CPT Bruce M. McClenathan, MC, USA; COL Kenneth G. Torrington, MC, USA; and Catherine F.T. Uyehara, PhD

Transcription

1 Family Member Presence During Cardiopulmonary Resuscitation* A Survey of US and International Critical Care Professionals CPT Bruce M. McClenathan, MC, USA; COL Kenneth G. Torrington, MC, USA; and Catherine F.T. Uyehara, PhD Objective: Recent international emergency cardiovascular care (ECC) and cardiopulmonary resuscitation (CPR) guidelines have recommended that health-care professionals allow family members to be present during resuscitation attempts. To assess whether critical care professionals support these recommendations, we surveyed health-care professionals for their opinions regarding family-witnessed resuscitation (FWR). Methods: We surveyed health-care professionals attending the International Meeting of the American College of Chest Physicians in San Francisco, CA, from October 23 to 26, 2000, about their CPR experience, their opinions on FWR, and demographic characteristics. The opinions of physicians, nurses, and other allied health professionals were compared, and differences in opinions based on demographics were examined. Results: Five hundred ninety-two professionals were surveyed. Fewer physicians (20%) than nurses and allied health-care workers combined (39%) would allow family member presence during adult CPR (p [ 2 test]). Fourteen percent of physicians and 17% of nurses would allow a family presence during pediatric CPR. There was a significant difference among the opinions of US professionals, based on regional location. Professionals practicing in the northeastern states were less likely than other US professionals to allow FWR during adult or pediatric resuscitations (p and p < 0.001, respectively [ 2 test]). Midwestern professionals were more likely than others to allow family members to be present during an adult resuscitation, when compared to professional in the rest of the nation (p [ 2 test]). Health-care professionals disapproving of family member presence during CPR did so because of the fear of psychological trauma to family members, performance anxiety affecting the CPR team, medicolegal concerns, and a fear of distraction to the resuscitation team. Conclusions: Our evaluation indicated that the majority of critical care professionals surveyed do not support the current recommendations provided by the ECC and CPR guidelines of (CHEST 2002; 122: ) Key words: cardiopulmonary resuscitation; family-witnessed resuscitation; practice guidelines; survey Abbreviations: AAST American Association for the Surgery of Trauma; ACCP American College of Chest Physicians; CPR cardiopulmonary resuscitation; ECC emergency cardiovascular care; ENA Emergency Nurses Association; FWR family-witnessed resuscitation In its August 22, 2000, issue, the journal Circulation published the American Heart Association 2000 guidelines for emergency cardiovascular care (ECC) and cardiopulmonary resuscitation (CPR), *From the Department of Medicine (Cpt McClenathan and Col Torrington) and the Department of Clinical Investigation (Dr. Uyehara), Tripler Army Medical Center, Honolulu, HI. The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the United States Government. Manuscript received February 20, 2002; revision accepted July 12, Correspondence to: Cpt Bruce McClenathan, MC, USA, Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859; Bruce.McClenathan@amedd. army.mil advocating family-witnessed resuscitation (FWR) 1 and recommending that family member presence be allowed during CPR attempts. This recommendation was rendered despite the controversy that has existed since pioneering studies began in 1987, when Doyle et al 2 decided to allow FWR at their institution. Since then, most research that has been done has been limited to small studies 3 12 or anecdotal reports. 4,13,14 Despite the paucity of data on FWR, some professional organizations, such as the Emergency Nurses Association (ENA), have resolved to support it. 15 Advocates for FWR state that the patient is part of a bigger whole, the family, which suffers during 2204 Special Reports

2 resuscitation. They conclude that family members actually deal with their grief better by witnessing the resuscitation. 2,3,6,7,9 They also report that on post- CPR surveys, most family members felt that their presence helped and supported their loved ones resuscitation. 5,6,9 Many of the health-care professionals who oppose FWR fear distractions to the CPR team by the family during resuscitation. 7,9,10,16,17 Helmer et al 17 state that the resuscitation suite should be free from distractions, which includes family members. They compare resuscitation critical task performance to piloting aircraft. To date, no study has demonstrated that FWR either improves or compromises resuscitative efforts. Another argument raised by those opposed to FWR is that allowing the presence of family members violates patient confidentiality and the patient s right to privacy. 17 Helmer et al 17 state that we must first protect the rights of our patient to optimal care, confidentiality and privacy. The needs of family members, as important as they are, must come second. Many health-care professionals also oppose FWR because they fear it will increase the risk of litigation and will cause psychological trauma to family members. 7,9,10 However, advocates of FWR state there may be less legal risk in FWR due to the strengthening of staff-family bonds. 