Published online October 1, 2007
PEDIATRICS
Vol. 120
No. 4
October 2007, pp.
e895-e901
(doi:10.1542/peds.2006-2943)
Family-Member Presence During Interventions in the Intensive Care Unit: Perceptions of Pediatric Cardiac Intensive Care Providers
Julie K. Kuzin, RN, CPNPa,
Jennifer G. Yborra, RN, ACPNPa,
Michael D. Taylor, MDa,
Anthony C. Chang, MDb,
Carolyn A. Altman, MDa,
Gina M. Whitney, MDc and
Antonio R. Mott, MDa
a Department of Cardiology, Texas Children's Hospital, Houston, Texas
b Department of Cardiology, Children's Hospital of Orange County, Orange, California
c Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tennessee
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ABSTRACT
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OBJECTIVE. Should family members be present during interventions in an ICU? This question is a source of debate among health care providers. We propose to define perceptions and practice regarding family-member presence during ICU interventions from a multidisciplinary group of pediatric cardiac intensive care providers.
METHODS. A 20-question survey was created and distributed to attendees of the 2004 Pediatric Cardiac Intensive Care Symposium, 1 year after the meeting. Interventions were defined as noninvasive (team rounds), invasive (tracheal intubation, central/arterial line placement, chest tube placement, or pericardiocentesis), or extremely invasive (cardiopulmonary resuscitation).
RESULTS. A total of 211 surveys (145 physicians and 66 nonphysicians) were completed. Of all responders, the majority believe family members have a right to be present during cardiopulmonary resuscitation (75%), team rounds (77%), and invasive procedures (57%). Sixty-five percent of respondents encounter families that frequently request to be present for team rounds. However, the majority of respondents encounter families that rarely request to be present during invasive procedures (69%) and cardiopulmonary resuscitation (73%). Many providers practice in ICUs where family-member presence is allowed; 64% allow family members to attend team rounds. Some of the concerns providers have regarding family-member presence in the ICU include family-member presence causing stress to the provider during invasive procedures along with distractions and nervousness among the team during cardiopulmonary resuscitation. The majority of providers predict family-member presence during cardiopulmonary resuscitation would not increase medicolegal concerns.
CONCLUSIONS. Most respondents, nonphysicians more than physicians, believe that family members have a right to be present during all ICU interventions. The majority of respondents encounter families that frequently request to be present for team rounds. However, the majority of respondents encounter families that rarely request to be present during invasive procedures and cardiopulmonary resuscitation. Most respondents believe family-member presence during cardiopulmonary resuscitation would not increase medicolegal concerns.
Key Words: family presence • CPR • physician rounds • invasive procedures
Abbreviations: ENA—Emergency Nurses Association • PCICS—Pediatric Cardiac Intensive Care Symposium • CPR—cardiopulmonary resuscitation
Family-centered care has become the new paradigm in the health care field, as evidenced by liberal visitation hours, "rooming in" sleeping accommodations, family friendly obstetrical delivery rooms, and improved information sharing. Pediatric and adult health care providers have begun to embrace this idea.1,2 A challenge to implementing this model is the practice of family presence during interventions (noninvasive and invasive) in the ICU.
Leaders in health care safety have in recent years followed the patterns and advances of the Federal Aviation Administration. In 1981, the Federal Aviation Administration released "the sterile cockpit rules," which are based on the premise that eliminating the potential for distraction during critical phases of flight will decrease errors.3 Although a logical assumption, this theory has not been thoroughly evaluated in the health care environment, where other variables are at stake. In addition, the 2000 Institute of Medicine report To Err Is Human4 has lead to a national mandate for improved processes in health care delivery that would improve patient safety. Indeed, preserving patient safety while supporting tenets of family-centered care, including family-member presence during interventions, is a challenge.
The American Heart Association, the American Association of Critical Care Nurses, the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association have endorsed the concept of family-member presence during interventions, although feelings among health care providers remain diverse.1 Currently, a standard regarding the appropriate extent of family-member involvement in patient care does not exist. Although many studies focus on family-member presence during resuscitation, there are fewer studies that investigate family-member presence during team rounds and invasive procedures.
This topic was the focus of an open forum at an annual Pediatric Cardiac Intensive Care Symposium (PCICS). We propose to define perceptions regarding family-member presence during ICU interventions (noninvasive and invasive) from a multidisciplinary group of pediatric cardiac intensive care providers.
