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F amilies in Critical Care

By Carolyn Bradley, RN, MSN, CCRN, Michelle Keithline, RN, MSN, CCRN, Meghan
Petrocelli, RN, BSN, CCRN, Mary Scanlon, RN, BSN, and Janet Parkosewich, RN, DNSc

Background Family presence during cardiopulmonary

resuscitation in acute care is not widespread. Patients
are not likely to be asked about their wishes for family
presence or if they wish to be the decision makers about
who should be present.
Objective To explore the perceptions of patients on general
medical units and to find factors independently associated
with family presence during cardiopulmonary resuscitation.
Methods A cross-sectional study of 117 randomly
selected adult patients was conducted at an academic
medical center. Participants were interviewed via a sur-
vey to obtain information on demographics, knowledge
of cardiopulmonary resuscitation, sources of information
on resuscitation, and preferences for family presence.
Results About half of the participants agreed or strongly
agreed that family presence during cardiopulmonary
resuscitation was important (52.1%), that the participant
should be the decision maker about who should be
present (50.4%), and that the patient should give con-
sent ahead of time (47.0%). Participants indicated that
they would want an adult sibling, parents, or others
(20.5%); spouse (14.5%); adult child (8.5%); close friend
(5.1%); or companion (4.3%) present during cardiopul-
monary resuscitation. Younger participants (20-45 years
old) were 6.28 times more likely than those ≥ 66 years
old (P = .01) and nonwhite participants were 2.7 times
more likely than white participants (P = .049) to want
family presence.
Conclusion Patients have strong preferences about family
presence during cardiopulmonary resuscitation, and they
should have the opportunity to make the decision about
having family present. (American Journal of Critical Care.
©2017 American Association of Critical-Care Nurses 2017;26:103-110)
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amily presence during cardiopulmonary resuscitation (CPR), endorsed by several pro-
fessional organizations,1-4 is not universally accepted in acute care. Permitting family
presence during CPR is usually at the discretion of health care providers (HCPs). Most
staff members are unaware of the existence of family presence policies5 or are incon-
sistent in adhering to these policies.6-8

Studies on family presence have focused on the Results of studies10,11,26 with patients indicated
perceptions of HCPs and patients’ family members. that patients who wanted family presence would
Most nurses who participated in these studies were feel supported and comforted during this time. Like
in favor of family presence during CPR6,9-13 and were patients’ family members, patients thought it was
more accepting of family presence than were physi- their right to have family presence during CPR.10,27
cians.10-12,14-16 Nurses thought they needed to antici- In 1 study,28 patients even indicated which family
pate family members’ emotional responses to members they wished to be present. Of note, family
resuscitation efforts and to tailor their multifaceted presence during CPR was something that patients
role in supporting patients’ families during this thought HCPs should ask patients about at the time
difficult event.6,13,17,18 Reservations of physicians of admission.11,29
stemmed from their concerns that the team would Drawing conclusions on the basis of studies on
underperform if patients’ family members were pres- family presence during CPR from a patient’s perspec-
ent.10,19,20 In addition, HCPs may feel anxious when tive is difficult because of the variation in research
patients’ family members are present.10,12,16 Concerns methods.10,11,23,25,26,28-30 More studies are needed to
about family members’ emotional responses to wit- adjust for important covariates, which are necessary
nessing a loved one’s resuscitation was a common to identify predictors of patients’ preference for fam-
theme in many studies.10,21,22 ily presence during CPR. Our aims were to explore
Views on family presence during CPR from the perceptions of patients hospitalized on general
the family members’ perspective are mixed. Family medical units and to determine factors independently
members who endorsed family presence thought associated with family presence during CPR.
that they needed to witness
the efforts of the HCPs in Methods
Few studies on order to understand what was Design, Setting, and Sample
family presence going on10,15 and that being We used a cross-sectional design to answer the
present was their right.10,15,23 following 5 research questions:
during CPR have been Families who remained with 1. How important is it for patients to have fam-
focused on patients’ their loved ones during CPR
found that being there helped
ily present during CPR?
2. Which family members would the patients
perspectives. with their grieving process, want to be present during CPR?
aided in closure, and provided 3. Do patients wish to be the decision maker
a positive presence and comfort to the patient.15,24 about family presence?
Persons with past experience witnessing CPR were 4. Do patients think it is important for them to
more likely than those without such an experience give consent for family presence?
to support family presence.25 Families who did not 5. What factors are associated with patients’
support family presence during CPR thought that preferences for family presence during CPR?
the experience might be too distressing.11 Family presence was defined as having someone who
is biologically or legally related to the participant, a
companion, or a close friend remain with the patient
About the Authors during CPR. CPR was operationalized as performing
Carolyn Bradley is a service line educator, Michelle chest compressions to regain pulse or circulation
Keithline, Meghan Petrocelli, and Mary Scanlon are clini-
cal nurses, and Janet Parkosewich is the nurse researcher,
and/or performing rescue breathing to regain venti-
Yale New Haven Hospital, New Haven, Connecticut. lation, breathing, or lung function.
Corresponding author: Carolyn Bradley, Yale New Haven
The study was conducted on 6 inpatient medi-
Hospital, 4-527A East Pavilion, 20 York St, New Haven, cine units at Yale New Haven Hospital, New Haven,
CT 06510 (e-mail: Connecticut, a 1541-bed academic medical center.

