chapter

The Familys Experience

With Critical Illness

COLLEEN NORTON

Stress, Critical Illness, and the

Impact on the Family
Coping Mechanisms
The Family and the Nursing
Process
Nursing Assessment
Nursing Interventions
Visitation Advocacy
Use of the Nurse
Family Relationship
Problem Solving With the
Family
Collaborative Management
End-of-Life Issues in
Critical Care
Nursing Interventions at the End
of Life
After the Patients Death
Cultural Issues Related to
Critical Illness
Conclusion

objectives
Based on the content in this chapter, the reader should be able to:
Describe the impact of a critical illness and the critical care
environment on the family.
Describe methods to assess the needs of individual family
members.
Describe nursing behaviors that help families cope with crisis.
Formulate a plan of care that reects the needs of the family.
Discuss end-of-life issues in the critical care environment that
have an impact on the family.
Identify nursing goals and behaviors associated with caring for
dying patients and their families.

here is no one practice against which I can speak

more strongly from actual personal experience, wide
and long, of its effects during sickness observed both
upon others and upon myself. . . . I would appeal most seriously
to all friends, visitors, and attendants of the sick to leave off
this practice of attempting to cheer the sick by making light
of their danger and by exaggerating their probabilities of
recovery.
Nightingale, in her 1859 publication Notes on Nursing,1
addressed the profound effect that visitors, family, and
friends had on the acutely ill. To approach critical care
practice from a holistic perspective, nursing must include
a consideration of the patients family. The interaction
between the family/support system and the patient in the
critical care environment, and the needs that result from
this interaction, remain a challenge and responsibility of
the contemporary critical care nurse.

The Oxford English Dictionary denes family as a group

of persons consisting of the parents and their children
whether actually living together or not; in a wider sense,
the unity formed by those who are nearly connected by
blood and afnity. For the purpose of this chapter, family means any people who share intimate and routine dayto-day living with the critical care patient. Anyone who is
a signicant part of the patients normal lifestyle is considered a family member. The term family describes the
people whose social homeostasis and well-being are
altered by the patients entrance into the arena of critical
illness or injury.
This chapter addresses the family in crisis, stressors in
the critical care environment, coping mechanisms, and the
family and the nursing process. Death and dying is also
discussed, with emphasis given to end-of-life issues for
both the patient and family.
27

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PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

STRESS, CRITICAL ILLNESS, AND

THE IMPACT ON THE FAMILY
A critical illness is a sudden, unexpected, and often lifethreatening occurrence for both the patient and the family that threatens the steady state of internal equilibrium
usually maintained in the family unit. It can be an acute illness or trauma, an acute exacerbation of a chronic illness,
or an acute episode of a previously unknown problem. A
family members entrance as a participant in the lifedeath
sick role of a loved one threatens the well-being of the
family and can trigger a stress response in both the patient
and the family. The family enters this unplanned situation
with its unexpected outcomes and often is forced into the
role of decision maker. The astute critical care nurse recognizes that the fear and anxiety demonstrated by the
patient and family members is an expected consequence of
activation of the stress response, a somewhat protective,
adaptive mechanism initiated by the neuroendocrine system in response to stressors.
Studied initially by Selye in 1956,2 stress was dened as
a specic syndrome that was nonspecically induced. Selye
also discussed the role of stressors, the stimuli that produced tension and could contribute to disequilibrium.
Stressors can be physiological (trauma, biochemical, or
environmental) and psychological (emotional, vocational,
social, or cultural). The critical care environment is rich in
both physiological and psychosocial stressors that threaten
the state of well-being in the patient and family.
In response to a stressor, the ght-or-ight mechanism is activated, releasing through the sympathetic
nervous system the catecholamines norepinephrine and
epinephrine. These hormones are responsible for the
increased heart rate, increased blood pressure, and vasoconstriction that comprise the physiological response to
the alarm stage, the initial stage of the general adaptation
syndrome to stress described by Selye. The alarm stage is
followed by the stage of resistance, which attempts to
maintain the bodys resistance to stress. According to Selyes
theory, all individuals move through the rst two stages
many times and become adapted to the stressors encountered during ordinary life. If the individual is unsuccessful
at adaptation, or if the stressor is too great or prolonged,
alarm and resistance are followed by the stage of exhaustion, which can lead to death, the result of a wearing down
of the human body. It is a challenge to the critical care
nurse to assist both the patient and his or her family
through this stress response, resulting in an adaptation to
the critical care environment. Helping the patients family
resolve the crisis response and facilitate successful coping
by creating a safe passage is an identied competency of the
contemporary critical care nurse.3
After the initial fear and anxiety over the possible death
of the family member, other considerations affect the family, including a shift in responsibilities and role performance, unfamiliarity with the routines of the ICU, and a
lack of knowledge concerning the course and outcome of
the disease. These issues can develop and persist over the
duration of the patients stay in the critical care unit (CCU).
Contributions to the family unit previously attributed
to the patient are added to the responsibilities of others.
Financial concerns are usually major and daily activities

