Professional Documents
Culture Documents
2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd 409
F. Demir
410 2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Presence of patients’ families during cardiopulmonary resuscitation
Table 1 The advantages and disadvantages of having patients’ families present during cardiopulmonary resuscitation (CPR)
Advantages Disadvantages
The presence of patients’ families during CPR gives families an CPR is a very traumatic event for patients’ families
opportunity to say goodbye
Families are aware of the effort given for their patients. They There is the possibility of repercussions (e.g. complaints, legal action)
are witnesses to everything necessary being carried out
Families feel like they supported the patient and did not leave Families may interfere with procedures
them alone
Fear and worry of families are lessened. It has a positive effect The team may be uncomfortable
on grieving and coping processes
With this practice the patient and family are considered as a It has a negative effect on patients’ privacy/confidentiality
whole, family-centred care is provided and professional
behaviours are displayed
There may not be enough room for the patients’ families in the
resuscitation room
It may have a negative effect on the technical performance of the
resuscitation team
If there are incorrect procedures litigation may occur
When CPR is unsuccessful there may be less confidence in the physician
It may increase the stress on the team
Families may not be able to endure this situation and may faint. Then the
team may have to care for the family member instead of taking care of
the patient, and their work would be hindered
(1987), 94% of families who stayed with the patient stated emergency department about the practice of the presence of
that if the same situation occurred again they would choose patients’ families during CPR in these units.
to be with the patient again, and 76% stated that staying was
beneficial in helping them accept the death. In the 1998 study
Design
by Meyers et al. 80% of the families would want to stay, and
in the 2000 study 97Æ5% of the families stated that they A descriptive survey design was used.
would want to be with the patient during CPR, and 100%
stated that this would be beneficial for them.
Participants
In recent years, influenced by professional organizations,
the media and research conducted on this topic, there has The study was conducted with staff in the emergency
been a steady increase in the practice of allowing family department and the cardiology and anaesthesia intensive
members to be present during CPR (Boudreaux et al. 2002, care units of an 1811-bed, university-affiliated hospital in
McClenathan et al. 2002, MacLean et al. 2003, Meyers et al. western Turkey. There were 102 nurses and 79 physicians
2004, Redley et al. 2004, Dill & Gance-Cleveland 2005). In working in these departments at the time of the study, and 62
spite of these developments and research, healthcare profes- physicians and 82 nurses participated. Therefore the response
sionals continue to have conflicting opinions on the issue rate was 79%. Among the 144 participants, 25 worked in
(Mason 2003, Meyers et al. 2004, Redley et al. 2004, Dill & emergency department, 41 in cardiology and 78 in the
Gance-Cleveland 2005, Fulbrook et al. 2005). These con- anaesthesia intensive care unit.
flicting opinions are also reflected in practice areas, and
institutional and personal differences occur (MacLean et al.
Data collection
2003).
The data were collected between 1 November 2006 and 26
January 2007. The aim of the study was explained to the
The study
nurses and physicians at continuing education meetings in
their departments. The survey questionnaire developed by the
Aim
researcher based on the literature was given to those who
The aim of the study was to determine the opinions of agreed to participate in the study. There were four open-
physicians and nurses who work intensive care unit and in an ended and 17 multiple choices in the questionnaire. The
2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd 411
F. Demir
open-ended questions concerned why was it necessary for Table 2 Respondent demographics
family members to be present or not to be present during Number (%)
CPR, who should make this decision, if the family was given
permission to be present during CPR what kind of reaction Department
Emergency department 25 (17Æ4)
they had, and whether or not the respondent had anything
Anaesthesia intensive care unit 78 (54Æ2)
they wanted to add. Cardiology intensive care unit 41 (28Æ4)
Age (years)
<30 96 (66Æ7)
Ethical considerations 30–39 40 (27Æ8)
40–49 5 (3Æ5)
The study was approved by a university ethics committee and
50–59 2 (1Æ4)
the medical directors of the hospital. Participant consent was ‡60 1 (0Æ7)
assumed by return of a completed questionnaire. Gender
Female 106 (73Æ6)
Male 38 (26Æ4)
Data analysis Profession
Physician 62 (43Æ1)
The data were evaluated using Statistical Package for Social
Nurse 82 (56Æ9)
Sciences. The responses were summarized using frequencies Education of physicians (n = 62)
and percentages. Responses to the open-ended questions were Medical degree 40 (64Æ5)
content analysed. The chi-square test was performed to test Specialization 22 (35Æ5)
for differences in opinion by profession, educational level and Education of nurses (n = 82)
Associate degree 9 (10Æ9)
number of years of working experience in the profession.
