- Providing the best care for patients is the primary goal of emergency physicians and nurses.
- The option of family member presence should be encouraged for all aspects of emergency care.[i]
- Family presence should never be forced on a family or the emergency staff. Hospital policy determines whether or not a family member can be present during a medical procedure.
- Relatives who remain with loved ones who are in critical condition often express appreciation for the efforts of emergency teams; because they understand that truly dedicated efforts were made.
- Emergency physicians save lives every day. We are experts in adult and pediatric emergencies.
What is family member presence in the emergency department?
Family member presence in an emergency department is the practice of allowing a patient's family member to stay in a treatment area while a patient is resuscitated or undergoes a medical procedure. The presence of family members generally is well-received by emergency department personnel who have experience with this practice. Many hospitals have always allowed family members to remain with their children or spouses during emergency department visits for minor problems. Information should be provided to families during interventions, regardless of the family's decision to be present or not.
Should family members remain during resuscitations or emergency procedures?
The decision to allow family presence is based on the family's wish to remain with their loved one, the opinions of medical personnel, the reactions of family members and patients, the nature of the emergency and the hospital's policy.
According to ACEP Now, “it is important for physicians to set expectations for family members, whose expectations for resuscitation might come from television shows such as ER or Grey’s Anatomy. Many people do not have an accurate perception of what occurs during resuscitative efforts, and some advocate that more education is needed to prepare families to attend resuscitative efforts.”[ii]
Just as the science of medicine is constantly changing, so too is the relationship between health care personnel and patients and their families. Patients and family members who in the past simply accepted the treatment plans prescribed by their physicians, now are invited to participate in all aspects of their medical care. With this increased involvement has come a related increase in the presence of families during the actual delivery of medical care.
In most hospitals that allow family presence, family members do not ask to remain; they simply are never asked to leave. In other hospitals, a family member may simply request to stay in order to remain. In some circumstances, medical personnel may sense uneasiness in family members and ask them to step outside to help them leave without feeling guilt for "abandoning" their loved one. Family members should never be forced to remain in the treatment area. Family members can be a help or a hindrance in the emergency department, depending on their behavior. Those who remain in a room quietly, or stand at a bedside and soothe or encourage a loved one, will not be a distraction to an emergency team. However, outbursts of hysterical behavior, physical interference with medical actions, or other types of disruptive behavior may require a family member to leave the room. Similarly, if a patient is agitated by the presence of a family member, then that person should leave.
The nature of a patient's problem also can dictate the appropriateness of family presence. For example, procedures which unduly expose the patient may prove embarrassing to both family members and patients. Some hospitals regulate family presence based on the criticality of the patient or intervention, limiting the presence of family members to only minor procedures on stable patients. Other emergency departments adopt the opposite philosophy, based on the belief that the more unstable the patient, the greater the need for family members to be present.
Does the presence of family members help?
The impact of family members in the treatment area is difficult to study objectively. To date, there is limited evidence that family members may relieve anxiety in children undergoing minor medical procedures. Although there are no data showing that a family member's presence has affected a patient's response to treatment, particularly in critical cases, there is good evidence the practice has beneficial effects on family members themselves. In fact, relatives who have remained with loved ones during care have expressed great appreciation for the efforts of emergency teams, better understanding that truly dedicated efforts were made, and more rapid closure with patients who don't survive. Almost universally, studies questioning family members who have remained in treatment areas during resuscitations or procedures have strongly favored the practice.
How can family presence affect medical decision-making?
“Family presence may improve perceptions of medical decision-making, patient care, and communication among health care providers as well as with family members. Although no studies have directly addressed the effect of family member presence on malpractice litigation, there is reason to believe that the presence of family may actually decrease litigation by improving patient and family satisfaction. “ [iii]
Are there any downsides to family member presence?
There can be drawbacks to the presence of family members during resuscitations and emergency procedures. For example, family members remaining with patients have collapsed during relatively minor procedures; some have been seriously injured, requiring medical assistance and care themselves. Even such medically mundane activities as insertion of intravenous catheters or simple laceration repairs have produced episodes of fainting in parents or spouses. Unfortunately, in some high-profile cases, people have successfully sued hospitals and health care providers over these instances.
In other cases, family members have witnessed actions they felt were below the standard of care and used this as a basis for legal actions.
Family presence may also improve perceptions of medical decision-making, patient care, and communication among health care providers as well as with family members.
The presence of family members can also present a challenge in teaching centers. Instruction of inexperienced students or physicians in training programs must be done tactfully when relatives are present at the bedside.
Q. What happens when disagreement occurs?
Occasionally, family members and medical personnel may disagree over the appropriateness of their presence. If time permits, or it involves an upcoming procedure, then discussions can be held with hospital personnel. However, in emergency situations, this generally is not an option, and decisions must be made in a timely fashion.
The first priority in any such disagreement is the patient's care. Delays in care should not occur because of arguments about relatives remaining in the room. If a family member must be removed from a treatment area, often the need for such a drastic measure can be addressed after the patient is stabilized. However, these disagreements are rare, and generally there is time for a brief discussion to resolve both family member and medical personnel concerns.
In most instances, an open dialogue between the attending physician and the family will lead to a rapid resolution of the disagreement or an agreeable compromise. Even when medical personnel feel strongly that it is inappropriate for family members to be present, assurance the family will be permitted to return to the bedside as soon as the procedure is completed often alleviates concerns.
Q. Are there any rules to govern family member behavior during resuscitation?
The only behavioral rule governing family presence is that the family must not interfere with the care of the patient. Disruptive behavior, whether verbal or physical, will not be permitted under any circumstances in any emergency resuscitation. If a family member does not feel he or she can maintain control, he or she can ask to be escorted from the resuscitation area.
Lack of interference does not imply lack of interaction. Provided it does not impede access to the patient, family members generally are encouraged to speak with, touch, comfort, and soothe emergency patients as appropriate. Emergency personnel will provide guidance as to the degree of physical interaction that will be helpful. Family members are encouraged to ask questions of emergency staff if it will help them understand what is happening. The timing of such questions or the length of answers will vary depending on the status of the medical procedure.
How should family members decide whether to remain?
Family members generally do not have to make a formal decision about remaining during a resuscitation or emergency procedure; they simply follow their instincts. It's a personal decision. Frequently, some family members want to stay and others do not. In fact, it's common for some family members to remain in the treatment area, some to remain in the waiting area, and still others to wander between the two. There are advantages and disadvantages to both approaches. What's important is for emergency personnel to make family members feel comfortable with whatever decision they make.
For more information, visit www.ACEP.org.
[i] American College of Emergency Physicians Policy Statement. “Patient- and Family-Centered Care and the Role of the Emergency Physician Providing Care to a Child in the Emergency Department.”2012. http://www.acep.org/Content.aspx?id=29598
[ii] ACEP Now, June 2015, “ Should Families Watch CPR in the Emergency Department,” http://www.acepnow.com/article/should-families-watch-cpr-in-the-emergency-department/
[iii] AAP, “Patient-and-Family-Centered Care of Children in the Emergency Department, Jan. 2015, http://pediatrics.aappublications.org/content/135/1/e255.long
(Last Updated 2015)