Online Continuing Education
Program
Case Study
Meet the Author
|
| Title |
End of Life Care:
Family Presence During Invasive Procedures and Resuscitation
Case Study SC0004 |
| Author |
Jean Vanderbeek,
RN, MS, CS |
| Contact
Hours |
1.5 |
| Target
Audience: |
Nurses working in acute care and emergency care
|
| Purpose/Goal: |
Implement
family presence during resuscitation in the acute care and
emergency care settings. |
| |
|
Sigma
Theta Tau International is accredited as a provider of
continuing education in nursing by the American Nurses Credentialing
Center's Commission on Accreditation.
|
|
Learner Objectives: Upon completion of this case
study, the learner will be able to:
- Identify techniques to assess family members’ ability to cope when present
during invasive procedures (IP) and resuscitation.
- Identify the perceived benefits to the family when present during invasive
procedures and resuscitation.
- Identify barriers to family presence during invasive procedures and
resuscitation.
- Identify family members’ attitudes toward their presence during invasive
procedures and resuscitation.
- Identify the most important needs named by family members of critically
ill patients.
Meet the Author
|
Jean
Vanderbeek, RN, MS, CS
Ms. Vanderbeek is an associate professor at Miami University of
Ohio and certified clinical specialist in medical-surgical nursing.
She received her bachelor of science in nursing from West Virginia
University and holds a master of science in nursing from Ball State
University. Ms. Vanderbeek has published several articles related
to end-of-life care. In addition, she has presented at numberous
nursing conferences. She received the 1999 Technical Achievement
Award from Miami University. Ms. Vanderbeek is a member of Sigma
Theta Tau International.
|
Instructions
- Read the case study.
Answer the questions at the end of the case study and click on the submit
button to have your answers checked. You will have the opportunity to
register for continuing education credit if you score 80% or higher.
- At any time in the case study you may review the references cited. References available
on line are indicated by an underline. To access simply click on the article.
- Acrobat
Reader may be needed to view some links in this case study.
- The web links were
checked and verified when this case study was published.
- Please report broken
links to onlinece@stti.iupui.edu.
Introduction to the case:
Charlotte is a middle-class, white, 72 y/o, female who was transferred to your medical unit yesterday evening from the intensive care unit (ICU).
Following morning report, you enter Charlotte’s room at 7:30 a.m. and find that she is confused but oriented to person. Her vital signs are stable. At 8:30 a.m., you reenter her room and find her unresponsive, tachypenic with a palpable systolic B/P of 80. While her physician is being notified, Charlotte has a cardiac arrest, and a CODE (mobilization of the cardiopulmonary resuscitation team) is called. Charlotte’s daughter, Joan, is also notified and advised of her mother’s condition.
Joan arrives on your clinical unit 15 minutes into the CODE. As Joan approaches her mother’s room, she finds that Charlotte has been intubated, is in pulseless ventricular tachycardia, and is being defibrillated. As Joan begins to enter the room, a security guard and health care worker stop her from entering.
Medical/Nursing History:
Five days prior to the CODE, Charlotte was admitted to the hospital through the emergency room with acute lower back pain. She has a history of hypertension, severe osteoporosis resulting in vertebral compression fractures, arthritis of the spine, and a stable abdominal aortic aneurysm. She was admitted through the emergency room because her primary care physician was out of town, and a colleague was covering his patients. The admitting physician believed the back pain to be related to Charlotte’s osteoporosis and arthritis, although she was adamant she is well aware of the pain her arthritis and osteoporosis cause, and this pain was not related to either. She was transferred to ICU two days following her admission as a result of a dramatic drop in her blood pressure, which was related to several doses of slow-release morphine in addition to her antihypertensive medications. While in ICU, Charlotte became very confused.
Family or Social History:
Joan, the patient’s daughter, is 45 years old and is a professor of nursing. She arrived from out of state two days following Charlotte's admission and was with her mother as often as permitted. Joan was with her mother until early in the morning, just a few hours before Charlotte arrested, and assisted the staff in dealing with Charlotte's confusion. The staff members involved in Charlotte's CODE were not aware that Joan is an RN. The staff members were aware of Charlotte's advance directives detailing her wishes not to use extraordinary means if the treatment would prolong a vegetative state.
The attending physician directing the CODE was unfamiliar with Charlotte's admitting diagnosis or medical problems. During the CODE, the physician was concerned about Charlotte's distended abdomen. The physician stepped out of the room and talked to Joan who was able to provide a detailed history of Charlotte's abdominal aortic aneurysm.
