Cardiopulmonary Resuscitation

Evidence Based Practice

Presentation
Group E

Introduction/Description of Nursing Practice

Issue

Family presence during resuscitation (FPDR) vs. requiring family to leave the
room during CPR - which practice promotes the best family outcomes?
Goal = identify the evidence-based best practice that optimizes family-centered
nursing care

Clinical Question (PICOT)

Does allowing the family of a patient undergoing cardiopulmonary resuscitation
(CPR) to be present during CPR versus restricting family presence promote positive
patient family outcomes as reported by the family during the time period
immediately following termination of CPR and up to a year after the event?
P: the family of a patient undergoing cardiopulmonary resuscitation (CPR)
I: to be present during CPR
C: restricting family presence
O: positive patient family outcomes as reported by the family
T: during the time period immediately following termination of CPR and up to a year after the event

Summary of Current Practice

-

The concept of FPDR came about ~ 20 years ago, and is gradually being accepted by
healthcare institutions and professionals.
In the past, FPDR has been viewed as inappropriate and harmful to families, as well as
inconvenient and distracting to healthcare professionals.
However, current research supports FPDR, presenting evidence that this practice is
beneficial to patients and families, as it meets their psychosocial needs in a time of crisis.
This new evidence has prompted many institutions to develop formal policies and
protocols for FPDR implementation, and previously noted concerns of healthcare
professionals (i.e. distraction, increased stress, fear of litigation) have been shown to
decrease with well-implemented FPDR protocols
Despite these evidence-based recommendations, only 5% of critical care units in the U.S.
have written policies that allow FPDR.
(American Association of Critical-Care Nurses, 2016)
(Porter, Cooper, & Sellick, 2013)

Summary of Current Practice

Institutions currently implementing FPDR have written protocols stating exactly what is
expected. These protocols include:
- Criteria for assessing the family to ensure uninterrupted patient care
- Standard procedure for presenting the option of family presence to the family
- Role of the family facilitator (nurses, social workers, physicians, or chaplains) in
preparing families for being at the bedside and providing support before, during, and after
the event
- Contraindications to family presence (e.g. family members who demonstrate combative or
violent behaviors, uncontrolled emotional outbursts)
- Proficiency standards for all staff involved in family presence
- Emphasis on staff support of the patients or family members decision regarding
FPDR--whether they choose family presence or not.
(American Association of Critical-Care Nurses [AACN], 2007)
(Porter, Cooper, & Sellick, 2013)

Summary of Strengths and Limitation of the Current Research

Studies Reviewed

Level of evidence is primarily level VI

Level I: 1 Qualitative literature review

Level II: 2 Randomized controlled trials
Level III: 1 Quasi Experimental
Level VI: 5 Descriptive qualitative, cross sectional, and exploratory studies

Sample Size: Ranges from 14 to 570 participants

570, 408, 309, 154, 65, 49, 48, & 14 participants

Qualitative literature review included 14 research articles

Summary of Strengths and Limitation of the Current Research

Strengths:

Data collection in the studies used in-depth surveys/questionnaires or multiple validated assessment tools.
Reviewing multiple studies allows for inclusion of data collected from both healthcare professionals and family
members.
Data collected from various time periods after CPR effort and FPDR.
Evaluation and data collection for both inpatient and outpatient settings.

Limitations:

Research evidence gathered primarily from emergency response units and intensive care units.
Randomized controlled trials did not actively restrict FPDR so secondary analysis was used to evaluate actual
family presence; however, this was not the basis of randomization.
Potential research bias.
Characteristics of the event and outcome of CPR was not always indicated, this may have had an effect on the
findings.

Synopsis
The majority of research has shown that FPDR has more perceived advantages
than disadvantages for family members and the patient (including lessened PTSD,
depression, complicated grief, etc)
However, the literature has also shown that the perspective of healthcare providers
can differ. Some HCPs believe that family presence during the beginning of CPR
prevents the health care workers from performing their jobs promptly. This could
affect the quality of CPR by delaying initiation time.
ISSUE: Although FPDR presents a more postve psychologcal outcome for patents
and famly members, does the practce affect the qualty of the code event?

