settings or isolated settings where there is no other qualified physician available.
How do families communicate with patients?
Effective Communication Ensures Better Patient Care Plus Builds Trust with their FamilyListen. 1Half of communicating effectively is listening. ... Look. 2Be mindful of nonverbal cues. ... Summarize and Ask. ... Ensure Patient Privacy. ... Be Tactful and Honest.
How do families interact with their patients?
3 Tips for Communicating with Patients' FamiliesListen. Many people think of communication as talking. But listening is as important, or arguably, more important. ... Pay attention to nonverbal communication. Words are only one part of what you may be saying. ... Make sure you are being HIPAA compliant.
Why doctors shouldn't treat their family and friends?
A patient who is treated by a doctor with whom there is a personal relationship — either as a friend or family member — may not give accurate information or an exact history, or pursue a second opinion or alternative treatment, simply because they feel it is inappropriate to question the care of a doctor they "know." ...
Should doctors treat their family members?
There is no law which specifically prohibits a physician from evaluating, diagnosing, treating, or prescribing controlled substances to a family member, employee or friend. However, the practice is discouraged.
Why can't doctors treat their own family?
Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician's personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.
How do family members help patients?
Family members help in sharing responsibilities, lessen the patient’s anxieties, and facilitate and encourage, communication between health care providers.
How does family influence health?
Families have a powerful influence on health equal to traditional medical risk factors and can be very helpful in identifying the history and precipitants of patient’s problems, as well as potential future obstacles to the management and treatment of psychiatric conditions. Illness exists in a social context, and a patient’s most important resource ...
What are the factors that affect the onset of illness?
Family-based risk factors that can adversely influence the onset and course of illness include poor conflict resolution; low relationship satisfaction; high interpersonal conflict; criticism and blame; intrafamilial hostility; lack of congruence in disease beliefs and expectations; poor problem solving; extrafamilial stress, lack of extrafamilial support systems; poor organization; inconsistent family structure; family rigidity; low cohesion and closeness; and the presence of psychopathology in family members.
What are the characteristics of a good family physician?
These include good communication, good problem solving skills, adaptability, clear rolls, achievement of family developmental tasks, mutual support, open expression of appreciation, commitment to the family and strong extrafamilial social connections. Most patients prefer that physicians involve family members in their care.
What are the indicators of family dysfunction?
Indicators of family dysfunction include continual noncompliance with treatment, or a lack of improvement despite adherence to treatment recommendations.
What is the most important resource for a patient?
Illness exists in a social context, and a patient’s most important resource is the family.Family interventions have been found to be helpful in managing a wide range of psychiatric disorders including substance abuse, depression, bipolar disorder, schizophrenia, borderline personality disorder, conduct disorder, ADHD, eating disorder and obsessive compulsive disorder.
What is the first step in determining the need for further interventions?
The essential task in meeting with family members for the first time is to evaluate and assess their functioning in the context of understanding their problem. The family assessment is the first step in determining both the need for further interventions, and the specific areas of family life that might need to be addressed.
What did the husband refuse to do in the case of the oncology service?
Her husband refused referral to palliative care and demanded that the oncology service remains the primary service. Two brothers of the patient disagreed with the husband's decisions and wanted to direct the care plan and they were supported by the patient's two adult children. They did not want the husband to make decisions on the patient's behalf. These differing opinions resulted in a full-fledged family conflict.
What happens if a patient is not able to identify MRFM?
If a patient is not able to identify MRFM due to mental status changes or any other reason, next of kin according to local laws will be designated by HCPs to serve as MRFM.
What is the current communication practice model?
The team developed the current communication practice model which represents the real-life situations highlights the anarchy of communications with patients and families [ Figure 1 ]. Health-care providers (HCPs) may have to talk to multiple FMs repeatedly delivering same information. This current practice may lead to frustration and wasted time and may result in conflict between the HCP and demanding FMs or among FMs themselves. The HCP may talk to FMs without the patient's knowledge or approval, and sometimes different HCP teams may talk to different FMs resulting in confusion and conflicts.
What is family involvement?