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METHODS
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A 20-question survey was created, which consisted of questions related to health care provider perceptions and experiences regarding family presence during interventions in an ICU. The survey was submitted to the institutional review board and was determined to be exempt. Interventions were defined as noninvasive (team rounds), invasive (tracheal intubation, central/arterial line placement, chest tube placement, and pericardiocentesis), and extremely invasive (cardiopulmonary resuscitation [CPR]).
The survey was distributed to attendees of the 2004 PCICS, 1 year after the meeting, via an e-mail–based Internet service (www.SurveyMonkey.com). The PCICS is an international meeting of which the attendees represent several disciplines of care in an ICU. The e-mail addresses were obtained from the attendee roster that was available to all of the attendees.
Statistical analyses were performed by using SPSS 12.0. (SPSS Inc, Chicago, IL). Summary statistics for the categorical data are reported as frequencies. Statistical comparisons for the categorical variables were performed by using Fisher's exact or the 
2 test. Statistical significance was defined as a P value of <.05.
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RESULTS
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Demographics
Of the 549 potential respondents who received the survey via e-mail, 211 (38%) completed the survey. The respondents represent 24 countries, 160 (76%) of 211 of which practice in the United States (Table 1).
Of the 211 respondents (120 women, 91 men), there are 145 physicians and 66 nonphysicians. The respondents are composed of 10 different types of pediatric care providers: cardiac intensivists (n = 49), ICU nurses (n = 36), anesthesiologists (n = 31), intensivists (n = 30), cardiologists (n = 19), nurse practitioners (n = 15), fellows-in-training (n = 10), NICU nurses (n = 13), cardiac surgeons (n = 6), and pharmacists (n = 2).
The clinical experience level of the respondents varied from <6 years (n = 62) to 6 to 10 years (n = 46) to >10 years (n = 104). The respondents practice in ICUs of various sizes: <6 beds (n = 5); 6 to 10 beds (n = 38); 11 to 20 beds (n = 113); and >20 beds (n = 56).
Formal Policies in the ICU
Team Rounds
There are 207 respondents. Of these, 86 (42%) of 207 respondents practice in an ICU that allows family members to attend team rounds and ask questions, whereas 45 (22%) of 207 practice in ICUs that allow family members to attend team rounds but not ask questions. There were 67 respondents (32%) who practice in an ICU with a policy that does not allow family members to attend team rounds. Nine respondents reported "other" responses, which included practice variation on the basis of the attending physician preference and not having formal ICU rounds.
Invasive Procedures
There are 207 respondents. There were 154 (74%) respondents who practice in an ICU that allows family members to be present during invasive procedures. However, of these 154 respondents, 145 (94%) report that allowing families to be present is at the discretion of the attending physician and/or bedside nurse. There were 38 respondents (18%) who practice in an ICU that does not allow family members to be present during invasive procedures. Fifteen respondents (7%) did not report an ICU practice and, thus, no policy regarding family-member presence during invasive procedures.
CPR
There are 207 respondents. There are 25 (12%) of 207 respondents who practice in ICUs that do not have a policy regarding family-member presence during CPR. Of the 153 (74%) of 207 that have a permissive policy, 110 (53%) of 207 report that the appropriateness of family-member presence is determined by the physician and sometimes by the bedside nurse. The remaining 29 (14%) practice in an ICU that has a policy that does not allow family members to be present during CPR. There were 40 of 207 respondents (19%) who noted that family members who choose to be present during CPR are accompanied by a hospital representative liaison to explain the course of events and for emotional support.
How Often Do Families Request to Be Present During Interventions?
Team Rounds
There are 201 respondents. The majority of respondents, 146 (73%) of 201, note that family members frequently request to be present during team rounds. There are 55 respondents (27%) who note that families rarely request to be present during team rounds.
Invasive Interventions
There are 201 respondents. The majority of respondents, 138 (69%) of 201, note that family members rarely request to be present during invasive interventions. There were 63 (31%) who noted that family members frequently request to be present during invasive procedures.
CPR
There are 201 respondents. The majority of respondents, 146 (73%) of 201, note that family members rarely request to be present during CPR. There are 51 (25%) who report that family members frequently request to be present. Only 4 respondents (2%) note that family members always request to be present during CPR.
Do Family Members Have a Right to Be Present?
The majority 155 (77%) of 201 of respondents believe that family members have a right to be present during team rounds, whereas 46 (23%) of 201 of the respondents believe that family members do not have a right to be present. There are 86 (43%) of 201 respondents who believe that family members do not have a right to be present during invasive procedures, whereas 115 (57%) of 201 believe that family members do have a right. There are 150 (75%) of 201 respondents who believe that family members have a right to be present during CPR, whereas the remaining 25% disagree (Table 2). When the responses of physicians and nonphysicians are compared, there is a significant difference of opinion (P < .05) between provider types regarding whether family members have a right to be present during interventions (Table 3).