18 They cite a preliminary randomized controlled trial pilot study by Robinson et al, 12 which demonstrated no adverse psychological effects to a small number of family members who witnessed resuscitation compared to those not offered FWR. FWR advocates have speculated that medicolegal risks would actually decrease, positing that family members increased knowledge would lower the risks of potential lawsuits. 18 Opponents of FWR cite one case report, in which a woman sued for nervous shock after witnessing the pain and suffering caused to her husband and three children after being involved in a motor vehicle accident. 19 When surveyed, the American Association for the Surgery of Trauma (AAST) members expressed concern that FWR would increase malpractice litigation. 17 Neither argument is supported by clinical evidence. Advocates of FWR state that allowing a family member presence during resuscitation leads to more professional behavior by the CPR team. According to Meyers et al, 9 70% of the professionals surveyed noticed modified staff conversations at the bedside and promoted a more careful choice of words... with less black humor. In addition, with family members present, professionals were more apt to consider the patient s dignity, privacy, and need for pain management. 9 While Meyers observations cannot be refuted, humor provides a psychological coping mechanism enabling health-care professionals to deal with depressing and dehumanizing situations. 20 In May 2000, our institution was confronted with a resuscitation that involved an unsolicited family member presence. This event led to considerable debate among our health-care professionals and prompted a literature search on FWR, which revealed limited data and great controversy among health-care professionals surrounding this new family-centered approach to resuscitation. 7,9,10,17,21 In response, we developed a survey to evaluate health-care professionals for their opinion on family member presence during CPR. In addition, we evaluated the reasons that health-care professionals would oppose family member presence during CPR. Materials and Methods An English language survey of six questions covering CPR experience, opinions on family member presence, as well as demographic data to determine health-care professionals opinions and experiences on FWR was distributed to physicians, nurses, and allied health-care professionals attending the International Meeting of the American College of Chest Physicians (ACCP) in San Francisco, CA, between October 23 and 26, The survey was deliberately short to allow its completion in 2 min. All attendees who walked through the main ACCP booth in the convention exhibition area were offered the opportunity to complete the survey, and survey responses were kept anonymous. One investigator and his spouse distributed all surveys and briefly explained the purpose of the survey. Consent to participate in the study was implied by the health-care professional s completion of the survey. All responses to the survey were handwritten on the questionnaire by individual health-care professionals. No remuneration or gift was given for completing the survey. The data were compiled and transferred to a standard worksheet (Excel 2000; Microsoft Corporation; Redmond, WA). 2 analysis (JMP Statistical Software; SAS Institute, Inc; Cary, NC) or the Fisher exact test (Number Crunching Statistics System, version 6.0; Statistical Solutions; Saugus, MA) were used to compare the proportions of those in favor of FWR for various demographic groups, depending on whether the sample sizes of the demographic subgroups were large ( 2 test used) or small (Fisher exact test was used if the number in an individual data cell was 10). The level of statistical significance was set at p For the analysis of regional variations, the United States was divided into the northeast, midwest, south, and west regions using the US Census Bureau methodology 22 (Fig 1). Results A total of 592 surveys were completed. Ten surveys were internally inconsistent and were not included in the analysis. Of the remaining 582 survey participants, 28 indicated that they had never been present during an attempted resuscitation. Thus, these respondents were excluded from further analwww.chestjournal.org CHEST / 122 / 6/ DECEMBER,

3 Figure 1. Regional variations in FWR opinions among health-care professionals. US Census Bureau methodology was used to separate the United States into four regions. FWR opinions were compared between each region and the rest of the United States. * statistically significant regional difference (p 0.05). ysis as their lack of experience made their opinions uninformed, leaving 554 surveys to be analyzed. Although many surveys had incomplete responses, the data were recorded and analyzed as long as they were not contradictory. Four hundred ninety-four of the 543 people that listed an occupation, indicated that they were physicians, which represented approximately 15% of the physicians who attended the ACCP International Convention. Twenty-eight nurses and 21 other allied health-care workers were surveyed, which represented approximately 8% of the nurses and other allied health-care professionals at the ACCP International Convention. Sixteen survey participants did not describe their professional training. Gender analysis of the survey participants showed that 394 (71%) were male physicians. Of the remaining 29%, there were 73 female physicians, 25 female nurses, 12 