Baccalaureate degree 72 (87Æ9)
Master’s degree 1 (1Æ2)
Primary position of physician (n = 62)
Findings
Research assistant 40 (64Æ5)
The age range of the participating physicians and nurses’ was Specialist 15 (24Æ2)
22–62 years. The mean age was 29Æ18 ± 6Æ11, the median Associate professor 4 (6Æ5)
Professor 3 (4Æ8)
was 27Æ50 ± 6Æ11 and the interquartile range (Q3–Q1) was
Primary position of nurse (n = 82)
6Æ75 years. Participant demographics are given in Table 2. Manager/administrator nurse 9 (11Æ0)
Respondents who thought it appropriate for the families to Ward/intensive care unit nurse 73 (89Æ0)
be present during CPR (13/144) were asked why this was Number of years in profession
necessary. Of these, 76Æ9% (10/13) stated that families could <3 69 (47Æ9)
4–7 35 (24Æ3)
see how much effort was made, 69Æ2% (9/13) that they would
8–11 22 (15Æ3)
be able to accept the situation more easily, 46Æ1% (6/13) that 12–15 9 (6Æ3)
it is a family’s right, 15Æ3% (2/13) that it increases families’ 16–19 3 (2Æ1)
confidence in physicians and 7Æ6% (1/13) that it improves ‡20 6 (4Æ2)
professional behaviour. Total 144 (100Æ0)
The percentage of physicians and nurses who did not think
it appropriate for the patients’ families to be present during permission (3Æ3%, 4/119), it would lengthen the time of
CPR was 82Æ6% (119 of 144). The reasons given for this were resuscitation (2Æ5%, 3/119), there were no national guidelines
as follows: they would interfere with the team’s activities on this topic (1Æ6%, 2/119), there might be litigation against
(56Æ3%, 67 of 119), the procedure was extremely traumatic them (0Æ8%, 1/119) and there was not enough space for the
(43Æ6%, 52 of 119), the team would be under pressure and patient’s family in the work environment (0Æ8%, 1/119).
this would have a negative effect on their performance Respondents who stated that they had given permission for
(22Æ6%, 27 of 119), the family would incorrectly interpret the families to be present during CPR (8Æ3%) were asked how
CPR procedure (21Æ8%, 26/119), the practice is not appro- this affected the families. Of these 5Æ5%, stated that family
priate for the cultural background and educational level of members became ill and fainted, 2Æ7% that family members
the Turkish public (15Æ9%, 19/119), family members might experienced fear, worry and anxiety, 1Æ3% that family
become ill or might faint and force the team to have to leave members felt guilty because it was a traumatic event, but
the patient to deal with them (15Æ9%, 19/119), only family 91Æ6% of respondents had never given permission to family
members who are also healthcare personnel should be given members to observe CPR.
412 2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Presence of patients’ families during cardiopulmonary resuscitation
The decision about whether the family could be present level (v2 = 1Æ844, d.f. = 4, P = 0Æ764) or number of years of
during CPR should be a team decision, according to 47Æ2% of working experience in the profession (v2 = 9Æ977, d.f. = 10,
the participating physicians and nurses; however, others P = 0Æ443).
thought that the decision should be made by a physician and
nurse (26Æ4%), a physician (20Æ8%), the physician and family
Discussion
(2Æ8%), or the family members (2Æ7%).
In response to the question about whether or not they
Study limitations
would like to add anything, 84Æ1% of physicians and nurses
did not add anything, but 8Æ3% stated that the Turkish This study was conducted in a university hospital emergency
public’s cultural background and educational levels were not department, cardiology and anaesthesia intensive care units
appropriate for observing this procedure, 5Æ5% that it was with physicians and nurses who were willing to participate.
not necessary to traumatize the relatives and 2Æ1% that only There are some differences between the emergency depart-
family members who were also healthcare personnel should ment and intensive care unit in terms of the rate of CPR,
be given permission to observe CPR. patients’ conditions and the work environment. The fact that
Responses to the fixed-choice questionnaire items are participants worked in the different departments may be a
shown in Table 3. There were no statistically significant limitation of this study. In addition, the research would have
differences according to chi-square test for finding the been more comprehensive if patients’ family members had
families’ presence during CPR to be appropriate according been included. Finally, in Turkey, health services are
to profession (v2 = 5Æ660, d.f. = 2, P = 0Æ060), educational provided by the Ministry of Health and funded by the
Table 3 Responses to fixed-choice questionnaire items about family presence during cardiopulmonary resuscitation (CPR)
Number (%)
2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd 413
F. Demir
Ministry of Finance. Therefore, it is not possible to make emotional effect on the family. In the study by Meyers et al.