that were of little consequence before become important

and difcult to manage. Chores such as balancing a checkbook, contributing to car pools, and shopping for groceries can become critically signicant if left undone. This
issue requires adding the responsibilities of the patient to
the responsibilities of others.
The social role that the patient plays in the family is
absent during the critical illness. Comforter, organizer,
mediator, lover, friend, and disciplinarian are examples
of important roles in family functioning that may be,
under normal circumstances, fulfilled by the patient.
When that role function is unfulfilled, havoc and grief
may ensue.
The circumstances surrounding the nature of the
patients illness can also be a stressor for the family. In a
sudden, unexpected event, such as a blunt trauma or an
acute myocardial infarction, the life of the family can be
brought to a halt in a matter of minutes. Having little or
no time to prepare for such an event, the family is overwhelmed with a massive amount of unmanageable stress
and can be thrown into crisis. The hospital CCU, in
many instances an unknown entity, becomes the center
of the life of the family. Such stress often can manifest
itself as anger toward the caregiver.
In other instances, the critical event is an acute exacerbation of a chronic but life-threatening illness. Such an
episode brings with it a different set of stressors, reminding the family of difficult and painful times in the past
when they have faced similar circumstances. Prolonged
critical illness can present emotional difficulties for the
family, which may increase the likelihood of crisis.

Coping Mechanisms
Coping mechanisms can be defined as an individuals
response to a change in the environment; they can be
positive or negative. The critical care nurse, as caregiver
to both the patient and family, should be aware of the use
of coping mechanisms by the family as a means of maintaining equilibrium. A sense of fear, panic, shock, or
disbelief is sometimes followed by irrational acts, demanding behavior, withdrawal, perseveration, and fainting.
The family attempts to obtain some sense of control over
the situation, often demonstrated by refusing to leave the
bedside or, alternatively, by minimizing the severity of
the illness. Reactions to crisis are difficult to categorize
because they depend on the different coping styles, personalities, and stress management techniques of the family. The nurse must be able to interpret the feeling that
a person in crisis is experiencing, particularly when that
person cannot identify the problem or the feeling to
himself or to others. The following are four generalizations about crisis:

Whether people emerge stronger or weaker as a

result of a crisis is based not so much on their character, as on the quality of help they receive during a
crisis state.
People are more open to suggestions and help during an actual crisis.
With the onset of a crisis, old memories of past crises
may be evoked. If maladaptive behavior was used
to deal with previous situations, the same type of

CHAPTER 3

behavior may be repeated in the face of a new crisis.

If adaptive behavior was used, the impact of the crisis may be lessened.
The primary way to survive a crisis is to be aware
of it.

THE FAMILY AND

THE NURSING PROCESS
Nursing Assessment
Nursing assessment by the critical care nurse involves
more than an appraisal of the patient. It is also the responsibility of the nurse to include members of the family in
order to provide holistic nursing care. The nursing assessment serves as a database on which care of the patient and
family can be supported. It includes not only physiological responses, but psychological, social, environmental,
cultural, economic, and spiritual reaction. It involves an
assessment of verbal and nonverbal behavior, and requires
clinical expertise. A thorough nursing assessment guides
the formulation of nursing diagnoses. The standards of
the American Association of Critical-Care Nurses emphasize and support the importance of an assessment of the
family and the continual involvement of the family in the
nursing care of the patient.4
An important part of the family assessment is a history
of the family. Who does the patient include in the description of his family? Although all patients belong to a family, the family might not include or be restricted to blood
relatives. Who are the people most upset about the
patients illness? Is there a formal or informal leader identied by the group? This becomes important when communicating with the family in decision making, as well as
with legal matters, such as obtaining consent. What is the
coping style of the family? Does the family have a history
of dealing with a critical illness? What are the relationships between the members of the family? How close is
the family? The family history can aid the nurse in interpreting how the family is coping with stress, how their
coping mechanisms will affect the patient, and how they
are adapting to the patients illness.
Four intrinsic elements of an assessment of the family
include:
1.
2.
3.
4.