female allied health-care providers, 9 male allied health-care providers, and 2 male nurses. Seven individuals (5 men and 2 women) did not list their occupations. Participants identified their ethnicity as follows: white, 293; Asian, 101; Hispanic, 24; African, 10; other, 59; and not specified, 67. Neither gender nor ethnicity influenced participants survey responses. Among the 494 physicians surveyed, the following specialties were represented: pulmonary, 388 physicians; critical care, 283 physicians; pediatrics, 20 physicians; sleep, 19 physicians; cardiothoracic surgery, 18 physicians; cardiology, 9 physicians; allergy, 5 physicians; other, 26 physicians; and not specified, 28 physicians. Many physicians indicated that they are certified in more than one specialty. Subgroup analysis by specialty failed to show significant differences among the groups. The mean ( SD) age of participants was years, and there was no significant difference in survey responses based on age. The average number of years since the completion of training was 11, and the number of years since training did not influence opinions on FWR. Also, there was no significant difference of opinions based on the size or type of the hospital in which the participant practiced. Regardless of occupation, the majority (78%) of all health-care professionals surveyed opposed FWR for adults. In examining opinions per occupation (Fig 2), a greater percentage of physicians (80%) than nurses and allied health-care professionals combined (61%; p [ 2 test]) or nurses alone (57%; p [ 2 test]), disapproved of FWR. The opinions of all participants regardless of occupation also showed that a great proportion (85%) were not in favor of FWR when resuscitation involved a child. The responses, by occupation, showed that even 2206 Special Reports

4 Figure 2. Variations in FWR opinions by occupation. * physician opinions differed significantly from nurses and other allied health-care professionals (p 0.05); opinions on adults and children were significantly different (p 0.05). fewer physicians (14%) would allow family members to be present during pediatric CPR compared to 20% allowing family member presence during adult CPR (p [ 2 test]). This tendency also was seen in nurses, as only 17% endorsed FWR during pediatric resuscitation compared to 43% endorsing adult resuscitations, although this difference was not statistically different (p [Fisher exact test]). There were significant differences in opinions regarding FWR based on the regional location of the health-care professional s practice (Fig 1). Healthcare professionals practicing in the northeast United States were less likely to allow family presence during an adult or pediatric resuscitation (12% and 5%, respectively) compared to health-care professional in the rest of the nation (25% and 21%, respectively; p and p 0.001, respectively [Fisher exact test]). Midwest health-care professionals (37%) were more likely to allow family member presence during an adult resuscitation than those in the rest of the nation (18%; p [Fisher exact test]). Midwest health-care professionals were also more likely to favor FWR in the pediatric patient compared to health-care professionals in the rest of nation, but this was not statistically significant. Of those participants who indicated whether their practice was in the United States or in another country, there were no differences in opinions between international (n 96) and US participants (n 341) concerning either adult or pediatric resuscitation. Of the 554 participants who had previous resuscitation experience, 22% would allow family presence during an adult resuscitation. In contrast, 42% of those with no previous resuscitation experience (n 24), who were eliminated from the above analyses, would allow family presence during an adult resuscitation attempt (p [Fisher exact test]). Three hundred forty-three participants (59%) had previously been involved in FWRs. Of the 343 with FWR experience, only 136 (40%) would allow FWR again. Respondents who disapproved of family member presence during resuscitation listed various reasons. The most common reason chosen was a concern for the psychological trauma to the witnessing family members (79%). Other reasons listed were medicolegal concerns (24%) and performance anxiety affecting the CPR team (27%). Forty-eight respondents (9%) noted additional reasons, beyond those listed on the survey, for why they would not allow FWR. The most common additional reason (26 respondents) was fear that family members would be a distraction to the resuscitation team. Respondents were allowed to list multiple reasons if they chose to do so. Discussion In our survey, as well as other surveys of staff members, 2,4,7 10,17 one common reason for not allowing family member presence during CPR was a fear of distracting the CPR team. In the largest survey of physicians prior to our study, 17 AAST members believed strongly that the presence of family members in the resuscitation bay would interfere with patient care. Representative comments from our survey participants include some family members fainted, their presence slowed the needed steps down, families become hysterical and distract us from doing our job, spouse had an altercation with the chaplain at the bedside, the family becomes so distressed that we have to resuscitate them, distraction for communication, possibly delay treat- CHEST / 122 / 6/ DECEMBER,

