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Debating the pros and cons of families in the ED
Earn 1 credit hour with this free continuing education course
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1010 Sync Street
Morrisville, NC 27560

Families in the ED: Helpful or Harmful?

Laura L. Morgan, MSN, RN, NEA-BC
This course is 1 contact hour
Course must be completed by December 15, 2020.
Goals and objectives:
The goal of this continuing education program is to provide nurses with information about family member presence during patient resuscitation, its history, common concerns, legal implications, and recommendations for family presence policies. After studying the information presented here, you will be able to:
  1. Discuss the history of family member presence during patient resuscitation
  2. Identify common concerns of healthcare providers about family member presence
  3. Discuss the legal implications or concerns of family member presence
  4. Identify how the concept of patient/family-centered care applies to family member presence educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit
. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See
“How to Earn Continuing Education”
to learn how to earn CE credit for this module or visit
TV programs, the internet, and movies often portray “code blue” or other critical situations as exciting and usually successful. We have all seen the prime-time dramas in which the actor performs a “defibrillation” to a patient over his gown. When was the last time you did this?
Way back when
Years ago, death was a family affair with family members providing care and emotional support to the dying person. Medical breakthroughs and technological advances made it possible to prolong a dying person’s life, and patients began to be transported to the hospital before or during death.

Over time, hospitals adopted the practice that family members could not watch the sometimes grueling resuscitation attempts. This practice was based on concern for patients, families, teaching and education, legal issues, comfort of the resuscitation team, and the need for distance from the “emotion” of knowing a patient. As nurses, we know that family members are included in our care of the patient. However, we may ask, “Should family members be allowed to watch a resuscitation attempt?” and “Should they be able to touch the patient?” These questions surround the issue of family member presence during code situations and invasive procedures. By being familiar with the history of family presence and the concerns, legal implications, and policy recommendations surrounding it, nurses will be better able to advocate for what they believe is best for patients and families.5 Much has been written in professional journals about family presence since the 1980s. At first, discussion focused on allowing parents to be present during a child’s medical procedures to alleviate separation anxiety. Later that decade, the focus expanded to family members in general and their wishes to be present during resuscitation attempts of loved ones.6 In the early 1990s, the healthcare community began to seriously consider whether the presence of family members might benefit patients during CPR. In 1990, Foote County Hospital in Jackson, Michigan, became the first hospital in the U.S. to develop a program allowing family members to be present during patient resuscitation.

The program came about after a woman requested to be at the bedside of her police officer husband, who was undergoing resuscitation efforts after an acute myocardial infarction. A pastoral support person in the ED made the request to the physician on the woman’s behalf.7,8
In 1993, the Emergency Nurses Association (ENA) went on record supporting the option of family member presence, and in 1994, first published a position statement supporting family presence in the ED (last updated in 2010 and archived in 2012). A textbook outlining the literature, policies, and research was published on the topic in 2007. These two products were updated and combined to create a clinical practice guideline on family presence during invasive procedures and resuscitation.9 (Level ML), 10 In 2000, the American Heart Association and an international consensus group revised their resuscitation guidelines to include support of family presence during CPR. These recommendations remain in the 2015 guidelines update, which includes provisions for cases involving infants and children.11 The AHA also recognized that family members present during CPR require support. Since that time, other authors have validated and expanded on that concept.

To support all stakeholders during the process, a skilled and informed support person is required.3 (Level B) The presence of family members during resuscitation may serve to improve understanding of the patient’s status and relieve family their feelings of guilt or disappointment, but a liaison must be provided to help the family with communication and education about the medical issues.10
How to earn continuing education
Read the Continuing Education article.
This continuing education course is
February 23, 2019
, courtesy of To take the test for FREE, go to
. After that date, you can take the course for
at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at
and complete the course on that system.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, Relias LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Relias LLC is also an approved provider by the Arkansas State Board of Nursing, District of Columbia Board of Nursing, Florida Board of Nursing, Georgia Board of Nursing, New Mexico Board of Nursing, South Carolina Board of Nursing, and West Virginia Board of Examiners for Registered Professional Nurses (provider # 50-290). Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.
Relias LLC's continuing education (CE) contact hours are generally accepted by most professional nursing organizations and state boards of nursing. Relias LLC has made substantial efforts to obtain appropriate providerships for CE offerings. However, Relias LLC does not warrant that all professional organizations or licensing authorities will accept its CE contact hours. If in doubt, nurses are advised to contact their professional organizations or licensing authorities to confirm their acceptance of these contact hours.
You can take this test online or select from the list of courses available. Prices subject to change.
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Facing the challenges
Despite the long-standing support by professional organizations for family presence, some reservations remain about the practice. Concerns expressed by healthcare providers include:12 (Level ML), 13 (Level B)
Fear that family members will be disruptive and interfere with care
Concern about the psychological effects on family members of witnessing resuscitation, especially during trauma codes
Worries that the family will be critical of the actions of the code team and will be more likely to initiate litigation
Lack of support for patient-centered care practices
  Resuscitation attempts are neither clean nor pretty — the situation is controlled chaos. Each member of the healthcare team has specific roles, and he or she must carry out his or her tasks uninhibited. Opponents of family presence worry about family members disrupting care. However, data indicate that family members do not interfere with patient care, nor does family presence during resuscitation increase the incidence of litigation.12 (Level ML) Some nurses are concerned that family members will suffer mental trauma after witnessing resuscitation attempts. Numerous studies have reported that families have shown no visible signs of mental trauma after witnessing resuscitation attempts, especially when a family facilitator was present to provide emotional support and technical information.10,14 In one study, 77% of ED providers in a university teaching hospital favored having family present during resuscitation attempts and believed that being present was beneficial to family members.15 Another survey in an urban hospital setting found that nurses felt family presence helped them see that everything possible was being done, their wishes were being accommodated, and witnessing the resuscitation attempt helped them achieve a sense of closure if the outcome was poor.13 (Level B) Other studies support these same conclusions.4 (Level B), 12 (Level ML)
Hospitals can plan for family presence by having a designated staff member accompany the family to the treatment area and prepare family members, to some extent, for what they will witness. The staff member, often a nurse, tells family members where to stand and what type of contact they may have with the patient. The best possible scenario is to have a culture and policy in place that provides interprofessional support of family presence.13 (Level ML) The patient’s family has always been important to nurses, second only to the patient. Increased focus on the concept of patient-centered care plays a key role in emergent situations. In a resuscitation attempt when the code team is caring for the patient, the primary nurse’s focus is on the family members by providing reassurance and updates with a caring, compassionate demeanor.