Providing a human, caring presence

Acknowledging multiple perceptions
Respecting diversity
Valuing each person in the context of the family5

Numerous assessment tools are available to aid the

nurse in determining the needs and problems the family
faces. One of the initial assessment tools was developed by
Molter in 1979.6 This method included a 45-item needs
assessment tool, which became an instrument to describe
the needs of critical care family members. Leske modied
the tool used by Molter by adding an open-ended item
and calling it the Critical Care Family Needs Inventory
(CCFNI).7 The CCFNI continues to be used today in
nursing research on the needs of critical care family
members. Medonca and Warren used the CCFNI to
assess the needs of family members and the importance

The Familys Experience With Critical Illness

29

of these needs in the first 18 to 24 hours after admission

of the adult patient to the CCU.8
Nursing research using these tools reveals consistency
in what areas should be assessed with family members.
These areas include but are not limited to:
1.
2.
3.
4.
5.

Family satisfaction with care given

Explanations that the family can understand
Honest information about the patients condition
An understanding of why things are done
Staff members who are courteous and show interest in how the family is doing
6. Assurance that someone will call the family with
any changes
The tools also suggest assessing how comfortable the
family is in the waiting room and inquiring about what
things could be made better for them. Strong communication skills on the part of the critical care nurse, as well as
an atmosphere of concern and caring, help to gather the
subjective and objective assessment data and formulate the
appropriate nursing diagnoses for the family. Examples of
nursing diagnoses appropriate to the family members of a
critically ill patient are given in Box 3-1. The nursing diagnosis guides both the nurse and the family in establishing
mutual goals. Addressing informational needs reects
only part of the familys adjustment to the critical illness.
Nursing interventions should address cognitive, affective,
and behavioral domains.9

Nursing Interventions
The time spent by the critical care nurse with the family
is often limited because of the physiological and psychosocial needs of the patient. Therefore, it is important
to make every interaction with the family as useful and

box 3-1 Examples of Nursing Diagnoses and

Collaborative Problems for the Family With
Critical Illness or Injury

Altered Role Performance

Altered Family Process
Altered Parenting
Caregiver Role Strain
Denial
Spiritual Distress
Ineffective Individual/Family Coping
Ineffective Denial
Decisional Conflict
Altered Health Maintenance
Sleep Pattern Disturbance
Hopelessness
Powerlessness
Knowledge Deficit
Impaired Memory
Anticipatory Grieving
Anxiety
Fear

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THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

box 3-2 nursing interventions for

Care of the Family in Crisis

Guide the family in defining the current problem.

Help the family identify its strengths and sources of support.
Prepare the family for the critical care environment,
especially regarding equipment and purposes of the
equipment.
Speak openly to the patient and the family about the
critical illness.
Demonstrate a concern about the current crisis and an
ability to help with the initial relationship.
Be realistic and honest about the situation, taking care
not to give false reassurance.
Convey feelings of hope and confidence in the familys
ability to deal with the situation.
Try to perceive the feelings that the crisis evokes in the
family.
Help the family identify and focus on feelings.
Assist the family to determine the goals and steps to take
in facing the crisis.

therapeutic as possible. Nursing interventions should be

designed to:

Help the family learn from the crisis experience and

move toward adaptation
Regain a state of equilibrium
Experience the normal (but painful) feelings associated with the crisis, to avoid delayed depression and
allow for future emotional growth

Suggestions for nursing interventions with the family in

crisis are outlined in Box 3-2. Considerations for the pediatric patient and the older patient are provided in Box 3-3
and Box 3-4, respectively.

Provide opportunities for the patient and the family to

make choices and avoid powerlessness and hopelessness.
Assist the family in finding ways to communicate with the
patient.
Encourage the family to help with the care of the patient.
Discuss all issues as they relate to the patients uniqueness,
avoiding generalizations.
Help the family to set short-term goals so that progress
and positive changes can be seen.
Ensure that the family receives information about all
significant changes in the patients condition.
Advocate the adjustment of visiting hours to accommodate
the needs of the family as permitted by the situation in the
unit.
Determine if there is space available in the hospital near
the unit where the family can be alone and have privacy.
Recognize the patients and familys spirituality, and suggest the assistance of a spiritual advisor if there is a need.

