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Ethical Dilemma in Current Events - Family Presence During Resuscitation

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Ethical Dilemma from Current Events
Family Presence During Resuscitation
Tracy Sitek
Grand Canyon University
Ethical Decision Making in Healthcare
NRS 437V
Barbara Trabelsi
April 17, 2011

Ethical Dilemma from Current Events Over the last decade, controversy over family presence during resuscitation (FPDR) and invasive procedures has markedly increased. Historically, it has always been thought that having a family member that was hysterical or asking questions for clearer understanding of the situation was a deterrent or distraction for the staff while they were trying to provide care to their critically ill relative. No one wanted the family in the room as they might potentially become another patient or they were in the way of the care providers. The family was escorted to a more private setting such as a quiet room, to await the occasional visits from staff to update them on the status of their loved one. A recent article written by Tamekia L. Thomas called “Family Presence: To Stay or Not to Stay?” discusses the idea that if family members were given the choice of being present during invasive procedures or resuscitation of a loved one, they would be at the bedside (Thomas, 2008). This presence has proven to assist in the bereavement process, provides the family with reassurance that all efforts were made during the resuscitation and decreases anxiety for the family. However, a change in culture is a slow process and controversy continues due to lack of written policy to enforce it.
Perhaps this change in culture hasn’t yet evolved because of past memories of families that could not cope with the resuscitation process or that due to the high incidence of punitive litigation, medical staff refused the family out of fear of being sued. Whatever the case may be, not allowing the family to be present during resuscitation is an example of virtue ethics, as the needs of the medical staff treating the patient alone presents itself without real consideration for the family. It could be argued that this approach is best for the staff, and may or may not be best for the patient and the family. Yes, evolution is slow, but it holds promise for the future.
In the case of a 62 year old man that reluctantly presented to the emergency department after four days of searing low back pain and new onset of vomiting, another type of ethical dilemma began. This patient was alert and oriented and discussed his known advanced cardiac disease and that his relatively small abdominal aortic aneurysm was being watched but was not yet operative. Waving goodbye to his wife and daughter, he was quickly taken to the radiology department for an abdominal CT to rule out an aortic dissection. The family was waiting nearby CT when the code blue tones began to sound overhead. Unresponsive and in cardiac arrest, he was rushed back to the ED where an intensive resuscitation ensued, with the wife and daughter standing outside watching. The unspoken dilemma was on the faces of the staff as they looked at the family – do we send them to the quiet room or do we allow them to stay and watch? The family was appropriately tearful and anxious, but not inappropriate or obstructive, and they were allowed to stay. Over the blurring next few minutes, many doctors and staff members were placing central lines, hanging vasopressors, performing CPR and visibly sweating while they valiantly provided this patient with critical care in an effort to restart his heart. During the chaos of the resuscitation, more family members had quietly gathered outside the room, watching and holding each other’s hands, united in hope. Occasionally they walked into the room and touched the man’s hand and spoke to him, with the staff working around them as they continued their effort. No bother, no question if they should be there or not. They just were, and it was alright. The daughter was watching the cardiac monitor, and realizing that the situation was grave, took her mother into the room to stand next to her husband. The daughter told her that it was time to say goodbye, because his heart wasn’t beating on its own anymore. The staff stepped away to allow all of the family members into the room, to be with him as his heart stopped and he breathed his final breath. During this code that ended 66 minutes later, the family was allowed to witness and experience the resuscitation and death of their beloved husband, father, grandfather and friend, and to say goodbye for the last time. Several days later, the wife and daughter were asked by the nurse manager how they felt about being there for the resuscitation. The wife stated that she wouldn’t have had it any other way and knows, without question, that everything possible was done for him and it allowed her to start grieving as he was dying. This situation was an example of consequential and utilitarian ethics where the needs of the family were evident and unobtrusive, and that in itself outweighed the needs of the medical staff and that since this situation was a positive difference from those in the past, to allow the family to be an integral part of the resuscitation. Several months after this case, the daughter of the patient was asked to speak at a Family Centered Care conference about her experience during the resuscitation and to express how important it was to her family to be there when her father died. This particular resuscitation set in motion a precedent for FPDR in this hospital, and continues to support it to this day.
A reasonable plan of action might be developed in that it would be a prudent decision for any medical staff in any setting to begin by evaluating the situation and immediately proceeding with the needed invasive procedure or resuscitation of the patient first. They should then assess if family is available, speak with them regarding the patient’s condition and plan of care, give them a choice to be in the room with their loved one, if appropriate, and continue the procedure or resuscitation to its finality. This allows choices and flexibility for both medical staff and family in the care of the patient, for the best possible outcome with everyone’s consideration. The findings in general are that family presence is beneficial during resuscitation both for the family and, to an extent, the patient. The competency, education and self-confidence level of the nurse involved with a particular patient holds great value as this could control whether a patient's family is invited to be present during CPR. Specialized training should occur with nursing staff and doctors alike, to ensure practice and performance with family presence is optimized in both environment and support systems (Weglarz, 2009). References
Thomas, T. L. (2008). Family Presence: To Stay or Not to Stay? Nursing2011, 38, 6-8. doi: 10.1097/01.NURSE.0000314638.49473.91. Retrieved from: http://journals.lww.com/nursing/fulltext/2008/04001/family_presence__to_stay_or_not_to_stay_.2.aspx
Weglarz, A. M. (2009). Nursing and Family Practice: Is Having Family in the Room When a Patient Receives CPR Beneficial to Anyone? Retrieved from http://nursing.advanceweb.com/Article/Nursing-and-Family-Practice.aspx

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