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Potential study participants were randomly selected (effect size 0.15; _ = .05; 80% power; 10 predictor
from a list of patients with full code status (n = 910). variables) for logistic regression. One participant
Of these patients, 46% (n = 418) met eligibility cri- withdrew from the study; therefore, 117 participants
teria, which included being able to read and speak were included in the data analysis. Data were ana-
English. Patients were excluded if they were under- lyzed by using SPSS, version 22, software (IBM SPSS).
going treatment for cancer or related complica- Measures of central tendency (mean, standard devi-
tions, had impaired decision-making capacity, or ation, range) for interval and ratio variables and fre-
had received narcotics or sedatives within the previ- quencies and percentages for nominal variables were
ous 2 hours. At time of recruitment, 58% of the used to describe the sample and responses to the first
participants were unavailable (eg, off unit, discharged, 4 research questions.
or asleep), 14% (n = 57) declined, and 28% (n = 118) To determine factors associated with the partici-
were enrolled in the study and completed the inter- pants’ preferences for family presence during CPR,
view. The study was approved by the institutional we recoded the outcome variable as a dichotomous
review board. variable by combining the agree and strongly agree
responses as a yes response and strongly disagree,
Procedures disagree, and uncertain responses as a no response.
After a participant provided written consent, a To determine candidate
15-minute private interview was conducted at the variables for the logistic Data on patients’
participant’s bedside by 1 of 6 investigators, who were regression, we used r2 anal-
not direct care providers, by using a survey designed ysis and independent t tests
demographics, CPR
specifically for this study. Face validity and content (age) to examine associa- knowledge and sources
validity of the survey were determined by a panel tions between demographic
of 6 advanced practice nurses. The survey was pilot factors, CPR knowledge, of information, and
tested by a small group of laypersons. The initial sources of CPR informa- preferences for family
survey items were focused on CPR knowledge. Par- tion, and the importance of
ticipants were asked to define CPR in their own family presence during CPR. presence during CPR
words, and their responses were documented verba- We used inductive con-
tim by the interviewer on the survey form. Responses tent analysis to gain further
were collected.
were read back to the participants to validate data insight into participants’
accuracy. For participants unable to define CPR cor- perceptions of family presence during CPR. Each
rectly, we reviewed the definition and asked them investigator independently interpreted and coded
to repeat this information to verify their under- every participant’s response to the open-ended
standing. We determined participants’ sources of questions written verbatim during the interviews to
CPR information by asking them if they had seen ensure accuracy and trustworthiness. Once this step
or heard about CPR from the media or through was completed, we met as a group to discuss the
discussions with HCPs or family members. codes and reach consensus about emerging themes.31
The survey contained 3 statements on family
presence during CPR. Participants were asked to Results
rate their level of agreement for each item by using Demographic Factors
a 5-point Likert scale. The 3 statements were as fol- The majority of the 117 participants were female
lows: Should you need CPR, it is important for you (56.4%), were white (60.7%), and had at least some
to (1) have a family member present, (2) be the college education (54.6%). The mean age was 54.2
one to decide if this person should be present, and years (SD, 15.9) (Table 1).
(3) give verbal or written permission ahead of time
to have a family member present. Finally, we asked CPR Knowledge and Sources of Information
participants to explain why family presence during Participants were knowledgeable about CPR.
CPR was or was not important to them. Responses Most (95.7%) were able to define CPR correctly.
were documented verbatim and were repeated to Of note, 46.2% of the participants reported that
the participant to verify accuracy. they were CPR certified at some point.
Five questions were asked to explore the partici-
Statistical Analysis pants’ sources of CPR information. Almost every
The number of participants (n = 118) in the ran- participant had seen CPR being performed on tele-
dom sample was based on an a priori power analysis vision or other media (98.3%). Most participants AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 105