Visitation Advocacy
The use and provision of visiting hours has long been a disputed, misunderstood topic between the nurse and the family. Visiting hours in the CCU were restricted for many
years, with the rationale that rest, quiet, and an undisturbed
environment were all therapeutic nursing interventions.
Families often interpreted these restrictions as being denied
access to their loved ones.
As early as 1978, Dracup and Breu reported that satisfying the needs of the families of patients was improved by

box 3-4
Providing Care for the Critically Ill
Older Patient
box 3-3
Providing Care for the Critically Ill Child

Provide parents with accurate, clear, honest, up-to-date

information and explanations throughout treatment.
Consistently involve the family in care and comfort of
the pediatric patient.
Involve the family actively in preparing the plan of care.
Allow parents open visiting time as well as private time.
Validate the positive behaviors observed in the parents
during their care of the child.
Respect the parents right to make as well as change
decisions about treatment options for the child.
Demonstrate the commitment of the nurse to the care
and comfort of the child.
Expose the family to all the members of the health care
team, especially when making decisions.

Respect the dignity, intelligence, privacy, and maturity

of the patient at all times.
Maintain the patients right to make decisions as long
as possible.
Avoid the use of paternalism in patient care.
Integrate the physiological and cognitive changes of
aging with the assessment and care of the patient.
Allow the family to share in the care of their family
member.
Provide active participation and a sense of control for
the patient and family.
Ascertain that the patient remains the focus of care,
and that interventions are performed for the good of
the patient.
Assess the impact that medical and nursing interventions play on quality of life and sense of well-being.
Determine family burden.

CHAPTER 3

relaxing a policy of restricted visiting hours and initiating

set communication with patients spouses.10 Increased visiting time was seen as a strategy to improve coping skills
and strengthen the relationship between nurses and the
family members of patients.11 Over time, many units
began the policy of unrestricted visiting hours. Such interventions were designed to strengthen the relationship
between the family and health care provider as well as foster adaptation to the crisis on the part of the family.
Through nursing research, family presence at the bedside
has also been shown to decrease the patients intracranial
pressure (ICP), decrease patient and family anxiety, increase
social support for the patient, and give the patient some
sense of control over the situation. These ndings support
the need for less restrictive and individualized visiting policies for patients and families. The focus should be on what
proves best for the patient, and not on what is dictated by
tradition or nurse preference.
Critical care nurses must take the responsibility for
revising visiting hours to meet the needs of patients and
families. When choosing a less restrictive policy, the physical layout of the unit must be considered. Smaller units
may not be appropriate for unrestricted visiting hours
with unlimited visitors. The effectiveness of changes in
visiting hours must also be evaluated. Additional nursing
research is needed to determine the effect of changes in
visiting hours on the needs of patients and families.
Family members should be prepared for the initial visit
to the CCU because it can be an overwhelming environment. The function of monitors, intravenous drips, ventilators, and other technologies, as well as the meaning of
alarms, should always be explained before and during the
family visits. The names, roles, and responsibilities of all
members of the health care team should also be identied
to both the patient and family. The nurse, by example, can
demonstrate the value of communication and touch to the
family. Encouraging family members to provide direct
care to the patient, if they are interested, can help to
decrease anxiety and provide the family with some control. Direct care activities for the family to perform may
include brushing teeth, combing hair, helping with a meal,
or giving a bath.
Allowing children to visit a CCU may require special
arrangements on the part of the staff. Visits should include
short, simple explanations to the child concerning the
patients condition. Answering the childs questions in
terms that he or she can understand helps reduce possible
fears. The person who is escorting the child into the CCU
should be aware that invasive monitoring and other equipment might upset a youngster. If a visit from the child is not
possible, arrangements can be made for a telephone visit.