Background: Family involvement is a critical component of patient-centered care that impacts the quality of care and patient outcome. Our aim was to develop a patient- and family-based communication model suitable for societies with extended families. Methods: A multidisciplinary team was formed to conduct a situational analysis and review the patterns of family involvement in our patient population. Patient complaints were reviewed also to identify gaps in communication with families. The team proposed a model to facilitate the involvement of the family in the patient's care through the improvement of communication. Results: A communication model was developed keeping the patient in the center of communication but involving the family through identifying the most responsible family member. To assure structured measurable contact, mandatory points of communication were defined. The model streamlines communication with the family but maintaining the patients' rights and autonomy. Conclusion: Our proposed model of communication takes into account the importance of communication with the family in a structured way. The team believes that it is going to be accepted by patients who will be explored in the pilot implementation stage as the next future step.
What is the unit of care?
According to our model, the unit of care includes the health-care teams, the patient, and the family. To streamline communication with the family, a single individual FM should be identified who will be the MRFM with the following characteristics:
Why was a woman admitted to the hospital for cancer?
She was admitted to the hospital for progressive dyspnea and chest pain. The reason for admission was symptom management and transition to a palliative care service for end-of-life care.
What is patient centered care?
Patient-centered care is one of the six domains of quality identified in the Institute of Medicine Report “Crossing the Quality Chasm.” [ 1] Involving the family in patient's care is critical as it has multiple benefits for the patients themselves, staff, and the organization [ Table 1 ].
What is the importance of discussing a patient's case together?
Minimize confusion. A patient’s care is often divided among multiple clinicians, so it is essential for them to discuss the case together. This doesn't mean making decisions for the patient. Rather, this means achieving professional consensus about the options and their corresponding risks and benefits so that family members receive consistent information from caregivers about potential next steps.
How to encourage patients to share their hopes?
Encourage the patient to be open. Remind patients that their family members might be more open to their desired care options than they think, and encourage patients to share their hopes.
What is patient autonomy?
Patient autonomy has traditionally been one of the most prominent principles of American medical ethics, but often patients don’t make decisions about their care alone. Some choose to involve family members, even sometimes allowing the family’s desires to supersede their own. Respecting autonomy necessarily means respecting patients’ decisions.
How can physicians engage patients in decision making?
Physicians can engage patients about decision-making in ways that are inclusive of family input, and help consider possible roles of surrogate decision-makers for patients who do not have decision-making capacity.
How to help family members at end of life?
Help everyone identify their values. Studies show patients’ values and those of their family members are often closely aligned, so facilitating a discussion about goals and values— especially independence—can generate consensus. In the case of end-of-life situations , this can help family members understand and respect each other’s perspectives.
What percentage of families believed that if they had been present it would have eased their grief.?
In terms of tangible benefit, the Parkland survey, in which families had NOT been given the option to be present, found that 64% of families believed that if they had been present it would have eased their grief. 76% of families at Foote that WERE present did believe that it eased their grief. 60% of families at Parkland believed that their presence would have aided their dying family member; 64% of families at Foote believed their presence did aid their dying family member. These survey data come after implementation of a formal program, and should be weighed much more heavily than survey data that exist when the question about FP is asked in isolation or outside of a formal program; navigating a scenario such as a resuscitation event without a family facilitator would be daunting for even the most informed1,2.
What is the primary concern of resuscitation?
During a resuscitation event, our primary concern is the patient . Given that resuscitation is often unsuccessful, the opinion of the patient can be difficult to ascertain. However, the limited information that is available from patients that had family members present during either invasive procedures or resuscitation attempts suggests that patients feel comforted, feel that healthcare workers are reminded of “personhood”, that their connection with their family was enhanced, and that their care was positively impacted. Of some concern is that patients who have been surveyed are unclear about which family member of loved one they would allow to be present. From an ethical decision-making standpoint, it is disingenuous to disallow families from being present because the patient has not made a determination about who they might want to be present, but to then immediately ask one of those same people to make surrogate decisions on behalf of that same patient after a partially successful resuscitation event.
How to prevent complicated grief?