Discussion
of Family Presence During Invasive Procedures and Resuscitation:
Nurses and health care workers have traditionally
been concerned that family presence during resuscitation “might cause more
harm than good” (Connors, 1996), that resuscitation might be “too traumatic
for the family to witness” (Meyers et al., 2000), or that “there is little
evidence to suggest what the long-term effects are likely to be” (van
der Woning, 1997).
Recent articles focusing on family presence are beginning to change health
care providers’ attitudes. Denise Huff, director of trauma services at Santa
Barbara Cottage Health System, stated: “We all realized nobody would be
able to keep any of us out, so how could we do that to another parent or
loved one?” (American Health Consultants, 2001). The Emergency
Nurses Association (ENA) has prepared a statement on family presence.
For an historical perspective on health care providers’ opinions on family
presence during invasive procedures or resuscitation please refer to the
following Web sites: Hanson
& Strawser, 1992; Doyle
et al., 1987; Eichhorn
et al., 1996; Redley
& Hood, 1996; and Adams
et al., 1994.
According to Brian Dolan, a staff nurse at Kingston, London, and an international
advocate for family presence, “Families don’t interfere. They don’t sue.
They just want to be there” (Farella, 2001).
In
Original Research: Family Presence During Invasive Procedures and Resuscitation,
Meyers and colleagues (2000) state: “We found that families perceived visitation
as a positive experience and that they believed being with the patient was
their right. Family members involved in family presence viewed themselves
as active participants in the care process, which met their needs for knowing
about, providing comfort to, and connecting with the patient. All the participating
family members surveyed believed that visitation was helpful to them and
noted that they would do it again. We found that family members who visited
with their loved ones during emergency care suffered no ill psychological
effects.”
In their new guidelines,
the American Heart Association (AHA) is now recommending that family
members be allowed in the resuscitation room (American Heart Association,
2000).
The family should have the authority to make the decision regarding its
presence during resuscitation. Teresa Meyers, one of the authors of the
Meyers’ study, discusses the incident that led to her study in the American
Journal of Nursing “Viewpoint
– Why couldn’t I have seen him?” (2000).
Family members should be assessed for their coping abilities and emotional
stability before the option of family presence during resuscitation is offered
(Meyers et al., 2000; Vanderbeek, 2000).
The North American Nursing Diagnosis Association’s (NANDA) nursing diagnosis
of ineffective individual coping is defined in Doenges & Moorhouse (1998,
p. 152), as “Impairment of adaptive behaviors and abilities of a person
in meeting life’s demands and roles.”
Objective-defining characteristics of ineffective individual coping include:
· Inability to problem solve
· Change in usual communication patterns
· Verbal manipulation
· Destructive behavior toward self or others
· Lack of assertive behaviors (Doenges & Moorhouse, 1998)
Dallas County Hospital District-Parkland Health & Hospital System Emergency
Services Department uses combative behavior, extreme emotional instability,
and behaviors consistent with altered mental status as exclusion criteria
for family presence. Their procedure
for family presence during invasive procedures/resuscitation also includes
removing family members from the bedside if they become faint, hysterical,
or disruptive (Meyers et al., 2000).
An anesthetist, cardiologist, and general practitioner discuss their perspectives
in “Should
relatives be allowed to watch resuscitation?’ (Adams et al., 1994).
Family
members’ attitudes (Barrat & Wallis,1999)
Retrospective
study of family interviews (Meyers et al., 1998)
Survey
of pediatric parents (Boie et al., 1999)
Discussion
focusing on the intensive care unit (Offord, 1998)
A
mother’s experience when access to the resuscitation room was denied her
(Gregory, 1995)
A mother’s
experience when accommodations were made for her presence during resuscitation
(Vanderbeek, 2000)
Course
of Care:
Despite all efforts, Charlotte's resuscitation
was unsuccessful and was terminated 30 minutes after it was initiated, when
Joan asked the staff to stop. Joan was very familiar with her mother's advance
directives and knew her mother would not want CPR to be continued.
Autopsy findings list a ruptured abdominal aortic aneurysm as the cause
of death.
References
Adams, S., Whitlock, M., Higgs, R., Bloomfield, P.,
& Baskett, P.J. (1994). Should relatives be allowed to watch resuscitation?
British Medical Journal, 308 (6945), 1687-1690. Retrieved August 6, 2001,
from http://bmj.com/cgi/content/full/308/6945/1687?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1
=adams%252C+s&titleabstract=should+relatives+be+allowed+to+watch&searchid=QID_NOT_SET&stored_
search=&FIRSTINDEX=0.
American Heart Association (2000). Guidelines 2000 for cardiopulmonary resuscitation
and emergency cardiovascular care. (p.8). Retrieved June 25, 2002, from
http://circ.ahajournals.org/cgi/content/full/102/suppl_1/I-371.
American Health Consultants (2001). Here’s how to meet needs of families.