Use of the NurseFamily Relationship

Initiating nursing interventions and establishing a meaningful relationship with the family tends to be easier during
crisis than at other times. People in crisis are highly receptive to an interested, caring, and empathetic helper. When
rst meeting the patients family, the nurse must demonstrate the desire and ability to help. Help that is specic to
the familys needs at that time demonstrates the nurses
interest. Deciding who is to be notied of the patients sta-

The Familys Experience With Critical Illness

31

tus and validating that contact persons telephone number

can be an overwhelming task. Assisting the family to determine immediate priorities is essential in the early phase of
crisis intervention.
With this type of timely involvement, the family will
begin to trust and depend on the nurses judgment. This
process then allows family members to believe the nurse
when the nurse conveys feelings of hope and condence
in the familys ability to cope with whatever is ahead of
them. It is important to avoid giving false reassurance;
rather, the reality of the situation should be expressed in a
kind, supportive fashion.

Problem Solving With the Family

As the relationship between the nurse and the family
develops from one interaction to another, the nurse is able
to begin to understand the dynamics of the problem facing the family. Problem solving with the family takes into
consideration items such as:

The meaning the family has attached to the event

Other crises with which the family may be coping
The adaptive and maladaptive coping behaviors previously used in time of stress
The normal support systems of the family, which
might include friends, neighbors, clergy, and colleagues

Using the assessment base, the nurse is able to help the

family deal with the stress. Areas to include in interventions are dening the problem, identifying support, focusing on feelings, and identifying steps.
DEFINING THE PROBLEM
A vital part of the problem-solving process is to help the
family clearly state the immediate problem. Often people
are overwhelmed and immobilized by the free-oating anxiety or panic caused by acute stress. Regardless of the difculty or threat the problem implies, being able to state it as
such reduces the anxiety by helping the family realize that
they have achieved some sort of an understanding of what
is happening. Dening the problem is a way of delimiting
its parameters.
Dening and redening problems can occur many
times before the problem is solved. Stating the problem
clearly helps the family assign priorities and direct needed
actions. Goal-directed activity helps decrease anxiety.
IDENTIFYING SUPPORT
Under high levels of stress, some people expect themselves to react differently. Rather than turning to the
resources they use daily, they become reluctant to involve
them. Asking people to identify the person to whom they
usually turn when they are upset, and encouraging them
to seek assistance from that person now, helps to direct the
family back to the normal mechanisms for handling stressful issues. Few families are truly without resources; rather,
they only have failed to recognize and call on them.
Dening and redening the problem may also help to
put the problem in a different light. It is possible in time
to view tragedy as a challenge and the unknown as an
adventure. The process of helping the family view a problem from a different perspective is called reframing.

32

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

The nurse can also help the family call on its own
inherent strengths. What is it as a family that they do best?
How have they handled stress before? Encouraging the
family members to capitalize on their strengths as a family unit is well worth the effort.
FOCUSING ON FEELINGS
A problem-solving technique emphasizing choices and
alternatives helps the family achieve a sense of control
over part of their lives. It also reminds them, and claries
for them, that they are ultimately responsible for dealing
with the event and that they will live with the consequences of their decisions.
Helping the family focus on feelings is extremely important to avoid delayed grief and protracted depression in the
future. The reection of feelings or active listening is necessary throughout the duration of the crisis. Valuing the
expression of feelings might help the family avoid the use
of unhealthy coping mechanisms, such as alcohol or
excessive sleep. In difficult and sad times, the critical care
nurse can promise the family, with some certainty, that
things will become easier with the passage of time. Adaptation takes time.
During the difcult days of the critical illness, the family may become dependent on the judgment of professionals. The family may have some difficulty identifying the
appropriate areas in which to accept the judgments of
others. It is important that the nurse acknowledges the familys feelings and recognizes the complexity of the problem,
while emphasizing the responsibility each member of the
family has for his or her feelings, actions, and decisions.
IDENTIFYING STEPS
Once the problem has been dened and the family begins
goal-directed activities, the nurse may help further by asking the family members to identify the steps that they
must take. Such anticipatory guidance may help to reduce
the familys anxiety. The nurse, however, must recognize
moments when direction is vital to health and safety. It is
often necessary to direct families, for example, to return
home to rest. This can be explained by stating that by
maintaining their own health, family members will, at a
later date, be as helpful to the patient as possible. To make
each interaction more meaningful and therapeutic, the
nurse should focus on the crisis situation and avoid involvement in long-term chronic problems.

Collaborative Management
The health care providers who most often meet the needs
of family members are generally thought to be nurses and
physicians. Additional help comes in the form of written
materials, other family members, the patient, and other hospital sources. In some cases, nurse-coached hospital volunteer programs have proven to be effective.12 These programs
consist of an inservice program taught by nurses and followed by the assignment of a nurse mentor to the volunteer.
Some families benet by a referral to a mental health clinical specialist, a social worker, a psychologist, or a chaplain.
A nurse can best encourage the family to accept help from
others by acknowledging the difculty and complexity of the
problem and providing several names and phone numbers.
It may be appropriate for the nurse to set up the rst meet-

ing, with follow-up meetings coordinated between the family and the consultant. Many CCUs have such resources on
a 24-hour on-call basis to ensure prompt interventions. An
objective professional with experience in critical illness and
its impact on the family can be an excellent resource.

END-OF-LIFE ISSUES
IN CRITICAL CARE
The goal of CCUs has long been viewed as assisting
the individual to survive a life-threatening physiological
process. Integral to that survival is the critical care nurse
who, with the assistance of advanced assessment modalities, multiple pharmacological agents, and sophisticated
technology, directs the care of the patient and the family.
Although healing is the goal, in reality the chance of being
a patient in a CCU during the last 6 months of life ranges
from 9% to 47%.13 Approximately 10% of people admitted to the CCU will die there, and 20% may leave the
CCU but die before discharge from the hospital.13,14 The
prevalence of debilitating chronic diseases in people older
than 65 years offers a challenge to the curative model of
todays CCU. This demonstrates the need for the critical
care nurse, long focused on curative care, to become procient as well in the delivery of palliative care.
Four cultural forces that are thought to inuence the
end-of-life care in CCUs are:
1. Biomedical knowledge as the dominant conceptual framework for understanding old age and
death (that is, death has become another disease
to be treated)
2. The power of the technological imperative to
determine events
3. The incompatibility of lay and medical knowledge
4. An ambivalence about end-of-life goals.15
Family members are unprepared for what they see and
the language they hear. They are confused and overwhelmed by the decision making required of them, and
are unable to transfer medical terminology into lay vocabulary. Critical care nurses can bring an awareness of these
issues into their units and into their individual practices.16
An important component of palliative care is the inclusion of the family in decision making and the provision of
patient care. Families are faced with complex end-of-life
decisions that must be made in the unfamiliar CCU.
These decisions can be made easier with the involvement of
the nurse in facilitating and guiding the decision-making
process. The focus of nursing care at the end of life should
be the entire family. This is often difcult in acute care
units with time and space constraints. Nurses personal
issues, such as previous experiences with the death of their
own family members, have the potential either to enhance
or threaten assessment and intervention.

Nursing Interventions at the End of Life

Nursing care is an essential component of improving endof-life care in todays CCUs. Miller and colleagues explored
cultural issues inuencing end-of-life care and factors that
surround the limited involvement of critical care nurses in
end-of-life decision making and care planning.16 Their recommendations for changing nursing practice include:

CHAPTER 3

The Familys Experience With Critical Illness

33

insights into clinical research

Meyers T, Eichorn D, Guzzetta C, et al: Family presence during invasive procedures and resuscitation. Am J Nurs
100(2):3242, 2000, and Meyers T, et al: Family presence during invasive procedures and resuscitation: Hearing the voice of
the patient. Am J Nurs 101(5):4855, 2001.

The purpose of this original nursing research study was to

explore, both quantitatively and qualitatively, the effects of
family presence at the bedside while their loved ones underwent cardiopulmonary resuscitation (CPR) or invasive
procedures. Thirty-nine family members and 96 health
care providers were surveyed after 43 instances of family
presence.
Results of the quantitative analysis revealed that families
perceived visitation as a positive experience and that they
believed being with the patient was their right. Family
presence helped the family members feel like active participants in the care process, and that this met their needs for
knowing about, providing comfort to, and connecting with
the patient. All the participating families felt that visitation
was helpful to them and that they would do it again. Family members who visited with their loved ones during emergency care suffered no ill physiological effects.
The views of the health care providers differed signicantly. More nurses and attending physicians supported
family presence than residents. Although 88% of the
health care providers thought family presence should be
continued, 38% expressed concerns about possible disrup-

Analyzing management of pain and other signs and

symptoms
Evaluating the involvement and support of the
patients family members
Evaluating protocols for withdrawal of life support
Developing strategies to involve family members in
care planning
Analyzing the patients and familys preparation for
death