Since unexpected severe illness and death predispose to complicated grief, one of our jobs as we care for these patients is to understand whether we can prevent or at least mitigate against this occurrence. Some things can be done to minimize the likelihood of complicated grief. One of the ways in which we may be able to mitigate the development of complicated grief is allowing families to be present during resuscitation efforts, both in the ED and in the ICU (this clearly does not apply to the operating room). The concept, or movement, began in earnest in 1982 at Foote Memorial Hospital in Michigan. By 1993 the Emergency Nurses Association endorsed a resolution allowing the option of FP during resuscitation, acknowledging several scenarios where such presence would not be appropriate—with obviously intoxicated family members, families exhibiting overly aggressive behavior, and those that were obviously emotionally unstable.
Why are some families screened out of FPDR?
Screening families quickly for FPDR has the potential for bias. Some families will be screened out due misconceptions or biases of the screener. To date, no study has rigorously looked at why some families are felt to be appropriate for FPDR while others are not. Some FPDR policies expressly prohibit families who do not speak English. While this may avoid interruption of the code and misinterpretation of information, it is not ethically sound to exclude one group based on their native language.
Is FPDR a right?
With this positive view, and the normalization of being a bystander during aggressive medical treatment that television provides, it is not surprising that the public perceives FPDR as a right. However, patients are much less likely to desire FP than their family members, and only 29% of patients undergoing cardiac or major vascular surgery desire FPDR13. In preparing for this debate, I did a small informal poll of medical professionals on this topic. When asked “Would you want your family present if you were being coded?”, the answer was uniformly “no”. The few studies that have asked this question have returned similar results. When health care providers are asked what they would want if they were the patient or the family member, most do not want FPDR14,15. This speaks volumes when those familiar with real world codes would not put their family members in that situation. Remembering that our duty is to the patient, we are violating the trust of the patient by permitting FPDR without prior patient approval.
Is FPDR evidence based?
FPDR has been touted as “evidence-based medicine”. However, there is very little strong data to support FPDR, especially outside of the ED setting, and much of the evidence used does not focus on the patient population treated by most cardiothoracic surgeons – elderly patients with chronic disease. Three of the often-quoted studies are examples of how studies with significant methodological weaknesses have been used to promote FPDR. In the seminal study by Doyle et al.9, they conclude that 94% of family members who witnessed an arrest would wish to be present again. However, this was based on only 47 returned, completed surveys and does not include surveys returned blank (3) or not returned (23). Further, 11% of the respondents felt that too much was done in the efforts to resuscitate the patient. This point is not addressed by proponents of FPDR. The study by Robinson et al.10looked at the psychological impact on those offered an opportunity for FPDR compared to those who were not. This under-powered, pilot study showed no difference in psychological outcome to family members (contradicting the putative benefits of FPDR), and the conclusions were based on only 13 family members who were studied at the 9-month follow-up point. In addition, the study was halted prematurely due to biases in the staff favoring FP which threatened to interfere with the randomization process. Finally, Eichhorn et al.11reported on interviews following FP. Despite being widely quoted in the FPDR literature, this study focused on patients undergoing invasive procedures, and included only one patient who had survived resuscitation. Interestingly, this patient did not remember that his wife was present during the code, underscoring that FPDR offers no benefit to the patient. These three studies, which are frequently cited to support FPDR throughout all areas of the hospital, are small, have significant limitations, and looked only at resuscitations in the ED. In total, they involved fewer than 70 family members, and only included one patient, yet have been used by proponents of FPDR to espouse the benefits in all situations.
What is John's condition after lung resection?
At surgery, the cancer proves to be too extensive for adequate access by VATS, so the procedure is converted to an open thoracotomy. After an extensive lung resection, John cannot be extubated, but remains hemodynamically stable. His oxygen requirement increases over then next few days and he is agitated and restless, requiring high doses of sedation. On the evening of his third postoperative day, Dorothy is with him when his agitation becomes much worse. After a brief period of bradycardia, his arterial monitor and EKG show flat lines. His nurse immediately appears in the room, assesses the situation instantaneously, and calls a mayday code.
Why is advance care planning important?