5 ment or interfere, family disrupts the normal flow, reduces effectiveness, interrupts efficient care, interference by family during rapid delivery of treatment, too many in room, don t have time to explain, would distract from at least one member of the team who would have to explain to the family. Hanson and Strawser 3 presented an opposing view in their 9-year retrospective study, which reported not one instance of actual interference with the resuscitation when family members were present. Similarly, Meyers et al 9 reported no actual interferences by family members. The discordance between our survey of critical care physicians and the results published in the literature demonstrates that prospective studies in ICUs are needed to assess the likelihood of family member interference during FWR. A major concern of professionals who are opposed to FWR is the fear of psychological trauma to family members who witnessed the resuscitation. In our survey, as well as other surveys of staff, 9,12,23 physicians, more often than nurses, were afraid of psychological trauma to those witnessing CPR. In fact, nearly 79% of the professionals in our survey cited a fear of psychological trauma to family members as a cause for excluding family members. Others have expressed this concern. For example, Osuagwu 16 stated that FWR was nontherapeutic, regretful, and traumatic enough to haunt the surviving relative for as long as he or she lives. However, FWR advocates argue that the medical profession encourages lay people to be trained in basic life support and CPR to help their loved ones survive in the case of an accident or emergency. Furthermore, many family members are the first responders to the scene and initiate CPR, only to be ejected from the resuscitation room once they arrive at the hospital. Others suggest that most people know what to expect during CPR due to frequent depictions of resuscitation and CPR on television programs such as ER and St. Elsewhere. 24 Van der Woning 24 states it seems a natural progression that the majority will soon no longer accept the traditional exclusion of themselves from the resuscitation of a family member. The veil of mystery and heroism has been lifted through TV, and for the general public resuscitation is a frequent and procedural event for the medical team. It is an event from which the general public need not be shielded anymore. 24 However, we agree with Osuagwu 16 and contend that the invasiveness and poor outcomes of real-life CPR attempts differ markedly from television s almost universally successful and bland depictions. In a small randomized, controlled pilot study, 12 the data showed no adverse psychological effects, with a trend toward lower degrees of intrusive imagery, posttraumatic avoidance behavior, and symptoms of grief among relatives who witnessed resuscitation as measured by five different psychological tests administered at 3 and 9 months after the attempted resuscitation. Although most physicians worry about psychological trauma to family members who have viewed a resuscitation, family members do not share this concern. 2 6,9 These small published studies suggest that health professionals concerns about psychological trauma following FWR may be unsubstantiated. Most advocates of FWR, including those who pioneered the idea, recommend family member presence in the resuscitation suite only after all invasive lines and tubes, such as central venous catheters, arterial lines, and endotracheal tubes, have been placed. 3 Exceptions to this standard are the ENA resolution 15 and the FWR policy at Parkland Memorial Hospital, Dallas, TX. 9 The CPR Guidelines 2000 of the American Heart Association do not describe the time during resuscitation when it is appropriate for family members to enter the resuscitation suite. We believe that health-care professionals would be more likely to accept family presence after invasive procedures have been completed, as this would afford a more controlled environment for the CPR team. Many health-care providers have had previous experience with FWR. In our study, 307 physicians (61% of those surveyed) had previous experience with FWR. Only 119 (39%) would allow FWR again. Thus, 60% of physicians considered FWR to be a negative experience. This parallels the sentiments of AAST members. Almost 75% of those physicians who had experience with FWR characterized their experience as negative. 17 Contrary to this, only 47% of the nurses in our survey considered their FWR experience as having been negative. This is in agreement with the survey by Helmer et al, 17 who found that only 36% of ENA members surveyed considered their previous FWR experience to have been negative. 17 While staff members 2 4,7 10,17,25 and family members 2 6,9,11,12,26 have been surveyed about FWR, there has been little research on what the patient would have wanted. Anecdotal cases of patients who have survived resuscitation have been reported. 4,12 Of those, most support FWR. For example, Belanger and Reed 4 have reported the case of a 60-year-old man, status post-massive myocardial infarction, who was aware of his wife s presence during an extended resuscitation. Afterward, he stated that her presence was sufficient encouragement to continue his fight for survival. 4 Opponents of FWR argue that dying patients may prefer loved ones to remember them as they were, and not the sight of nurses and doctors gagging their throats and stamping their chest during 2208 Special Reports