Although end-of-life skills involve life-long learning,

indicators that are important for nurses include improved
listening skills, attention to the proper environment for
end-of-life discussions, and a willingness to facilitate endof-life discussions.17
As stated earlier, open visitation practices are benecial
in CCUs. This is especially true at the end of life. Although
restricted visiting hours tend to limit noise and promote
patient rest, research suggests that most nurses do not
restrict visitation by family members, even where restricting visiting hours are in place.18
Caring for a patients family at any point during the
dying process encompasses three major areas: access, information and support, and involvement in caregiving activities. Family members of dying loved ones should be
allowed more liberal access in both visiting hours and number of visitors allowed. Ensuring that a family can be with
their critically ill loved one will be a source of comfort.
Information has been identied as a crucial component in
the familys coping, and support in the form of the nurses
caring behaviors is inuential in shaping the critical care
experience for both the patient and family. Honesty and
truth telling are important skills in this emotionally charged

tions by family members during visits, although no such

instances had occurred during the study.
Results of the qualitative analysis identified seven
themes. Three of these related to the positive effects that
family presence had on patientsit comforted them,
provided help, and served to remind providers of the
patients personhood. Two themes involved how family
presence reflects the reciprocal nature of the patient
family bonds and the patients right to have the family
present. The remaining two themes characterized how
patients perceived the effects of the experience on their
families and the health care environment. Patients saw
both positive and negative effects on those who were present but felt the benets to families outweighed the potential problems.
Although the researchers suggest further study on this
topic, it was clear that family presence appeared to deliver
many benets, with apparently few drawbacks or adverse
effects to patients, their families, and their care providers. As
a result of the authors research, a hospital-wide protocol for
family presence during CPR and invasive procedures was
approved and implemented in their health care facility.

time. Finally, family involvement in caregiving, in tasks as

simple as being physically present to those as complex as
assisting with postmortem care, may help families work
through their grief. Facilitation of family involvement is a
practical nursing intervention.19

After the Patients Death

The manner in which a family is informed of a death has a
signicant impact on the grief response. The family should
be escorted to a quiet, private room, near the patients
room, which is accessible to other arriving family members.
Emotional support for the family at this time is critical. Specic information should also be provided to the family on
an ongoing basis. When death appears to be the probable
outcome, the family must be notied in a clear, concrete
manner. Acceptance of death is facilitated by preparation.
The pronouncement of death requires a caring, empathetic approach. Two health care team members should
be identied to approach the family, one to notify the family of the death and the other to offer support to the grieving family. It is important to use the term death and to
avoid more abstract terms that might lead to anxiety and
confusion. A warm, compassionate, honest tone should be
used, and the information should be repeated.
The nurse can offer to contact a clergy member. It is
important to recognize the spirituality of the patient, and
contact with a spiritual advisor should be made. Requests
by the family for specic people or cultural rituals after the
death should be encouraged and honored.
The viewing of the body is the most difcult time for
many family members, second only to the pronouncement

34

PART 1

THE CONCEPT OF HOLISM APPLIED TO CRITICAL CARE NURSING PRACTICE

of death. Viewing of the body has been found to be benecial for the family because it makes the loss real, allows
family members to say goodbye, and in the case of sudden
death, eliminates any question or confusion. Family members should always be given the option of viewing the body
and they should be allowed to make this decision on an
individual basis. It is important to ask more than once,
because family members may change their minds after
rst declining the offer.
The nurse should prepare the family for the condition of
the body and describe the presence of any wounds, dressings, or tubes. The family should be allowed to stay as long
as they feel is necessary and to come back and forth and stay
at the bedside. Intense emotional reactions sometimes
occur and may be a cultural method of grieving. Should this
behavior occur, the nurse could compassionately confront
the individual and escort him to a quiet place until composure is regained.
After the viewing, a health care team member should
stay with the family to help complete the appropriate
paperwork, to answer any questions about the patients
death, and to provide brief grief counseling. The family
will benet from a referral to a grief support group. If possible, the family should be escorted out of the hospital. A
member of the staff should make a follow-up phone call
24 to 48 hours after the death.