Researchers found that family presence during resuscitation had positive psychosocial results for the family, and that family members did not interfere in care, increase stress within the medical team, or result in medicolegal issues.12 (Level ML), 13 (Level B), 14 Newer research endeavors have expanded the focus of family presence to other cultures and regions of the world. In many countries, family presence is not the norm or expectation, and in fact, is frowned on. In studies examining the attitudes of healthcare workers from Middle Eastern nations, most nurses and physicians opposed the practice and denied the requests of patients and family members to be present during resuscitation. However, most nurses in North America support family presence during resuscitation. These findings highlight just one of the differences in perception of family presence. It is crucial to understand the cultural and regional beliefs of the family, patients, and healthcare team when offering the family the opportunity to be present during resuscitation.3,4 (Level B),7,12 (Level ML),14
The media inundates us with erroneous information about the way hospitals operate and how patients respond, and this misinformation forms the basis of the public’s opinions about hospital procedures and, most notably, patient outcomes. The public believes that cardiopulmonary resuscitation has a 60% to 75% success rate, which is a significant overestimate. According to the American Heart Association’s 2016 update, the rate of survival to discharge following cardiopulmonary arrest is only 24.8% (in hospital) and 12% (out of hospital).1,2 The media frequently paints a false picture of the role of families during patient resuscitation as well. The TV family is restricted from the resuscitation area — or is in the area, but impeding the staff’s efforts. Most often, patients depicted by the media are young with quick and positive outcomes — long-term outcomes are rarely shown. However, the literature suggests that allowing families to be present while their loved one undergoes lifesaving measures or invasive procedures can benefit the patient, family, and healthcare staff.3,4
When providers do not have experience with family presence, they are often hesitant to participate in a resuscitation attempt with family members in the room. Experienced providers are more comfortable with the practice of family presence. One study involving nurses in inpatient and outpatient departments of an urban hospital found that nurses with more experience with resuscitation events had greater confidence and perceived benefits of family presence than those with less experience.13 (Level B) Nurses and residents must learn the appropriate actions to take during CPR, and they must practice these skills until they are second nature. Some critics believe it is difficult to provide instruction with family members present. Others believe that family presence is helpful to parents of children during CPR, and that residents should be trained in this practice.16 (Level B) One solution is to review a typical resuscitation scenario and the roles of each healthcare provider with new staff members before an actual event. Prior instruction would probably eliminate, or at least minimize, the need for instruction during the code. The family’s chaperone could use any instruction the staff does to educate the family about the care their loved one was receiving.3 (Level B)

Family presence during invasive procedures and resuscitation
9 (Level ML)
ENA’s clinical practice guideline recommendations on decision options, interventions, and level of recommendation:
• There’s little or no evidence to indicate that the practice of family member presence is detrimental to the patient, family, or healthcare team. • There’s some evidence from the international literature that acceptance of family presence may have some cultural basis. • There’s evidence that healthcare professionals support the presence of a designated healthcare professional assigned to support family members and provide explanation and comfort. • There’s some evidence that a policy regarding family member presence provides structure and support to healthcare professionals involved in this practice.
Family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members, based on a written institution policy.
The role of experience
Read the full CE online and take the test.
Deborah C. Varnam, MSN, RN, FNP-BC; Margi J. Schultz, PhD, MSN, RN, CNE, PLNC; and Gayle Walker-Cillo, MSN/Ed, RN, CEN, CPEN, FAEN; past authors of this educational activity, have not had the opportunity to influence the content of this version. OnCourse Learning guarantees this educational activity is free from bias Laura L. Morgan, MSN, RN, CCRP, NEA-BC, serves as the clinical education specialist at Lincoln County Medical Center in Ruidoso, New Mexico. She is a reviewer for the New Mexico Nurses Association and Presbyterian Healthcare Services continuing education programs and a basic life support and advanced cardiovascular life support instructor for healthcare providers.