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Table 1
Demographic characteristics of the
sample (n = 117)
one-half of the participants agreed or strongly agreed
Characteristics No. (%) that family presence during CPR was important
(52.1%), that they wished to make the decision
Age, y
20-45 36 (30.8) about who should be present (50.4%), and that
46-65 55 (47.0) giving verbal or written consent ahead of time to
* 66 26 (22.2) have a family member present was important
Sex (47.0%; Table 2). These participants identified a
Female 66 (56.4) preference for the person they wanted to be present
Male 51 (43.6) by indicating a spouse (14.5%), adult child (8.5%),
Marital status close friend (5.1%), or companion (4.3%). The
Married or with a domestic partner 48 (41.0) highest percentage of participants (21%) selected
Single 44 (37.6) the other category and wrote in their preference to
Divorced 22 (18.8)
have a sister, brother, mother, father, girlfriend,
Separated 3 (2.6)
fiancé, or person with power of attorney present
Race or ethnicitya should they need CPR. In particular, 1 participant
White 71 (60.7)
Black 27 (23.1)
specified “anyone but my son.”
Hispanic 11 (9.4)
Asian 2 (1.7) Research Question 5
Mixed 5 (4.3) The variables demographics, CPR knowledge,
Educationa and sources of CPR information were examined to
Eighth grade 3 (2.6) determine the factors associated with the importance
Some high school 5 (4.3) of having family presence during CPR (Table 3). Of
High school 43 (36.8)
the demographic factors, age, race or ethnicity, and
Some college 33 (28.2)
College graduate 21 (17.9) education had a statistically significant unadjusted
Graduate school 10 (8.5) association with the importance of family presence
during CPR. Participants with a mean age of 50 years
Some data are missing.
agreed with the importance of family presence during
CPR, whereas patients with a mean age of 58.7 years
(52%) had not discussed with family members the disagreed with this statement (P = .003). To further
participants’ wishes to have CPR performed should examine the association between age and family
the need arise. However, upon admission to the hos- presence during CPR, we created 2 dummy variables:
pital, only 30.8% of the sample recalled talking with ages 20 to 45 years as the younger age variable and
HCPs about CPR wishes. Of these participants, just ages 46 to 65 years as the middle age variable. Ages
a small percentage (24%) remembered the person 66 years and older was used as the reference variable.
they had spoken with, namely, the physician (12%), Most participants in the younger age group (72.2%)
staff nurse (11%), or advanced practice nurse (1%). agreed with the importance of family presence
during CPR, compared with middle-aged (47.3%)
Research Questions 1 to 4 and older (34.6%) participants (P = .008). In addi-
Family presence during CPR was an important tion, nonwhites (68.9%) were more likely than
topic for the study participants. Approximately whites (42.3%) to agree with this statement (P = .005),

Table 2
Participants’ preferences regarding family presence
during cardiopulmonary resuscitation (n = 117)

No. (%) of patients

Question: Strongly Strongly
Should you need CPR…. disagree Disagree Uncertain Agree agree

It is important for you to have a family member present. 24 (20.5) 18 (15.4) 14 (12.0) 30 (25.6) 31 (26.5)
It is important for you to be the one to decide if this person
should be present. 19 (16.2) 16 (13.7) 23 (19.7) 20 (17.1) 39 (33.3)
It is important for you to give verbal or written consent
(permission) ahead of time to have a family member present. 30 (25.6) 11 (9.4) 21 (17.9) 22 (18.8) 33 (28.2)

