TABLE 2

Summary of Reviewed Articles

StudySampleProcedures PerformedDesignResultsCommentsLimitations
Level I evidence
    Robinson et al23 (1998)ED in university-affiliated community hospital in United Kingdom: 22 patients unsuccessfully resuscitated (age 8 to 82 y); 2 groups of bereaved relatives: control group (not given opportunity to witness resuscitation, at 1 mo [n = 10] and 6 mo [n = 7]) and study group (given opportunity to witness chaperoned resuscitation, at 1 mo [n = 8] and 6 mo [n = 6])CPR, EI, central venous cannulation, tube thoracocentesis, pericardiocentesisRCT: questionnaires were filled out via mail or an in-person interview at 1 and 6 mo after unsuccessful resuscitation; 1-mo questionnaires were returned on average at 3 mo and 6-mo questionnaires were returned on average at 9 moParent perspective: 0 of 8 relatives in the witnessed resuscitation group had to leave the room because of distress, and none reported being frightened by the process; 7 of 8 felt their grief had been eased by presence; 8 of 8 were content with decision to stay present; no statistical difference was noted between the study and control groups on all 5 questionnaires at both 1 and 6 moNo resuscitations were reported to have been interrupted by FMP or have delayed the decision to discontinue resuscitation; no negative comments were reported by family members about the technical or procedural difficulties encountered; all 3 patients who survived resuscitations (although excluded from study) reported they were content that a relative remained and that neither their confidentiality nor dignity was compromisedSeveral relatives in both groups were lost during follow-up; differences in answers between in-person vs mail-back questionnaire completion were not analyzed and/or reported
Level II evidence
    Bauchner et al21 (1991)Pediatric ED in university GH in US: 50 parents accompanying 50 patients (median age: 12 mo [range: newborn to 3 y old]); 28 clinicians (2 attending physicians, 20 resident physicians, and 6 nurses)Venipuncture, intravenous cannulation, laceration repair, arterial blood sampling, LP, suprapubic catheterizationProspective cohort and observational study of 2 closed-ended forced-choice questionnaires for clinicians and parents; a research assistant observed and recorded interactions between the clinicians and parentsParent perspective: 62% remained during procedures (43% were asked to remain by a resident or nurse); of those not present, 42% would have preferred to remain, 32% did not know they could, and 26% would have preferred not to remainThe decision to stay was not related to parental age, gender, race, marital status or level of education or to the residents' age, gender, or level of training; parents were significantly more likely to stay if they had previously stayed with current or another child (P = .05)Study excluded parents of children requiring emergent medical procedures and/or resuscitation; small sample size; excluded emergent procedures
Parents' reasons for preferring to remain: thought child wanted them present, their presence would calm child, and wanted to know what physician was doing
Clinicians' reasons against parent presence: makes parents nervous or upset, parents do not understand what is happening, makes clinician nervous, makes child more upset, parents could get in the way, too busy to explain procedure to parents
    Saccehetti et al24 (1996)Pediatric ED in university GH and ED in university community hospital in the US: 111 family members accompanying 96 patients (median age: 14 mo [range: newborn to 9 y old]); 98 clinicians (65 attending physicians, 23 resident physicians, and 10 nurses)Vascular access, LP, urethral catheter, nasogastric tube placement, intubation, fluid resuscitation, foreign-body removalProspective cohort study: survey completed by family members with companion survey of ED staff performing procedures with FMPParent activity during procedure: 50% helped restrain child, 31% stood at bedside, 19% soothed child, and 0% interferedMost clinicians said they would continue the practice the next time they needed to perform a procedure; of the 6 parents who felt that FMP was a bad idea, 4 felt their presence helped their child and would remain again; parent activity was self-initiated and not a result of previous instruction; FMP did not interfere with medical student or resident trainingActivity of family members from the clinicians' perspectives; only captured perspectives of parents who chose to remain
Parent/family-member perspective: 91% felt that remaining helped the patient, 87% felt that remaining helped the family member, and 5% felt that remaining was a bad idea
Clinician perspective: 94% felt that having a family member remain was a good idea, 4% noted that FMP made them nervous, and 26% of resident physicians felt that FMP was a bad idea