Have Respondents Witnessed a Positive Event With a Family Member Present?
The majority (172 of 201 [86%]) of respondents have witnessed a positive event with family-member presence during team rounds, 121 (60%) of 201 during invasive procedures and 149 (74%) of 201 during CPR. When physician and nonphysician responses are compared, both groups tend to have witnessed more positive experiences, but a larger percentage of nonphysicians than physicians note having witnessed positive experiences during team rounds (P = .028) and CPR (P = .004). During invasive procedures, there was less of a difference between physicians and nonphysicians (P = .067; Table 4).
Have Responders Witnessed a Negative Event With a Family Member Present?
There are 94 (47%) of 201 respondents who have witnessed a negative event during team rounds, 109 (54%) of 201 during invasive procedures and 90 (45%) of 201 during CPR. Physician and nonphysician responses were compared, and the responses are listed (Table 5). Overall, nonphysicians report witnessing less negative events during ICU interventions than physicians. Nonphysician providers report witnessing negative events less frequently than physicians, specifically during team rounds (P = .023).
Provider Predictions and Responses to Clinical Scenarios
The predictions of the cohort when presented with clinical scenarios are presented (Table 6). The cohort was divided into physician and nonphysician, and the predictions of the 2 groups are presented (Table 7). The 2 groups’ responses differed regarding family presence during CPR: interfering with or being an obstruction to patient care (P = .009), being stressful/traumatic for families (P = .001), providing assurance to family members that all measures were done (P = .001), leading to misunderstandings of dialogue and events (P = .003), causing distractions and nervousness among the team (P = .001), and interfering with teaching and training (P = .001). The 2 groups’ responses also differed in response to family presence during invasive procedures potentially providing comfort to the patient (P = .05; Table 7).
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TABLE 7 Predictions of Health Care Providers Regarding Family-Member Presence During Interventions: Nonphysician Versus Physician
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DISCUSSION
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In the current era, the extent of family-member involvement has not been defined, and its true impact has yet to be realized. Family-centered care adds another dimension to the traditional patient-health care provider interaction. Family members are now empowered to venture into aspects of patient care that have previously been reserved only for health care providers.
Do family members have a right to be present during interventions? Physician and nonphysician providers have differing views. Nonphysicians, specifically nurses, tend to support the right of a family member to be present during invasive procedures and CPR.1,5–8 In a survey of members of the ENA, a national nursing organization, the majority of members support the family member's right to be present during interventions. However, in a survey of members of the American Association for the Surgery of Trauma, a national physician organization, the majority of respondents believe otherwise.9 Among physicians, there is varying opinion. Physicians who have frequent contact with critically ill children tend to support the right of a family member to be present during interventions.10 A recent study by Gold et al11 of adult and pediatric physicians revealed that 93% of those surveyed would allow a family presence during resuscitation if the family so desired in at least some situations.
The majority of responders in our survey support a family member's right to be present during team rounds, invasive interventions, and CPR. The responses represent those of the 211 individual providers, of which some practice at the same institution. Of note, a larger percentage of nonphysician providers than physician providers favor a family member's right to be present during ICU team rounds, invasive procedures, and CPR. In the study by Gold et al,11 those physicians who were in support of family presence during resuscitation felt that it was a family's right. Likewise, nonphysician providers more so than physician providers report having had more positive than negative past experiences when family members are present during ICU interventions. The definition of a negative and positive experience was not defined in this survey.
Some have speculated that physician concern for litigation may be a factor as to why there is a difference of opinion between physicians and nonphysicians.11 The majority of respondents in our survey noted that family-member presence during CPR would not increase medicolegal concerns. There was no difference of opinion between nonphysicians and physicians. However, Helmer et al9 noted that physicians more so than nurses were concerned about the risk for malpractice suits during trauma resuscitation. Moreover, Meyers et al,8 in corroboration, also noted that in a survey of nurses and attending and resident physicians, 57% of providers were concerned that family members may misinterpret what they hear and/or see during resuscitation events, and 29% believe that families might initiate future litigation.
There are insufficient data to evaluate rates of litigation. Some speculate that litigation may actually decrease when the doubt and secrecy of resuscitation is removed and families are able to witness the efforts undertaken to save a family member's life.11,12 The use of a hospital staff member liaison to accompany the family member may prove beneficial, especially with the increasing use of advanced diagnostic and therapeutic technologies. This liaison may also provide emotional support to the family member. Additional investigation is warranted, in particular for the long-term psychological impact on family members who witness interventions, as well as those who do not.