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Table 3
Unadjusted factors associated with the preference
of participants to have family present during
and participants with less than a college education cardiopulmonary resuscitation (CPR)
(64.7%) were more likely than were participants
with some college education or higher (42.2%) to No. (%) of participants
agree (P = .02). Variable No Yes P
We found no association between the CPR
Age, y .008
knowledge of participants and their perception of 20-45 10 (27.8) 26 (72.2)
the importance of family presence during CPR. Simi- 46-65 29 (52.7) 26 (47.3)
larly, participants’ sources of information, including *66 17 (65.4) 9 (34.6)
being CPR certified, watching CPR on television or Sex .33
other media or being performed (live) on someone, Male 27 (52.9) 24 (47.1)
and discussing CPR with HCPs or a family member Female 29 (43.9) 37 (56.1)
were not associated with this perception. Marital status .70
After demographic factors, CPR knowledge, and Not married 32 (46.4) 37 (53.6)
sources of CPR information were adjusted for, age Married 24 (50.0) 24 (50.0)
and race or ethnicity were independently associated Ethnicity .005
with the perceived importance of family presence All other ethnicities 14 (31.1) 31 (68.9)
during CPR. Participants 20 to 45 years old were more White 41 (57.7) 30 (42.3)
than 6 times more likely to agree with wanting to Education .02
have family presence during CPR than were partici- < College education 18 (35.3) 33 (64.7)
pants 66 years and older (95% CI, 1.466-26.868; * College education 37 (57.8) 27 (42.2)
P = .01; Table 4). Participants who report their race CPR definition .58
as nonwhite were about 2.7 times more likely than Incorrect definition 3 (60.0) 2 (40.0)
Correct definition 53 (47.3) 59 (52.7)
whites to agree with the importance of family pres-
ence during CPR (95% CI, 1.002-7.316; P = .049). CPR certification .09
Participants with less than a college education were Not certified 34 (54.8) 28 (45.2)
Certified 21 (38.9) 33 (61.1)
more likely than participants with a college educa-
tion to agree with the importance of family presence Seen CPR being performed on someone .35
No 33 (44.6) 41 (55.4)
during CPR (95% CI, 0.988-7.001; P = .05).
Yes 23 (53.5) 20 (46.5)

Qualitative Analysis Seen CPR being performed on .95

The overarching theme of the qualitative analy- No 1 (50.0) 1 (50.0)
sis was patient- and family-centered care (see Figure). Yes 55 (47.8) 60 (52.2)
Within this overarching theme, 6 subthemes emerged
Talked with health care providers .93
that described why family presence was or was not about wishes
important to participants. The 3 subthemes related No 39 (48.1) 42 (51.9)
to the importance of family presence are elaborated Yes 17 (47.2) 19 (52.8)
in the following material. Talked with family about wishes .98
Beneficial to Patient and Patient’s Family. Benefits No 29 (47.5) 32 (52.5)
for the patient included not being alone or dying Yes 26 (47.3) 29 (52.7)
alone and receiving comfort and a helpful presence Age, mean (SD), y 58.7 (15.7) 50 (15.0) .003
from a family member. For example, participants
commented, “If it’s your last breath, it should be
with someone you love,” and “I believe that encour-
agement from family can make me stronger—it Table 4
would help.” Adjusted associations with the preference
Participants expressed the importance of having of having family member present during
cardiopulmonary resuscitation
their family witness all that was being done for them
during the resuscitation: “I would want my loved Variable P Odds ratio 95% CI
one to see the efforts involved in my resuscitation,”
and “I wouldn’t want her to wonder what else could Age (20-45 y) .01 6.280 1.466-26.868
have been done to save my life.” Race (nonwhite) .049 2.708 1.002-7.316
On the basis of the close and supportive relation- < College education .05 2.630 0.988-7.001
ship that patients have with their family members, AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2 107

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Patient- and family-centered care

• Beneficial to patient and patient’s family Maintenance of Patient-Focused Care. Participants