    Powers and Rubenstein26 (1999)PICU in university-affiliated GH in the US: study group (16 parents [accompanying children 3 mo to 18 y old] and 16 nurses involved with same procedure) and control group (7 parents [accompanying 7 children 20 mo to 12 y old])EI, central line, and chest tube placementProspective cohort study: 3 separate surveys, all completed within 24 h; the study group included parents given option to be present for procedures performed by the study physicians (authors), and the control group included parents excluded from procedures performed by physicians not involved with studyParent perspective when present: 94% would repeat their choice to be present, 88% said it was helpful to child, and 81% said it was helpful to the medical staff and to themselvesNo significant difference in nurse responses based on years of nursing experience; study physicians reported that no parent interfered or was in the way during any of the procedures; no parent opted to leave the room during the procedure(s)Small sample size; questionnaire did not generate reasons why parent presence reduced anxiety; unequal group sizes with dissimilar child demographics and number of previous hospital/ICU experiences
Nurse perspective when parent present: 94% thought it was helpful to child and parent, and 72% indicated that a policy that allowed parents to observe procedures was appropriate
Parent anxiety when present vs not present: parental presence significantly reduced the parental anxiety related to the procedure
    Saccehetti et al25 (2005)ED of university-affiliated teaching community hospital in the US: 54 family members (accompanying 37 patients [median age: 3 mo]); 1–3 observing physiciansLP, EI, fracture reduction, tube thoracostomy, shoulder reductionProspective observational study of family members witnessing invasive procedures on pediatric patients over a 12-mo periodFamily-member activity/behavior: 30% soothed child, 16% asked questions, 7% helped restrain, 3% interfered with care, and 15% other (including cried, watched from a distance, and not described)Two observed events were labeled as “parent interfered with care,” but both events were “minor” and did not alter patient care: 1 mother experienced near-syncope event standing during LP, and 1 mother stopped reduction of shoulder dislocation because she felt the pain control was inadequate even though the child was deeply sedated with propofolPerformed at single institution where personnel have extensive experience with FMP during invasive procedures
    Mangurten et al22 (2005)Urban pediatric ED in the US with an established FMP protocol/policy: 92 of 120 clinicians returned surveys (18 physicians, 36 residents/fellows, 38 nurses); 63 facilitators (17 nurses, 31 social workers, and 15 child life specialists); 22 parents were interviewed (6 present for a resuscitation and 16 present during an invasive procedure)Laceration repair, incision/abscess drainage, LP, esophageal foreign-body removal, central line insertion, endoscopic exploration, ear graft, emergency intubation, CPRProspective study of clinicians' perspectives and retrospective study of parent perspectives; clinicians and facilitators were surveyed within 1 d of the event; parents were interviewed within 3 mo using a 20-item Pediatric Family Presence survey and an 11-item Pediatric Family Presence Attitude scale to assess parent opinions about FMP and the impact of remaining at the besideParent perspective: 100% agreed that they would repeat the decision to be present, 100% felt their presence was helpful to their child, 95% said being there helped them personally, 86% believed they had a right to be present, and 82% did not think their presence made a difference in how the clinicians cared for their childParent attitudes about FMP: gave them peace of mind, allowed them to let their child know they loved him or her, and helped them know that everything possible had been done to treat their childExcluded parents whom the facilitator determined to be emotionally unstable, combative, involved in suspected child abuse, or exhibited an altered mental status; parents were interviewed 3 mo after the procedure/resuscitation event; because FMP was a standard of practice, the overall favorable attitude of clinicians toward FMP may not be generalizable to other settings
Clinician perspective: 97% of nurses felt parents had the right to witness resuscitations vs 67% of the physicians and 63% of the residents (P < .05), 92% of the nurses and 78% of the physicians supported FMP for invasive procedure vs 35% of the residents (P < .05), 92%-96% felt treatments given and time spent were the same, 89% said their performance was not effected, 88% said resident training was the same, and 8% thought the outcome might have been different without FMPClinician attitudes about FMP: the majority agreed that FMP was something they would do again, that it helped meet the family's needs, and that it helped the family understand that clinicians had done everything they could for the child; only one quarter of clinicians expressed medical-legal concerns and/or that parents might misinterpret treatment activities