Advance care planning is meant to safeguard the patient's autonomy when that individual is unable to make his or her own healthcare decisions. Yet, families do not always agree with the specific wishes of their family member when there is a need to make critical decisions, such as continuing treatment because of some new research protocol ...
Why is the decision making process so complicated?
When there are patient-family disagreements, the decision-making process is even more complicated if the patient is fully able to participate because competent patients have the right to make their own healthcare decisions. In addition, family members may not agree with each other.
What is advance care planning?
Advance care planning is meant to safeguard the patient's autonomy when that individual is unable to make his or her own healthcare decisions. Yet, families do not always agree with the specific wishes of their family member when there is a need to make critical decisions, such as continuing treatme ….
What is FPDR in hospitals?
Given the importance of patient- and family-centered care, many hospitals have been implementing policies allowing for family presence during resuscitation (FPDR). Notably, FPDR confers psychological benefits for family members present during arrests regardless of the treatment outcome. Furthermore, patients are proponents of having relatives at the bedside during resuscitation as well.
How to facilitate FPDR?
Previous literature has offered a framework to effectively enact FPDR 33, 37 Most authors advise assigning a member of the resuscitation team (eg, nurse, chaplain, social worker, and other provider) to dedicate their role toward helping facilitate FPDR. This would entail (1) identifying if family members are present and informing them about the ongoing resuscitation (if not already at the bedside), (2) assessing whether FPDR is appropriate based on the family’s emotional state (eg, not overly grievous, aggressive, or altered) and the resuscitation team being agreeable to FPDR, (3) limiting the number of visitors, (4) preparing the family about what to expect and where to position themselves in the room, and (5) update the family about the specific resuscitation efforts taking place and provide emotional support. Importantly, the facilitator may solicit the surrogate decision maker’s input on whether to continue resuscitation efforts.
What is FPDR in resuscitation?
In the hope of addressing the needs of family members during resuscitation, many institutions have adopted policies that allow for family presence during resuscitation (FPDR). Recent evidence suggests that FPDR confers psychological benefits for family members present during arrests in both the out-of-hospital 1 and the in-hospital setting, 2 regardless of the treatment outcome. Furthermore, patients are proponents of having relatives at the bedside during resuscitation. 3, 4 As a result, a growing number of hospitals have begun to implement policies allowing for FPDR 5 with some demonstrating improvements in family member satisfaction surrounding the resuscitation event. 6 However, there remains uncertainty surrounding the safety of such policies during resuscitation. 7
Why is FPDR important?
Given the increasing importance of patient-centered care, universal implementation of FPDR policies is a compelling means to change the paradigm of resuscitation care. However, empirical evidence on how a hospital policy allowing for FPDR affects patterns and processes of care is needed to ensure its safety given the potential for unintended consequences, and to reassure hospital policymakers. To address this uncertainty, we analyzed a large cohort of patients participating in the largest national registry of in-hospital cardiac arrests. We hypothesized that hospitals with an FPDR policy would have similar processes and outcomes of care compared with those without this policy.
What are the primary outcomes of resuscitation?
Our primary outcomes included (1) return of spontaneous circulation (ROSC), defined as the restoration of a pulse for ≥20 minutes during the cardiac arrest and (2) survival to discharge. To address concerns about whether any observed changes in resuscitation efficacy associated with the FPDR policy may result in worse neurological status at the time of discharge, we also evaluated neurological outcomes among survivors by FDPR. Information on neurological status was obtained using cerebral performance categories: no major disability, moderate disability, severe disability, coma or vegetative state, and brain death. 19 Consistent with previous work, we categorized favorable neurological status among those surviving to hospital discharge as a cerebral performance category score of 1 or 2. 20
Who had full access to the data in the study?
Drs Goldberger and Cooke had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. No financial support was received for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article.
Is there a difference between pharmacological and nonpharmacological interventions during arrest?
There were no significant differences among the broad categories of pharmacological and nonpharmacological interventions delivered during the arrest between hospitals with and without a policy allowing for FPDR, in both unadjusted and adjusted analyses ( Table 5 ).
What to do after family member has finished speaking?