Although opinion may vary among health care providers, family-member opinion is very consistent. Meyers et al8 noted that the majority of family members support a family member's right to be present during interventions. These findings have also been corroborated in other reports.7,8,13–15 Furthermore, the American Heart Association in 2000 adopted guidelines supporting the right of family members to be present during CPR. The recommendations further assert that family members often do not ask to be present; therefore, the option should be offered to them.16 In our survey, 65% of respondents encounter families that frequently request to be present for team rounds. However, the majority of respondents encounter families that rarely request to be present during invasive procedures (69%) and CPR (73%).
Can family-member presence during an intervention compromise patient safety? The 2000 Institute of Medicine report presented sobering data that describe a health care delivery system that is plagued by inefficient processes/practices that compromise patient safety.4 In the aviation industry, eliminating the potential for distraction during critical phases of flight has decreased errors.3 This premise has to be considered when family members are present during invasive procedures and CPR. In addition, increased staff stress (performance anxiety) in response to family presence has been documented.6,9,11,12,17,18 Wasseem et al17 noted that 22% of health care providers were distracted, and 12% experienced nervousness when family members were present during an intervention. In our survey, 47% of physicians believe that family-member presence would cause distraction and nervousness, but 53% of nonphysicians believe otherwise.
The interest in family-member presence during more aggressive interventions such as invasive procedures and CPR has overshadowed its impact on the least-invasive intervention but potentially the most-intrusive intervention, team rounds. During team rounds, dialogue is the primary intervention, albeit a very important intervention. Trainee education during team rounds may be compromised if there is reluctance to have dialogue that may include the questioning of management decisions and/or verbalizing constructive criticism. Because of physician trainee time constraints, time at each bedside is limited, and extended discussions that can potentially benefit family members may not occur. As important in the current era, the potential of breaching patient privacy rights is ever present when family members attend team rounds. There is the potential for adjacent families to hear confidential information about other patients.6,9,12,17,18 Although all of these issues are key concerns, the American Academy of Pediatrics Committee on Hospital Care in a 2003 policy statement noted that health care providers need to support and facilitate options for the child and family regarding approaches to care, as well as sharing honest and unbiased information on an ongoing basis.19
Despite the growing interest in the concept of family-centered care and the presence of family during interventions, many hospitals do not have formal policies to address this issue.11 In a survey of the American Association of Critical Care Nurses and ENA members, only 5% of respondents worked in ICUs that had a formal written policy to address this issue.18 In our survey, 72% of respondents have a formal policy regarding family presence during invasive procedures and CPR. Absence of formal policy, however, does not mean absence of practice. As noted by Maclean et al,18 in ICUs that lack a formal policy, 45% of respondents allowed family-member presence during CPR, and 51% allowed family-member presence during invasive procedures. The lack of a formal policy supporting or not supporting family presence during interventions can potentially create a practice variation that will inevitably be a source of confusion and frustration to care providers and to family members.
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LIMITATIONS
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There are study limitations that warrant noting. The sample size of our study is small and may not reflect the opinions of the 62% that did not respond to the survey. The data presented are a reflection of individual respondent's practice and experience, as many of the respondents may practice at the same institutions. In this survey, the authors did not differentiate between acute/unexpected CPR and repeated CPR events in moribund situations. Positive and negative events were not defined in the questions regarding provider past experiences with family presence.
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CONCLUSIONS
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Most respondents, nonphysicians more than physicians, believe that family members have a right to be present during all of the ICU interventions. The majority of respondents practice in ICUs with a formal policy regarding family presence during invasive procedures and CPR. Most respondents note encountering families that frequently request to be present for team rounds but rarely request to be present during invasive procedures and CPR. Most respondents believe that family-member presence during CPR would not increase medicolegal concerns.
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ACKNOWLEDGMENTS
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We acknowledge the leadership and members of the Pediatric Cardiac Intensive Care Symposium for their commitment in addressing all aspects of care delivery to children with cardiac disease and their support to the families who care for them.
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FOOTNOTES
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Accepted Feb 19, 2007.
Address correspondence to Julie K. Kuzin, RN, CPNP, Texas Children's Hospital, 6621 Fannin St, MC-19345-C, Houston, TX 77030. E-mail: jkkuzin{at}texaschildrenshospital.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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ABSTRACT
METHODS