Family-member activity/behavior: 100% emotionally supported, talked to, or soothed their child, 91% touched their child, 86% provided team with the health care information, 77% asked questions, 73% prayed for and kissed their child, 50% of parents helped position their child for procedure, and none interfered with care
Level III evidence
    Jarvis16(1998)PICU in university-affiliated hospital in the United Kingdom: 56 clinicians (19 physicians and 37 nurses)Resuscitation for respiratory and/or cardiac arrest in childrenRetrospective study: 2-part questionnaire (close-ended quantitative questions and open-ended qualitative questions requiring clinician comments)Clinician perspective: 68% of the MDs and 100% of the RNs thought parents should have option to be present during resuscitation, 68% of the MDs and 84% of the RNs believed a support member should accompany parents, 89% of the MDs and 94% of the RNs would allow FMP if requested, 53% of the MDs and 65% of the RNs who experienced FMP would give option to be present in the future, 37% of the MDs and 76% of the RNs believe if a child were to die, FMP would help parent grieving, MDs more than RNs felt they have a right to not allow FMP, and RNs were concerned that asking parents may pressure them to stay even if they do not want to stayAdvantages of FMP: reduces suspicions, thus risk of litigation, helps with parents' grieving process, and helps parent gain realistic view of attempted resuscitation and deathNo qualitative statistics were used to evaluate clinician comments; small sample size
Disadvantages of FMP: increases risk of parent being emotionally traumatized, increases stress for staff, inhibits treatment by junior staff, and risk of distraction from interference/violence
    Boie et al9 (1999)ED in urban teaching hospital in the US: 400 parents/grandparents in ED waiting area were asked to imagine their child undergoing 5 different pediatric scenariosVenipuncture, laceration repair, LP, EI, resuscitationScenario-based study: survey with 5 pediatric procedures (with description, diagram of procedure, and explanation of a child's likely reaction); scenarios were presented from least to greatest level of invasivenessParents would want to be present: 98% for venipuncture, 94% for laceration repair, 87% for LP, 81% for EI, and 65% for all scenarios, and 7% would want physician to determine their presence in all scenariosWith increasing procedural invasiveness, parents' desire to be present decreased; a notable increase in desire to be present if the child was likely to die during resuscitation; results suggested that parents do not want physicians to determine if they stay or leave the bedside during procedures and/or resuscitations; no SD in response on the basis of gender, education, income, or previous experience with procedure(s)Parents/guardians were not required to have experienced scenario with their child; order of scenarios may have caused answers to be biased by fatigue
Parent presence during resuscitations:83% would want to be present if death were likely, 81% would want to be present if child was conscious, and 71% would want to be present if child was unconscious
    Saccehetti et al19 (2000)3 hospitals in the US: urban teaching ED with a routine FMP practice (“R-ED,” n = 32), suburban ED with an occasional FMP practice (“O-ED,” n = 36), and an urban teaching pediatric ED with a rare FMP practice (“N-ED,” n = 17)Venipuncture, LP, EI, CPR, CRMail-back cross-sectional written survey on FMP for 5 different clinical scenariosAcceptance of FMP on the basis of ED scenarios: CR, R-ED 63% vs O-ED 52% vs N-ED 12%; CPR, R-ED 72% vs of O-ED 44% vs N-ED 12%; EI, R-ED 50% vs O-ED 33% vs N-ED 0%; LP, R-ED 69% vs O-ED 33% vs N-ED 12%The percentage of clinicians who favored FMP for LP, EI, CPR, and CR was significantly correlated to the type of FMP practice to which they were accustomed (P < .002); personal experience with FMP was most significant predictor of a positive opinion on FMP for most scenarios; for FMP during CPR, both the personal experience and the hospital of practice were significant predictors of a favorable opinion; no correlation between years of medical emergency experience and having negative opinions on FMPOpinions of physicians-in-training were not captured (only attending physicians were surveyed); they only report data for 4 of the scenarios with regards to the opinions of ED personnel on FMP
Opinions of FMP on the basis of exposure: CR: ∼61% with experience vs ∼9% with none said it was a “good idea”; CPR: ∼59% with experience vs ∼18% with none said it was a “good idea”; EI: ∼44% with experience vs ∼4% with none said it was a “good idea,”; and LP: ∼42% with experience vs ∼29% with none said it was a “good idea”