After the family member has finished speaking, summarize it. Repeating their communication back to them in your own words is a great way to let them know you understand what they are saying. It also helps you solidify that information in your own memory.
How to navigate emotionally challenging situations?
Here are some tips that can help you navigate those emotionally challenging situations. 1. Listen. Many people think of communication as talking. But listening is as important, or arguably, more important. Listening isn’t just being quiet when the other person talks. Really listening requires being fully present.
What is the most important part of nursing?
As a nurse, you already know communicating with patients and their families is one of the most important parts of your job. You are likely often busy with many tasks and may be looking after multiple patients, but taking the extra moment to connect can be vital to patient care, or in some cases, a matter of life and death.
Can family members give medical information?
In some circumstances, family members may want medical information you are not legally able to give. You can usually give medical information to family members involved in treatment or payment for treatment, provided the patient does not object.
Do you ask follow up questions?
Don’t forget to ask follow up questions. According to Harvard Business Review, “asking a good question tells the speaker the listener has not only heard what was said, but that they comprehended it well enough to want additional information.”
Why is family presence important?
Families also believe they have the right to be present during these intimate and personal events [1, 8] and that being present can be therapeutic and provide reassurance that everything that could have been done, was done [2, 13]. Some could argue that since family presence would be primarily for the potential benefit of the family member and not the patient, family presence should not be permitted and could indeed hinder the resuscitation of the pediatric patient. However, as discussed above, FPDR allows family members to provide information that could facilitate decision making, and it eliminates the need for explanation of services being provided [1, 8]. In this sense, FPDR also upholds the principle of respect for family autonomy.
What is family presence during resuscitation?
Family presence during resuscitation (FPDR) can be 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” [5]. The controversy surrounding FPDR first emerged in the literature in the early 1980s when a hospital in Mississippi described a situation in which two family members demanded to be present during the resuscitation of their loved ones [6]. Studies of FPDR have shown that family members and staff who were involved in resuscitations report positive attitudes about the practice [1-3, 7-9]. In one study, the majority of family members reported being able to understand the therapeutic interventions performed, to advocate for their child, and to calm or reassure their child during such an event [1]. Families also believe that FPDR is a parental right [1, 8], and clinicians believe that it can help both the medical team and families whose child dies [2]. Moreover, some studies suggest that FPDR does not negatively impact clinical performance or resuscitation efforts [9-12].
Why should parents not be allowed to resuscitate?
A prominent argument is that parental presence during pediatric resuscitations should not be permitted because it is not in the child’s best interest. Parents might misunderstand treatments provided to their child, which could create a stressful environment for staff and contribute to rather than relieve patient anxiety [2]. Moreover, task performance of inexperienced staff or physicians participating in the resuscitation might be negatively impacted by parental presence [2]. Additionally, clinicians have argued that it should be up to them—not families—to determine in which situations family presence ought to be granted [14, 15]. Finally, those opposing FPDR could rightfully argue that the data upon which these conclusions are drawn are scant, as many surveys have poor response rates [8].
What is the caveat of FPDR?
Respect for autonomy. An important caveat is that FPDR must be allowed in a way that ensures that families are supported and informed. In most situations, this is achieved through a family support facilitator [1, 3, 9, 13], because family presence during a trauma resuscitation absent the context with which to frame such efforts can be detrimental to the family present [1, 9, 12].
What are the four ethical principles of FPDR?
Because patients, family members, and clinicians can have different perspectives on whether FPDR helps or hinders trauma care, the four ethical principles described by Beauchamp and Childress—respect for autonomy, nonmaleficence, beneficence, and justice [16]—will be used here to evaluate FPDR from each of these stakeholder perspectives.
Why does moral conflict exist?
According to Nibert, a “moral conflict exists because two opposing obligations collide: an obligation to the family members who desire to be present with their loved one during CPR and an obligation to the healthcare providers who do not want patients’ family members to witness resuscitation efforts” [4].
Does FPDR affect life support?
Another study demonstrated that FPDR does not negatively impact the performance of advanced trauma life support tasks [11]. Given the positive psychological impacts and lack of negative clinical impacts, one could argue for an overall net positive impact of family presence for the patient.