ED Nursing, 4 (3), 34-35.
Barrat, F., & Wallis, D.N. (1999). Relatives in the resuscitation room:
Their point of view [Abstract]. Journal of Accident and Emergency Medicine,
16 (1), 78. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9570053&dopt=Abstract.
Belanger, M.A., & Reed, S. (1997). A rural community hospital’s experience
with family-witnessed resuscitation. Journal of Emergency Nursing, 23 (3),
238-239.
Boie, E.T., Moore, G.P., Brummett, C., & Nelson, D.R. (1999). Do parents
want to be present during invasive procedures performed on their children
in the emergency department: A survey of 400 parents [Abstract]. Annals
of Emergency Medicine 34 (1), 70-74. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10381997&dopt=Abstract.
Connors, P. (1996). Should relatives be allowed in the resuscitation room?
Accident and Emergency, 10 (44), 42-44. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8850759&dopt=Abstract.
Cummins, R.O., Hazinski, M.F. (2000) The most important changes in the international
ECC and CPR Guidelines 2000. Retrieved July 8, 2002, from http://circ.ahajournals.org/cgi/content/full/102/suppl_1/I-371.
Doenges, M.s E., & Moorhouse, M.F. (1998). Nurse’s pocket guide: Diagnoses,
interventions, and rationales (6th ed.0. Philadelphia, PA: F.A. Davis Company.
Dossey, B.M., Guzzetta, C., Keegan, L. (2000). Holistic nursing: A handbook
for practice (3rd ed.). Gaithersburg, MD: Aspen.
Doyle, C.J., Post, H., Burney, R.E., Maino, J., Keefe, M., & Rhee, K.J.
(1987). Family participation during resuscitation: An opinion. Annals of
Emergency Medicine, 16 (6), 673-675. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3578974&dopt=Abstract.
Eichhorn, D.J., Meyers, T.A., Mitchell, T.G., & Guzzetta, C.E. (1996). Opening
the doors: family presence during resuscitation [Abstract]. Journal of Cardiovascular
Nursing 10 (4), 59-70. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8796490&dopt=Abstract.
Emergency Nurses Association (1995). Presenting the option for family presence
[program educational booklet]. (n.a.). Park Ridge, IL.
Emergency Nurses Association (n.d.). Family presence at the bedside during
invasive procedures and/or resuscitation. Retrieved August 2, 2001, from
http://www.ena.org/services/posistate/statements/FamilyPresence.htm.
Farella, C. (2001). When kin and crash cart collide. Nursing Spectrum Metro
Edition, 2 (1), 14-16.
Gregory, C.M. (1995). I should have been with Lisa as she died. Accident
and Emergency Nursing 3 (3), 136-138. Retrieved August 6, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7627610&dopt=Abstract.
Hanson, C., & Strawser, D. (1992). Family presence during cardiopulmonary
resuscitation: Foote Hospital emergency department’s nine-year perspective.
[Abstract] Journal of Emergency Nursing, 18 (2), 104-106. Retrieved August
2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1573794&dopt=Abstract.
Jarvis, C. (2000). Physical examination and health assessment (3rd ed.).
Philadelphia, PA: W.B. Saunders Company.
Kozier, B., Erb, G., Blais, K., Wilkinson, J., & VanLeuven, K. (2000). Fundamentals
of nursing concepts, process, and practice (6th ed.). Menlo Park, California:
Addison Wesley.
Leske, J.S. (1986). Needs of relatives of critically ill patients: A follow-up.
Heart and Lung, 15 (2), 189-193.
Meyers, T.A. (2000). Viewpoint: Why couldn’t I have seen him? American Journal
of Nursing, 100 (2), 9. Retrieved August 2, 2001, from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=101520.
Meyers, T.A., Eichhorn, D.J., & Guzzetta, C.E. (1998). Do families want
to be present during CPR? A retrospective survey [Abstsract]. Journal of
Emergency Nursing 24 (5), 400-405. Retrieved August 2, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9814254&dopt=Abstract.
Meyers, T.A., Eichorn, D.J., Guzzetta, C.E., Clark, A.P., Klein, J.D., &
Calvin, A. (2000). Family presence during invasive procedures and resuscitation
[Abstsract]. American Journal of Nursing, 100 (2), 32-42. Retrieved August
2, 2001, from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=101523.
Meyers, T.A., Eichhorn, D.J., Guzzetta, C.E., Clark, A.P., Klein, J.D.,
Taliaferro, E., Calvin, A., & Mitchell, T.G. (n.d.). Family presence during
invasive procedures and resuscitation: Best practice Network. Retrieved
August 2, 2001, from http://www.ena.org/services/posistate/statements/FamilyPresence.htm.