6 the traumatic event of CPR. 27 In the study by Robinson et al 12 of three patients who survived resuscitation and were interviewed later, all were content that a relative remained with them and felt supported by their presence. None believed that his confidentiality or dignity had been compromised. We recommend that FWR choices be included as a component of advanced directives. The argument about FWR has been framed in an ethical context, in which health-care professionals must choose between patient autonomy and their own tendency to practice benevolent paternalism. 28 Those who support FWR contend that the patient s family knows best whether they should be present and have the most invested in the resuscitation. 2,4,6,28 Opponents to FWR argue that physicians are more knowledgeable about the risks and benefits of FWR both for the patient and family members. They assert that laypersons are unprepared to comprehend the complexities of the situation. 28 Walker 28 summarizes the ethical dilemma of FWR by stating recognition of a relative s right to witness resuscitation depends on health-care professionals willingness to promote the principle of respect for autonomy. Surveys of the opinions of family members and health-care professionals on FWR have shown distinct differences. Most family members strongly desire to be present, or at least to be offered the opportunity to be present, during a loved-one s resuscitation. 5,6,9,11,12,26 The majority of family members state that FWR allows them to better deal with grief and made the adjustment to death easier. 2,4,6,28 In addition, many thought that their presence was beneficial to the dying patient. 2,4,6,28 Others have stated that it aided closure by allowing loved ones to say good bye while the patient could still hear and made the family aware that everything was done. 2,9,28 Surveys of health-care professionals 7 10,17,23,25 have demonstrated that physicians are less likely than nurses to accept FWR. For example, in our study 80% of physicians did not endorse FWR compared to 57% of nurses (p ). This correlates with the results of the study by Helmer et al 17 of AAST members (physicians) and ENA members (nurses). In that study, 97.8% of physicians opposed FWR compared to 80% of nurses (p 0.001). A 1997 survey of 57 health-care providers suggested that different resuscitation perspectives account for the difference in opinions. 25 To reconcile the strongly differing opinions between family members and physicians, and between physicians and nurses, we believe that hospitals need to educate staff members about the international ECC and CPR guidelines for 2000 dealing with FWR. Health-care professionals need to study the published data and make educated decisions. We recommend that hospitals, which implement FWR policies, consider training staff members during basic life support or advanced cardiopulmonary life support classes, an approach that has been shown to be successful. 23 Contrary to our survey results, the literature 29 demonstrates greater staff support for FWR during pediatric resuscitations. Our findings may reflect the fact that most professionals we surveyed were adult critical care physicians. Only 20 of 494 physicians (4%) listed pediatrics as their specialty. Adult intensivists and critical care workers are less likely to deal with children and thus have less experience with child-parent bonds and family member interactions with a child. Our study is the first to report a significant difference in opinions on FWR based on regional location within the United States. As shown in Figure 1, those in the Midwest were more likely to allow FWR in adults when compared to the rest of the nation (p 0.002). We also found that professionals in the Northeast were the least likely to support FWR for either children or adults compared to the rest of the nation. While the reasons for these differences are unproven, we speculate that 10 years of efforts by the Foote Hospital (Jackson, MI) staff may have taken root in the Midwest, making FWR more acceptable in that region. 2 4 This survey of 592 US and international physicians, nurses, and other allied health-care providers showed that the latest recommendations by the ECC are generally not supported. This is important because the population we studied is composed primarily of critical care professionals who frequently deal with end-of-life issues. Their strong negative attitude toward FWR should not be dismissed as uninformed. We believe that the American Heart Association recommendations go beyond standard intensive care practices and require further study before implementation. Our findings confirm those from previous surveys 7,9,17,21,29 of hospital staff, which demonstrated that nurses are statistically more likely to support FWR than physician colleagues (p 0.02). We suggest that this attitude results either from nurses decreased legal liability compared to physicians, or because nursing students generally receive greater emphasis on patient-family dynamics during training than do medical students. Contrary to the results of previous studies, 8,9 our study showed a significant difference of opinion on FWR based on previous resuscitation experience. Health professionals lacking CPR experience were more likely to recommend FWR than were those with previous resuscitation experience. We propose that professionals who have participated in typically hectic CPR attempts with difficult vascular access CHEST / 122 / 6/ DECEMBER,