Family presence
is important to • Lack of confidence in health care providers were concerned that a family member’s presence
the patient • Lack of trust in health care providers during CPR would distract the health care team
from saving the patient’s life: “Focus should be on
emergency work and not family member.”
Family presence • Worries about family member Some participants were fearful about delays in
is not important • Maintenance of patient-focused care
care if they indicated that they wanted a family mem-
to the patient • Family presence unnecessary
ber present should they need CPR. They thought
that they would have to wait until family members
were contacted for CPR to be performed: “In case
Figure Themes for the importance of family presence to no one was around I wouldn’t want to miss the care.”
patients during cardiopulmonary resuscitation.
Family Presence Unnecessary. Some participants
revealed that during resuscitation they would not
participants thought the family members would be aware of their surroundings, others did not have
want to be present: “Family wouldn’t agree with a caring relationship with their family, and, ulti-
being asked to leave, especially my mother.” mately, family presence would not affect the out-
Another positive effect of witnessing CPR come of CPR. Comments included the following:
expressed by participants was related to helping “I don’t think I would be aware of who was there
their family cope with the end of life: “I think it if I was in that condition.” “I don’t think it is import-
would help my partner suffer less if he can see ant; my family does not care.” “Either way it would
everyone working to bring me back.” not matter if a family member was present or not; it
Lack of Confidence in HCPs. Participants who would be the same outcome.”
wanted family presence thought that HCPs would
perform better and do more to save them with a Discussion
family member present: “If they are in the room, This study was the first of its kind with a ran-
they will help to urge the health care team to work dom sample of inpatients with a face-to-face private
harder to revive me. Better work would be done if interview in which multivariate analysis was used
family is watching over them.” to determine factors independently associated with
Lack of Trust in HCPs. Participants had a desire for patients’ wishes to have family presence during CPR.
their family members to witness that CPR was being Similar to the findings of other studies,10,25,28-30 our
properly performed. Participants were also concerned results indicated that some patients wished to have
about abuse or the lack of proper care: “If some- family members present during CPR. Our results
thing went wrong, the family could witness it,” and were comparable to those of other investigations25,28
“Protection to make sure I am not being abused.” in which younger age had a statistically significant
Similarly, 3 subthemes conceptualized why partic- association with a desire for family presence. In an
ipants indicated that family presence is not important. unadjusted analysis, Benjamin et al28 found a trend
Worries About Family Member. The idea of family for the association between nonwhite race and fam-
presence during CPR raised numerous concerns for ily presence. However, in our study, after important
participants. They worried that the experience would covariates were adjusted for, younger age and non-
be traumatic, upsetting, scary, or stressful for their white race were independently associated with this
loved ones: “Too traumatic for them, especially if it preference. Therefore, these demographic variables
didn’t work,” and “There’s not much they can do. may be important predictors of patients’ wishes to
Why put them through that?” have families present.
Some participants did not want their family Our results concur with those of other investi-
members to have false hope about the participant’s gators11,29 who found that patients want to be asked
recovery from the event, whereas others did not want about family presence during CPR and want the
this event to be the last memory of them: “As a patients’ preferences taken into consideration. The
health care provider, I have performed CPR . . . it participants in our study were specific about the
gives families a glimmer of hope that their loved person they wanted with them should they require
one will be saved. Then, when we have to stop, CPR. HCPs cannot assume which family member a
they ask ‘Why?’” Another participant commented, patient would want to be present during CPR. Unlike
“Wouldn’t want my family to remember last thoughts other researchers, we specifically asked our partici-
of me as being coded.” pants about the importance of obtaining consent

108 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2017, Volume 26, No. 2

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for family presence and discovered that many do status at the time of admission to the hospital.
agree with the formality of consent. Our results were used to create a policy on family
Like others,10,11,26 we found that patients who presence during CPR in our hospital with the spe-
favored family presence during CPR thought they cific aim of providing patient- and family-centered
would feel supported and comforted. However, we care. Other acute care hospitals can replicate this
identified 2 novel reasons for family presence that process to develop or revise a policy on family pres-
were related to patients’ lack of confidence and trust ence during CPR, which may include determining the
in HCPs. In our participants’ minds, having family patient’s preference.
observe resuscitation efforts would motivate the
team to work harder and ensure that care was being We extend our appreciation to Wei Teng, PhD, and Nelson
provided properly. Leach, RN, BSN, CCRN, for their contributions to the study.
In our study and in other investigations, com-
mon reasons for not wanting family presence during This research was supported by a grant from Sigma
CPR included patients’ concern for their loved one’s Theta Tau International Honor Society of Nursing, Delta
reaction11,28 and a desire to keep HCPs focused on Mu Chapter.
resuscitation efforts without family distractions.28
Some patients in our study thought that family pres- Now that you’ve read the article, create or contribute to an
ence was unnecessary because it would not make a online discussion on this topic. Visit
and click “Submit a response” in either the full-text or PDF
difference to them or the outcome of CPR. Another view of the article.
new concern that emerged in our study was fear of
delaying CPR; some patients thought that HCPs
would not start CPR until a patient’s family mem- SEE ALSO
bers had arrived. This misperception should be clari- For more about family presence during resuscitation,
visit the Critical Care Nurse website, www.ccnonline
fied during discussions on code status and family .org, and read the article by Pasek and Licata, “Parent
presence, highlighting the importance of having Advocacy Group for Events of Resuscitation” (June 2016).
these discussions at the time of hospital admission.
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Nurses’ perceptions of family presence during resuscitation. (ext 532); fax, (949) 362-2049; e-mail,

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Perceptions of Adult Hospitalized Patients on Family Presence During Cardiopulmonary
Carolyn Bradley, Michelle Keithline, Meghan Petrocelli, Mary Scanlon and Janet Parkosewich
Am J Crit Care 2017;26 103-110 10.4037/ajcc2017550
©2017 American Association of Critical-Care Nurses
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(AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext.
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