Mitchell, M.H., & Lynch, M.B. (1997). Should relatives be allowed in the
resuscitation room? Journal of Accident and Emergency Medicine, 14 (6),
366-369; discussion 370. Retrieved August 2, 2001 from http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9413775&dopt=Abstract.
Molter, N. (1979). Needs of relatives of critically ill patients: A descriptive
study. Heart and Lung, 8.
Offord, R.J. (1998). Should relatives of patients with cardiac arrest be
invited to be present during cardiopulmonary resuscitation? [Abstract].
Intensive Critical Care Nurse, 16 (6), 288-293. Retrieved August 2, 2001,
from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10196912&dopt=Abstract.
Redley, B., & Hood, K. (1996). Management. Staff attitudes towards family
presence during resuscitation. [Abstract]. Accident and Emergency Nursing,
4 (3), 145-151. Retrieved August 6, 2001, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8920399&dopt=Abstract.
Robinson, S.M., Mackenzie-Ross, S., Campbell Hewson, G.L., Egleston, C.V.,
Prevost, A.T. (1998). Psychological effect of witnessed resuscitation on
bereaved relatives. Lancet, 352 (9128), 614 -617. Retrieved August 2, 2001,
from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9746023&dopt=Abstract.
Timmermans, S. (1997). High touch in high tech: The presence of relatives
and friends during resuscitative efforts. Scholarly Inquiry for Nursing
Practice, 11 (2), 153-168; discussion 169-173. Retrieved August 6, 2001,
from
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9329276&dopt=Abstract.
Vanderbeek, J. (2000). Till death do us part. American Journal of Nursing,
100 (2), 44. Retrieved August 6, 2001, from http://www.nursingsociety.org/education/SC0004_add.html#2.
van der Woning, M. (1997). Should relatives be invited to witness a resuscitation
attempt? A review of the literature [Abstract]. Accident and Emergency Nursing
5 (4), 215-218. Retrieved August 6, 2001, from http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9407780&dopt=Abstract.
Test Questions
Please select the correct
answer for each of the following questions. If you answer 80% or more correctly,
you will be given the opportunity to register for continuing education credit.
After receipt of the registration information and fee, a continuing education
certificate will be mailed to you.
Question 1
Families present during invasive procedures and resuscitation perceived:
That everything possible had been done for the patient.
That the visit helped the patient—except when the patient was unconscious.
That the visit had no long-lasting effect on grieving.
That small children were particularly helped by being able to visit.
Question 2
Health care team members expressed the following concern about having a family member present during invasive procedures and resuscitation:
Health care team members feel uncomfortable about being watched.
Health care team members fear family members might interfere with the resuscitation efforts.
Health care team members fear family members might misinterpret the health
care team’s behavior and/or activities.
Question 3
To assess family members’ coping abilities, the nurse could:
Provide for a quiet environment and arrange equipment as much out of view as possible.
Use reality orientation by making references to time and place.
Ascertain the family members’ understanding of the current situation and
the implications.
Question 4
When interviewed after being present during resuscitation, family members indicated:
Family members would choose not to be present if they could do it over.
Family members described their roles during invasive procedures as “helpers.”
Just knowing they could be present if they wished was enough.
Waiting outside the patient area and receiving updates on the patient’s
condition was less traumatic for families than actually seeing for themselves
what was happening.
Question 5
Which of the following is an actual barrier to implementing family presence during invasive procedures and resuscitation?
Lack of sufficient resources to support family members in the resuscitation room
Lack of support by health care administration and providers
Lack of protocols for FP during IP and resuscitation
Question 6
What are the benefits of implementing family presence during invasive procedures and resuscitation?
Health care providers participating in FP are better able to cope with their feelings about unsuccessful resuscitations.
Families know that everything possible was done; they feel that they support the patient; it reduces family anxiety and fear, and eases their grieving.
Families who are present during resuscitation and IP encounter fewer long-term traumatic memories of the event.
Health care providers worry less about litigation because families are less
likely to pursue lawsuits against the health care providers if the resuscitation
is unsuccessful.
Question 7
The most important needs identified by family members of critically ill patients are:
Being with the patient and being accepted, comforted, and supported by health
care personnel.
Being accepted, comforted, and supported by health care personnel, and feel that the patient was being given adequate care.
Being helpful to the patient and being informed of the patient's condition
(excluding impending death).
Being informed of the patient's condition (excluding impending death) and
being with the patient.
Question 8
What is the American Heart Association’s position on family presence during invasive procedures and resuscitation?
They do not recommend family presence during resuscitation.
They have taken no stand on this issue.
They are forming a committee to make recommendations.
They are recommending family presence in the resuscitation room.