Recommendations for Best Practice

Family members of all patients undergoing resuscitation should have the option to have family presence at the bedside
All patient care units should have an approved written practice document (policy, procedure, standard of care) for
presenting the option of family presence during resuscitation (giving family time to process)
It is important to find a way to improve experiences and attitudes of healthcare professionals related to this
phenomenon. Furthermore, developing local guidelines and multidisciplinary training plans is needed to respond to the
needs of patients and their families.
There is little evidence to indicate that the practice of family member presence is detrimental to the patient, the
family or the health care team
There is evidence that health care professionals support the assignment of a designated health care professional to
family members that are present, in order to provide explanation and comfort

(Twibell, R. S., Craig S., Siela D., Simmonds, S., & Thomas, C., 2015)
(Filho, C. M. C., Santos, E. S., Silva, R. C. G., Nogueira, L. S., 2015)
(Jabre, P. et al, 2014).

Application and Guidelines for FPDR

1. Ensure that your health care facility has written policies and procedures that support family presence during resuscitation - should no such
policy exist, an interdisciplinary task force composed of various healthcare personnel should meet to develop a family presence policy
2. Policies and procedures and educational programs for professional staff should include the following components:
Benefits of family presence for the patient and the patients family
Criteria for assessing the patients family to ensure uninterrupted patient care
Role of the family facilitator in preparing families for being at the bedside and supporting them before, during, and after the event, including
handling the development of untoward reactions by family members; family facilitators may include nurses, physicians, social workers, chaplains,
child life specialists, respiratory therapists, and nursing students
Support for patients or family members decision not to have family members present
Contraindications to family presence (eg, family members who demonstrate combative or violent behaviors, uncontrolled emotional outbursts,
behaviors consistent with an altered mental state from drugs or alcohol, or those suspected of abuse)
Family presence during resuscitation and invasive procedures. (2016). Crtcal Care Nurse, 36(1), e11-4. doi:10.4037/ccn2016980

Application and Guidelines for FPDR

3. Determine your units rate of compliance in offering patients families the option of family presence during resuscitation; if
compliance is < 90%, develop a plan to improve compliance:
Consider forming a multidisciplinary task force (ie, nurses, physicians, chaplains, social workers, child life specialists) or a unit core
group of staff to discuss approaches to improve compliance
Re-educate staff about family presence; discuss the intervention as a component of family-centered care and evidence-based practice
Incorporate content into orientation programs as well as initial and annual competency verifications
Develop a variety of communication strategies to alert and remind staff about the family presence option
4. Develop proficiency standards for all staff involved in family presence to ensure patient, family, and staff safety
5. Develop documentation standards for family presence and include rationale for when family presence would not be offered

Family presence during resuscitation and invasive procedures. (2016). Crtcal Care Nurse, 36(1), e11-4. doi:10.4037/ccn2016980

Implementation of FPDR

Timeline for Implementation into Practice

Cost Analysis for Implementation (Alaina)

-The average hourly rate for Registered Nurses in Arizona is $25-30/hr.
-Units included for the cost analysis are Emergency Room and Intensive Care Units.
-At Banner University Medical Center, these units contain approximately 50-60 nurses. There are around 200-250 nurses
that would need to be trained.
-Each employee would need approximately 1 hour of computer based training annually on family presence during CPR.
-This would cost the hospital $5,000- $7,500 for nurse training.
-Physician training would be included in their annual training. This would not be an additional cost to the hospital.
(Citation)

Risks vs. Benefits to Hospital and Patient (Karen)

Risks

Some health care providers believe that families could be traumatized from the unpleasantness of what
they may witness during intensive procedures including CPR.
However, evidence does not support this concern, with many studies showing a decrease in
traumatization or PTSD.
Concerns persist among health care provider that FPDR will increase malpractice litigation.

However, evidence shows that improved patient and family communication decreases lawsuits.

Additionally, hospitals that have implemented FPDR policies have not reported increased
litigation.
Health care providers have concerns that families may interfere with how the code is run and worry
that family presence may serve as a distraction during the resuscitation process.

Although, one study showed the detrimental effect of FPDR on the performance of trainee
physicians during a simulated, particularly with disruptive families, no data from real-life
situations shows that FPDR worsens the quality of resuscitative efforts.

Risks vs. Benefits to Hospital and Patient (Karen)

Benefits

FPDR can help families understand the seriousness of their loved ones condition.
Witnessing the resuscitation removes doubt in the family about what is happening to the patient and
the family is able to see everything that is being done for their loved one.
It may be that witnessing the trauma of unsuccessful resuscitative efforts can facilitate surrogate
decision-makers comfort with suspending further resuscitation attempts.
FPDR can also promote closure and assist with grieving for family members after unsuccessful
resuscitations.
The family moves more positively through the grieving process; decreased symptoms of PTSD, major
depression, and complicated grief.
For patients with some awareness of their surroundings (such as when a patient awakens shortly after
a successful resuscitation), FPDR can provide comfort through the presence of loved ones.
FPDR provides an opportunity for the health care team to educate family members about the patients
condition and the steps that are being taken to provide appropriate patient care.
FPDR reminds clinicians of the patients personhood, and may promote more professionalism at the
bedside.