7 and tracheal intubation, emesis, and rib fractures understand the reality of CPR and have concluded that family members should be excluded from witnessing these events. We have identified several limitations to our study. First, due to the nature of the survey and the manner in which it was distributed at an international convention, a response rate could not be obtained. This theoretically could skew the results of our study, as only those with a strong opinion for or against FWR may have taken the time and effort to complete the survey. Second, although participants were questioned on their opinions about pediatric resuscitations, their responses may not reflect those of pediatric intensivists. The results should be interpreted carefully, as only 20 of the physicians surveyed listed pediatrics as a specialty. Finally, the fact that this survey was not a rigorously controlled, prospective research study may have affected its reliability and validity. Conclusion Our survey of 592 US and international critical care physicians, nurses, and allied health-care professionals, who were attending an international pulmonary and critical care medicine conference, indicated that the majority of all health-care professionals surveyed do not support the current recommendations promulgated by the ECC and CPR guidelines of We speculate that the statistically significant difference between physicians and other health-care professionals attitudes that we and others have found may relate to the fact that physicians have ultimate responsibility for the outcomes of resuscitation efforts. Critical care professionals oppose FWR for many reasons, which include the fear of psychological trauma to the witnessing family members, increased medicolegal risk, performance anxiety among the CPR team, and the distraction of the resuscitation team. Our survey participants, critical care professionals who frequently deal with end-of-life issues, are on the front lines of medical ethics, and their strongly negative attitude toward FWR cannot be dismissed as uninformed. Because the American Heart Association recommendations appear to exceed the standard critical care practices, we encourage rigorous scientific study of FWR before its widespread implementation. References 1 American Heart Association. Guidelines 2000 for Cardiopulmonary Resuscitation: part 2. Ethical aspects of CPR and ECC. Circulation 2000; 102(suppl):I12 I21 2 Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med 1987; 16: Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department s nine-year perspective. J Emerg Nurs 1992; 18: Belanger MA, Reed S. A rural community hospital s experience with family-witnessed resuscitation. J Emerg Nurs 1997; 23: Eichhorn DJ, Meyers TA, Mitchell TG, et al. Opening the doors: family presence during resuscitation. J Cardiovasc Nurs 1996; 10: Meyers TA, Eichhorn DJ, Guzzetta CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs 1998; 24: Jarvis AS. Parental presence during resuscitation: attitudes of staff on a paediatric intensive care unit. Intensive Crit Care Nurs 1998; 14:3 7 8 Sacchetti A, Carraccio C, Leva E, et al. Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience. Pediatr Emerg Care 2000; 16: Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation: the experience of family members, nurses and physicians. Am J Nurs 2000; 100: Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accid Emerg Nurs 1996; 4: Barratt F, Wallis DN. Relatives in the resuscitation room: their point of view. J Accid Emerg Med 1998; 15: Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998; 352: Hartley D. From the foot of the gurney. JAMA 2001; 284: Adams S, Whitlock M, Higgs H, et al. Should relatives be allowed to watch resuscitation? BMJ 1994: 308: Emergency Nurses Association. Resolution 93:02: family presence at the bedside during invasive procedures and/or resuscitation; General Assembly Park Ridge, IL: Emergency Nurses Association, Osuagwu CC. ED codes: keep the family out. J Emerg Nurs 1991; 17: Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. J Trauma 2000; 48: Brown JR. Letting the family in during a code: legally, it makes good sense. Nursing 1989; 19:46 19 Lomax L. Closing the floodgates [letter]. New Law J 1991; 17: Andreasen NC, Black DW. Introductory textbook of psychiatry. 2nd ed. Washington, DC: American Psychiatric Press, 1995; Chalk A. Should relatives be present in the resuscitation room? Accid Emerg Nurs 1995; 3: United States Census Bureau. Census regions and divisions of the United States, March 2001 (regional map). Washington, DC: US Department of Commerce, US Census Bureau, Geography Division, Bassler PC. The impact of education on nurses beliefs regarding family presence in a resuscitation room. J Nurses Staff Dev 1999; 15: Van der Woning M. Should relatives be invited to witness a resuscitation attempt?: a review of the literature. Accid Emerg Nurs 1997; 5: Timmermans S. High touch in high tech: the presence of 2210 Special Reports

8 relatives and friends during resuscitative efforts. Sch Inq Nurs Pract 1997; 11: Boie ET, Moore GP, Brummett C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 1999; 34: Osuagwu CC. More on family member presence in the resuscitation room [letter]. J Emerg Nurs 1993; 19: Walker WM. Do relatives have a right to witness resuscitation? J Clin Nurs 1999; 8: Back D, Rooke V. The presence of relatives in the resuscitation room Nurs Times 1994; 90: CHEST / 122 / 6/ DECEMBER,