    McClenathan et al17 (2002)Attendees of International Meeting of American College of Chest Physicians in October 2000: 543 physicians, 28 nurses, and 21 allied health care professionalsSurvey covering previous experience and clinicians' opinions on FMP was handed out at a conferenceClinician perspective: 39% of the physicians who had previous experience with FMP would allow it in the future, 85% of clinicians opposed FMP for pediatric patients, and 78% of clinicians opposed FMP for adult patientsOverall, clinicians oppose family presence during resuscitations, especially during pediatric resuscitations; physicians more than nurses were afraid of psychological trauma to those witnessing CPR; first study to report significant difference in opinions on FMP on the basis of regional location within the USOptional questionnaire, so it may have only been completed by those with strong opinions about FMP; most clinicians identified their specialty as “adult”; fewer than two thirds of physicians surveyed had actual experience with FMP
Significant regional variations: only 5% of clinicians in Northeast vs 21% in Midwest, South, and West favor FMP for pediatric patients
Reasons cited for why clinicians oppose FMP: psychological trauma to family, performance anxiety affecting the CPR team, and medical-legal concerns
    O'Brien et al18 (2002)Attendees of the AAP Annual Uniformed Services Pediatric Seminar: 245 clinicians (221 physicians, 17 nurses, and 5 other)Resuscitation for respiratory and/or cardiac arrest in childrenResuscitation for respiratory and/or cardiac arrest in childrenSurvey distributed with on-site course materialsWould allow FMP during a pediatric code: 35% of total respondents, 50% of pediatric residents, 58% of inpatient-oriented specialists, and 26% of outpatient-oriented specialistsWhen opinions were compared among specialty groups, inpatient-oriented specialists and residents were significantly more willing to allow parent presence during a pediatric code compared with outpatient-oriented specialists (P < .01); no significant difference in willingness to allow FMP during CPR on the basis of gender, military affiliation, or years of practiceFormat did not explore reasons behind opposition of FMP
Likelihood of repeating the practice of FMP (only 43% reported experiencing a pediatric code with FMP): 63% of experienced respondents, 68% of experienced pediatric residents, 74% of experienced inpatient-oriented specialist, and 55% of experienced outpatient-oriented specialist
    Waseem and Ryan20 (2003)80 directors of EDs in the US with pediatric and EM residencies or pediatric EM fellowship programs: 58 physicians respondedVenipuncture, intravenous injection, urinary catheter, laceration repair, fracture reduction, LP, EI, major resuscitationMail-back, 3-part cross-sectional questionnaireMail-back, 3-part crosssectional questionnaireAllow FMP on the basis of procedural invasiveness: 91% for venipuncture, 83% for bladder catheters, 86% for intravenous injection, 84% for laceration repair, 36% for LP, 55% for fracture reduction, 24% for ETI, and 22% for major resuscitationMore than 87% of physicians stated that they allow parents to remain with their children during simple and more frequently performed procedures; physicians less likely to allow parent presence for complex procedures that are performed less commonly and in sicker children; physicians with additional training in EM and pediatric EM had a higher level of comfort and were much more likely to encourage parents to stay during procedures than were general pediatriciansResponses received may reflect the respondents' institution and not their personal practice; did not separately evaluate the responses of physicians-in-training in comparison with those no longer in training
Physician perspective on FMP during procedures: 41% encourage and 21% allow parent to decide
Physician specialty training and FMP: EM and pediatric EM directors, 56% encourage it and 35% allow parents to decide; general pediatricians, 20% encourage it and 29% allow parents to decide
Effect of FMP on physicians: 46% find it helpful, 22% consider it a distraction, 18% were indifferent, and 12% said it makes them feel nervous
    Fein et al14 (2004)ED in tertiary care children's hospital in the United StatesIntravenous injection placement, urinary catheter, suturing, fracture, fracture reduction, LP, chest tube placement, major resuscitation, trauma resuscitationInternal mail-back, 3-part cross-sectional questionnaire distributed to all ED faculty, ED nursing staff, and pediatric residentsApprove of or consider FMP during procedures: 64% during LP: attendings (84%), nurses (93%), residents (43%); 43% for chest tube placement: attendings (79%), nurses (76%), residents (14%); 28% for endotracheal intubation: attendings (58%), nurses (55%), residents (5%); 32% for medical resuscitation: attendings (63%), nurses (66%), residents (4%); 31% for trauma resuscitation: attendings (63%), nurses (62%), residents (4%)Adavntages of FMP: calms the patient; adds to parent's knowledge that everything was done; decreases parent's feelings of helplessness; facilitates parent education and forges rapport; additional help from parents during procedureLittle information available in regards to medical-legal issues, families’ confidence in the health care providers, or difficulty teaching in the FMP setting