Specific study findings paraphrased from Jabre et al., 2013 & 2014, Tudor et al., 2014, and Twibell et al., 2015. Conclusions interpreted from all
research articles referenced.

Evaluation (Megan)
Evaluation: Identify measurable, realistic, specific, timely outcomes, which will indicate whether your solution will be successfully
implemented.

To evaluate family members psychological state: Evaluation to be completed within 1 week of CPR, and again at 3
months and 12 months post CPR. A psychologist, ask family members to complete different questionnaires: the
impact of event scale (IES), the hospital anxiety and depression scale (HADS), the inventory of complicated grief
(ICG), and the structured diagnosis of a major depressive episode (MINI).
Also evaluate hospital staff training and education concerning new CPR protocol within one year of use. Include this
role in practice or mock codes. Annual nursing education exams to evaluate familiarity with the protocol and
reasons for implication.
Hospitals have patient satisfaction surveys; have specific surveys for these family members evaluating their
experience and perceived helpfulness of staff during the resuscitation process.

Summary (Kit)

References
AACN Practice Department Editors, & Cox, B. (2007). AJCC patient care page. family presence during CPR and invasive procedures.
Amercan Journal of Crtcal Care : An Offcal Publcaton, Amercan Assocaton of Crtcal-Care Nurses, 16(3), 283.
doi:16/3/283
Compton, S., Levy, P., Griffin, M., Waselewsky, D., Mango, L., & Zalenski, R. (2011). Family-Witnessed Resuscitation: Bereavement
Outcomes in an Urban Environment. Journal Of Pallatve Medcne, 14(6), 715-721 7p. doi:10.1089/jpm.2010.0463
Family presence during resuscitation and invasive procedures. (2016). Crtcal Care Nurse, 36(1), e11-4.
doi:10.4037/ccn2016980
Farmanova, Elina, Christine Maika, and Maria Judd. Better Together: A Change Package To Support The Adopton Of Famly Presence
And Partcpaton In Acute Care Hosptals And Accelerate Healthcare Improvement. 1st ed. Ottawa, Ontario: Canadian Foundation
for Healthcare Improvement, 2015. Web. 21 Mar. 2016.

References
Filho, C. M. C., Santos, E. S., Silva, R. C. G., Nogueira, L. S. (2015). Factors affecting the quality of cardiopulmonary resuscitation in
inpatient units: perception of nurses. Revsta da escola da enfermagemda USP, 49(6), 907-913. DOI:
10.1590/S0080-623420150000600005
Jabre, P., Belpomme, B., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., Tazarourte, K. (2013). Family Presence during
Cardiopulmonary Resuscitation. The new england journal of medcne, 368(11). doi: 10.1056/NEJMoa1203366
Jabre, P., Tazarourte, K., Azoulay, E., Borron, S. W., Belpomme, V., Jacob, L., ... & Adnet, F. (2014). Offering the opportunity for
family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensve care medcne, 40, 981-987.
doi:10.1007/s00134-014-3337-1

References
Porter, J., Cooper, S. J., & Sellick, K. (2013). Attitudes, implementation and practice of family presence during resuscitation (FPDR): A
quantitative literature review. Internatonal Emergency Nursng, 21(1), 26-34. doi:10.1016/j.ienj.2012.04.002
anced Nursng, 71(11), 2595-2608. doi:10.1111/jan.12736
Sak-Dankosky, N., Andruszkiewicz, P., Sherwood, P. R., & Kvist, T. (2015). Factors associated with experiences and attitudes of
healthcare professionals towards family-witnessed resuscitation: A cross-sectional study. Journal of Adv
Tudor, K., Berger, J., Polivka, J., Chlebowy, R., & Thomas, B. (2014). Nurses perceptions of family presence during resuscitation.
Amercan Journal of Crtcal Care, 23(6), e88-e96
Twibell, R. S., Craig S., Siela D., Simmonds, S., & Thomas, C. (2015). Being There: Inpatients Perceptions of Family Presence
During Resuscitation and Invasive Cardiac Procedures. Amercan Journal of Crtcal Care, 24, 108-115;
doi:10.4037/ajcc2015470