CULTURAL ISSUES RELATED TO

CRITICAL ILLNESS
Nursing interventions for the critically ill patient should
also include recognition and appreciation of the cultural
uniqueness of each individual. In todays diverse society,
culture affects the nursing care of patients in many ways
from pain control and visitation expectations to care of the
body after death. Critical care nurses must recognize the
uniqueness of each individual, and the ways in which that
uniqueness affects the needs of the family.
A health care provider in Western medicine often
addresses a critical illness as a disease process and focuses on
the physical symptoms, the pathology of organ function, or
injury to a body part. The patient and family, having a different cultural perspective, may view the illness in a more
psychophysiological manner, focusing on the physical, psychological, personal, and cultural ramications of the illness. In other cultures, the patients critical illness may be
viewed as a curse or disharmony in the universe.
Although it is unrealistic to expect that the nurse
should know the customs and beliefs of all critically ill
patients he or she cares for, it is not unreasonable to expect
some degree of cultural competence. Glass and colleagues
make the following suggestions20:

Be aware of ones own ethnocentrism.

Assess the familys beliefs about illness and treatment.
Consistently convey respect.
Request that the family and patient act as guides for
cultural preferences.
Ask for the patients personal preference.
Respect cultural differences regarding personal space
and touch.

Note and allow if possible the use of appropriate complementary and alternative medical (CAM) practices.
Incorporate the patients cultural healing practices
into the plan of care.
Be sensitive to the need for a translator.

Cultural characteristics such as language, values, behavioral norms, diet, and attitudes toward disease prevention,
death and dying, and management of illness vary from culture to culture. Critical illness may be viewed by the family from a religious or spiritual perspective. Astuteness and
sensitivity on the part of the critical care nurse ensure that
the beliefs of the highly technological, illness-focused
health care system will not clash with cultural beliefs in folk
medicine, rituals, religious healing, and medicine men.

CONCLUSION
The nature of the critical care environment exposes the
nurse to repetitive achievements and losses. It is essential
that the nursing staff in CCUs support each other, especially
by listening in a tolerant way when a colleague is expressing
what might be interpreted as an unacceptable feeling.
Critical care nursing requires concern, compassion,
caring, and a quick mind. Many of these talents come with
professional maturity and specic educational opportunities as well as supervision from appropriate role models.
The intensity of emotion and involvement demanded by
a nurse in critical care makes these nurses particularly vulnerable to the burn-out syndrome.
Nurses providing crisis intervention for families under
stress is an important preventive mental health function.
The nurses knowledge of, and proximity to, the problem
allows him or her to act as a rst-line resource professional. As a patient advocate, the role of the nurse is to
realize and point out that dealing with a psychological crisis in the family greatly affects the recovery and well-being
of the patient and decreases the chances for further disequilibrium in the family unit.

clinical applicability challenges

Self-Challenge: Critical Thinking
1. Mrs. Jones is a critically ill patient with multiple trauma

who has been admitted to your unit. She is not expected to

survive her injuries. Mrs. Jones husband, her two children
ages 6 and 10, and her parents have just arrived on your
unit. Formulate a plan of care that reects end-of-life issues
that will assist the Jones family in dealing with the probable
death of their loved one.
2. Mr. Ernest is a 73-year-old man admitted to your unit
postresuscitation. He has a long-standing history of cardiac
disease and collapsed at home after what has been interpreted as a life-threatening rhythm disturbance. Although
he received cardiopulmonary resuscitation (CPR), he was
unconscious for 10 minutes before the rescue team arrived.
His older daughters are ghting over the maintenance of
ventilatory support. Discuss how you would help his daughters at this difcult time.

CHAPTER 3

3. Mr. and Mrs. Patel are the parents of a critically ill patient

on your unit. They are Indian and speak very little English.
Describe the criteria you would use to assess their degree of
stress and anxiety. How could you be certain that the cultural needs of the Patel family will be met while their child
is a patient in your unit?

Study Questions
1. To help the family develop a sense of control, the nurse may
a. offer reassurance that the patient is receiving the best

possible care.
b. refer family members to a grief counselor or clergy.
c. offer choices for the family whenever possible.
d. all of the above
2. Assisting the family members to dene or state a problem
associated with a crisis is useful because it
a. decreases their sense of understanding of the problem.
b. implies parameters or limits of the problem.
c. denies family members a sense of cognitive mastery.
d. all of the above
3. The family enters a crisis under several conditions. Identify
the conditions most likely to increase the probability that the
family will enter a crisis.
a. An event has lasting consequences for a family.
b. A familys ability to problem solve is inadequate.
c. The equilibrium of the family is disturbed.
d. All of the above

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