71% of clinicians completed surgery: 19 attending physicians, 56 residents, and 29 registered nursesServices that would help encourage FMP: having family support staff always present; bereavement staff available; ability of the family membes to decline to be present; ability of physician to request the family not be present and/or escorted out; helping families during tragic experiencesDisadvantages of FMP: patient adversely affected by parent anxiety; parent perceived as complicit in painful procedures; may lead to stressful or disturbing memories; obstruction of procedure by parent; increased anxiety or distraction of staff; difficulty teaching; need for extra staff or time; medical or legal concerns
    Booth et al13 (2004)162 United Kingdom EDs from the 2002 Critical Care Directory (excluding those identified as minor injury units): clinician was defined as most senior doctor or nurse available for telephone interviewResuscitationVolunteer telephone survey performed over a 3-wk period of senior doctor or nurse of selected EDsPermission of FMP in ED during resuscitation: 21% of EDs reported that they do not permit FMP, and 11% of EDs overall reported having a written protocol for FMPFMP during resuscitations is more common when children are being resuscitated than adults; for departments that permitted FMP during resuscitation, all reported that efforts are made to provide relative with a chaperone; only 1 ED mentioned medical-legal issues arising from allowing FMP; no ED that permitted FMP during resuscitations had any plans to stop on the basis of adverse eventsOnly 1 clinician from each site was interviewed, so they may not accurately reflect that particular institution's practice guidelines
EDs that allow FMP during resuscitation: 93% allow FMP during pediatric CPR, and 79% allow FMP during adult CPR
Clinician's beliefs about FMP: 48% feel it helps the relative accept that everything was done, 48% feel it helps the relative accept the person's death, 38% feel it helps the relative with grieving, and 2% feel it does not benefit the relative
Adverse effects on the resuscitation process: 35% of EDs reported episodes that involved the distress of a relative, attempted interference by a relative, the distraction of resuscitation team by a relative, and inappropriate demands by a relative
    Gold et al15 (2006)Members of the AAP and ACEP (144 pediatric/NICU, 190 pediatric ED, 147 general ED, 40 other): 521 (479 attending physicians (34 residents/fellows, 3 nurses, and 5 unidentified)Members of the AAP and ACEP (144 pediatric/NICU, 190 pediatric ED, 147 general ED, 40 other): 521 (479 attending physicians (34 residents/fellows, 3 nurses, and 5 unidentified)Pediatric CPROptional, mail-back, 40-question survey with multiple-choice and short-answer questionsAllowing FMP: 93% would allow a family member to be present if they desired, 71% of the physicians wanted the option to be present for his or her own child, 68% reported that most parents want the option to be present, and 19% would allow minor siblings to be presentLevel of physician's support for FMP is markedly higher than previously reported; for those who oppose FMP, the majority wrote comments that being present during CPR would be haunting and traumatic for families; physicians who support FMP suggest that support staff for the family had to been present, that staff should be comfortable with families in the room, or that they were committed to the concept of FMP; opinion that FMP was a good experience did not differ by provider gender, age, being a parent, being a pediatric provider, or having a personal history of witnessing CPR on a family memberLow response rate; thus the population captured may have only been those with strong feelings for or against FMP
Clinicians experienced with FMP during pediatric resuscitations: 38% feel it helps the relative with grieving, 2% feel it does not benefit the relative, 65% vs 53% felt FMP was more helpful to families when the child died vs survived, 61% vs 51% felt FMP was more helpful to families when the child had a chronic medical condition than when the child was previously well, 52% felt it had been good for the family, 33% felt it had been sometimes good and sometimes bad, 8% were not sure about how they felt, and 7% felt it had been a bad experience
Resident training and FMP: 79% felt pediatric residents should receive FMP training during CPR, 71% would allow FMP if residents were participating in CPR, 75% thought that FMP during resuscitation would intimidate a resident, and 25% said they personally would be intimidated by FMP during CPR
  • EI indicates endotracheal intubation; GH, general hospital; LP, lumbar puncture; EM, emergency medicine; CR, critical resuscitation; FMP, family-member presence; MD, physician; RN, nurse.