direct comparisons with reports in the literature which relate (2004), 57% of healthcare professionals were concerned that
to countries where health care is funded through insurance or the family would incorrectly interpret CPR and later demand
other systems. However, it is suggested that the findings in a legal investigation, while 26% of nurses said this in the
this study are useful at a national and an international level study by Fulbrook et al. (2005). In the current study,
by reflecting cultural differences in the opinions of healthcare however, 21Æ8% of respondents thought that the family
professionals. would incorrectly interpret the CPR procedure, and 0Æ8%
that they might open a court case. This result may have
occurred because of the low numbers of court cases opened
Discussion of findings
against healthcare personnel in Turkey. In contrast to all
Very few respondents (9%, 13 of 144) found it appropriate these concerns, no reports were found in the literature of
for patients’ families to be present during CPR. This result is problems with having the patients’ families present during
very low in comparison with other research conducted in CPR, that families interfered with the procedure or that being
recent years (MacLean et al. 2003, Meyers et al. 2004, Halm present had a negative effect on the family (MacLean et al.
2005). In the study by MacLean et al. (2003) 75% of 2003, Redley et al. 2004, Aldridge & Clark 2005, Dill &
intensive care unit and emergency department nurses and in Gance-Cleveland 2005). During CPR when the family is
the study by Meyers et al. (2004) 96% of emergency given the choice with the appropriate conditions mentioned
department nurses supported the presence of families during above, the concerns of healthcare professionals on this
CPR. This difference in acceptance level may arise from subject may be alleviated.
cultural differences There has been no research in Turkey on In the present study, a very small percentage (2Æ5%, three of
how physicians’ or nurses’ assumptions about patients’ 119) of respondents thought that the duration of the resusci-
cultural and educational backgrounds affect their decisions tation procedure would be extended in the presence of the
for their patients. Although this issue needs further investi- family. In the study by Fulbrook et al. (2005) 38Æ7% of the
gation, it is common for older and uneducated Turkish nurses thought that this would be the case, but in the study by
women, in particular, but also for Turkish men, to express Meyers et al. (2004) 85% of healthcare professionals stated
their grief physically with loud wailing, beating their chests that they could comfortably work in the presence of the family
and fainting. Patients’ family members have even assaulted during CPR and 84% that, even if the family was present, their
emergency department physicians and nurses in Turkey when performance and the patient outcomes would not change.
a patient has died. There is also the unfounded assumption by Nearly all (93Æ8%, 135 of 144) of the respondents in the
nurses and physicians that people who are more culturally present study stated that there was no written policy on this
‘refined’ and have a higher educational level will be more topic in the unit where they worked, and the that family
likely to go to a private hospital and that the majority of their members were not permitted to be present during CPR. In the
patients at a university hospital are culturally ‘ignorant and study by MacLean et al. (2003) with intensive care unit and
backward’. Although these attitudes are difficult to quantify, emergency department nurses, the presence of a policy giving
they may have bearing on physicians and nurses’ attitudes the family the permission to be present during CPR was 5%
towards their patients, being judgmental, belittling or, in this and the presence of a policy forbidding their presence was
instance, not being willing to take the time to explain CPR to 1%. Our findings are therefore consistent with the literature.
family members. Four of the physicians and nurses included in our research
In this study, the percentage of physicians and nurses who stated that there was a written policy forbidding the presence
did not think it was appropriate for the patients’ families to of the patients’ families during CPR. However, this is not
be present during CPR was very high (82Æ6%, 119 of 144) consistent with responses from other individuals working on
(Table 3). The reasons given for this were that the family the same units. The managers of the three units where this
would interfere with the team (56Æ3%, 67 of 119), that the research was conducted were asked about this situation and
procedure was extremely traumatic (43Æ6%, 52 of 144), and they responded that there was no written policy. In conclu-
that the team would be under pressure (22Æ6%, 27 of 119) sion, none of the units where this research was conducted had
and it would have a negative effect on their performance. In a a policy (giving permission or forbidding it) about the
study by Meyers et al. (2004), 38% of the healthcare presence of families during CPR. Not having a formal policy
professionals thought that the family would interfere with may have led to misunderstanding and different practices.
CPR, while Fulbrook et al. (2005) reported that 20Æ2% of the Previous research has shown that the overwhelming
nurses studied were concerned that it would have a negative majority of families want to be with the patient during
414 2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Presence of patients’ families during cardiopulmonary resuscitation
2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd 415
F. Demir
416 2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd