Teaching Clinical Ethics Using a Case Study: Family Presence During Cardiopulmonary Resuscitation

Ainslie T. Nibert
Crit Care Nurse 2005;25:38-44
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Teaching Clinical Ethics Using a Case Study

Family Presence During Cardiopulmonary Resuscitation

Ainslie T. Nibert, RN, PhD

issue debated among healthcare professionals who routinely face lifethreatening situations. Presentation of a case study involving a familys presence during CPR provides students in a critical care nursing course valuable experience in making ethical decisions that will prepare the students for the inevitable dilemmas faced by professional nurses.

Case Study
A 40-year-old man lost control of his vehicle and struck a guardrail in a single-car collision. He was not wearing a seat belt and was thrown through the windshield, sustaining a traumatic, closed-head injury. He was brought to the trauma center via helicopter and was admitted to the surgical intensive care unit. The night staff provided support to the patients wife during her first visit to see her husband, who was receiving mechanical ventilation and was unresponsive and surrounded by multiple invasive catheters and equipment. The trauma team briefly met with her soon after admission to explain her husbands grave prognosis. The next day, a senior student in an undergraduate critical care nursing course assisted the nurse preceptor in managing the patients complex care. The patients wife came into the unit for her second visit just as the nurse preceptor and the student were preparing the patient for the morning visit. As the patients wife approached the bedside, the alarms of the monitors for the cardiac and arterial catheters sounded, indicating a cardiac arrest, and CPR was initiated. The healthcare personnel

ritical care nurses often find themselves in the midst of challenging ethical situations that involve conflict between the needs of critically ill patients and the patients family members and the preferences of physicians and other healthcare providers who initiate and manage resuscitation measures. Yet, many critical care nurses have reported

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that they received little preparation in their basic education programs to deal with these sensitive issues. Because new graduate nurses often choose to specialize in critical care, nurse educators who design and teach undergraduate critical care nursing courses are obligated to address ethical decision making as part of the curriculum. In this article, I present a case study of an ethical issue in critical care and describe a method of clinical ethical analysis that nurse educators can use when teaching students about making ethical decisions in clinical practice. The presence of patients family members during cardiopulmonary resuscitation (CPR) is an ethical

Author
Ainslie T. Nibert is the director of research at Health Education Systems, Inc, and a clinical associate professor at College of Nursing, Houston Center, Texas Womans University, in Houston, Tex.
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handling the code situation pulled the privacy curtains around the bed in an attempt to screen the situation from view by the patients wife and the other patients and their visitors within the unit. At that moment, the student took the stunned wife into the hallway, and a nursing supervisor arrived to lead the woman into a private waiting room. The student later reported the events of the morning to her peers at a clinical conference, including the fact that the patients wife had arrived just as the code started. The student explained that the patient did not survive despite the teams efforts and that the patients wife did not have the opportunity to see him again before he died. The students statement caused the instructor to question the policy in almost all adult critical care units that family members access to loved ones during CPR should be restricted. The ethical dilemma that arose in this situation involved the conflict between the desire of the patients wife to be present during CPR and the desire of the trauma team to exclude her.

initiating a change in accepted policy that would allow patients families to be present, reinforcing the existing policy that prohibits their presence, or selectively permitting them to be present on the basis of screening according to predetermined criteria.

Using a Clinical Approach to Resolve Ethical Dilemmas

Nurse educators teaching critical care courses can increase students understanding of ethical dilemmas by having the students participate in a clinical analysis of a case study. The debate about whether to offer family presence during CPR is an example of an ethical dilemma that arises within critical care nursing practice. In small groups, students can begin their analysis of the issue by reviewing the current literature on family presence. Discussion of findings with their peers helps students identify key issues within the ethical dilemma. Once the issues defining the dilemma are exposed and described, students can search for relevant practice guidelines endorsed by medical, nursing, and other health-related organizations. After the review of the literature and the search for current practice guidelines are completed, students will be ready to further define the opposing arguments inherent in the ethical conflict. During the discussion of these issues, the instructor should function as both facilitator and moderator and should be responsible for ensuring that all points of view are equally represented and discussed as the ethical analysis unfolds. The clinical analysis of the case study is designed to answer the question, Does an overriding obligation exist to honor the desires of the fam-

ily or the desires of the healthcare providers? Once students formulate an answer to this question, they can advance recommendations that reaffirm the traditional policies that restrict family presence or that promote the adoption of new policies that lift restrictions on family presence in the critical care setting. Step 1: Reviewing the Literature Family presence during CPR is a relatively new issue in healthcare. Students conducting a review of the literature may be surprised to discover that most of the available information has been published within just the past 2 decades. No ethical dilemmas of this type existed before the development of CPR in the late 1950s because family members were present at almost all deaths. A dying persons last moments were most often controlled by his or her family in the home rather than by medical personnel in a hospital. The advent of high-tech medical practices moved patients out of homes and into hospital beds. When patients were too sick to be treated on general nursing units, they were moved to critical care units. Even though such a move offered greater proximity to lifesaving equipment, it removed patients from their families. Molter1 published a landmark study that was the first to acknowledge the needs of families of critically ill patients. Once critical care nurses began to actively question the enforcement of restrictions on visiting hours, access of patients families to critically ill patients gradually increased during a 20-year period. Hanson and Stawser2 published the experiences of the emergency

What Constitutes an Ethical Dilemma?

A moral conflict exists because 2 opposing obligations collide: an obligation to the family members who desire to be present with their loved one during CPR and an obligation to the healthcare providers who do not want patients family members to witness resuscitation efforts. The focus of the ethical questions that stem from this clash of desires is determining which obligation deserves to be fulfilled while the opposing obligation is ignored or compromised. Resolution of the ethical dilemma involves

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department staff at Foote Hospital in Michigan, attributed as being the first hospital to allow family presence during CPR. As early as 1982, the staff at Foote Hospital began questioning the merit of restricting access of patients family members to the patients during CPR. The issue came to the attention of the Emergency Nurses Association in 1993, and a resolution was passed encouraging health professionals to offer patients families the chance to be present during CPR.3 Guidelines to assist staff in creating these policies were published by the association in 1995,4 and an educational booklet for families on the subject was developed. Articles and letters to editors continued to be published through the late 1990s in many medical and nursing journals that supported either retaining traditional restrictions on family presence or adopting more lenient policies that allowed family presence in selected situations.5-10 However, few articles offered research-based findings on the issue until Meyers et al11 published the results of the first formal research study in which the responses of family members who had participated in family presence at Parkland Hospital in Dallas, Tex, were examined. Subsequent studies resulted in the publication of the first evidence-based guidelines, which recommended that hospital personnel remove restrictions on family presence. The guidelines were based on reports of perceived advantages and disadvantages of family presence given by patients family members, healthcare providers,12 and patients.13 The articles were published in the American Journal of Nursing, and findings were widely disseminated to the public through the mass media. Advantages and disadvantages of family presence during CPR from the perspectives of patients family members and healthcare providers (Table 1) varied slightly. Family members viewed family presence

Table 1 Perspectives of patients family members and healthcare providers on family presence during cardiopulmonary resuscitation
Family members Perceived benefits 5,8,12,14,15 Fosters greater appreciation for efforts of code team to ensure that everything possible was done to save the patient Enhances feeling of usefulness by offering medical history and actively supporting the patient Gives opportunity for patients values to be expressed to staff Increases spiritual connectedness felt with the patient Reduces guilt and anxiety about leaving the patient in crisis Allows closure with the patient, facilitating grief process; offers the chance to say goodbye Perceived problems 5,10,12,15-17 Feeling pressure to be present even if family member does not desire to participate in situation Risk of insensitivity by staff who may assume that all family members wish to be present Fear of becoming emotionally traumatized as a consequence of being present during the code Healthcare providers (staff) Reminds staff of patients personhood when a family member of the patient is present during the code situation Helps staff provide more holistic care to the patient during the crisis situation

Encourages professional behavior among staff

Allows a patients family members to recognize staffs efforts made to save the patient Reaffirms the role of the nurse as an advocate for patients Focuses staffs attention on patients privacy and dignity Fear that staff might be distracted by a patients distraught family members

Unease about the potential for litigation brought by patients family members who view the code Concern that codes might be prolonged in futile situations because a patients family members are present Anxiety about loss of control of environment and possibility of disruptive behavior by patients family members leading to physical assault

Concern that staff may unnecessarily prolong the code, even in a futile situation, because the family member is in attendance

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not only as a fundamental right but also as a way of offering support to their loved ones in crisis. However, they also expressed concern about feeling emotionally traumatized and obligated to witness CPR when they might prefer to decline.5,8,12,14,15 Patients also thought they had a right to have their families present. Some patients said that they felt safer and less afraid with family members present. However, other patients reported that they preferred to face death alone and did not want estranged relatives allowed to invade their privacy.13 Healthcare providers viewed family presence as an opportunity to maintain the dignity and personhood of patients but feared physical assault by distraught family members, increased threats of liability and subsequent litigation, and loss of control over the code situation.5,10,12,16,17 Interestingly, all parties involved agreed that family presence during CPR could result in subjecting patients to prolonged resuscitations in medically futile situations because the trauma team might be reluctant to call the code in the presence of a patients family member.9 Step 2: Reviewing Practice Guidelines Position papers and codes of ethics from various medical and nursing professional organizations can be scrutinized to determine which groups have identified standards of practice for family presence. Some organizations have offered broad statements that reflect the importance of service to patients and patients family members as a primary goal of healthcare and have designated all other actions as subordinate to this obligation.18-24 However, only the Emergency Nurses

Association and the American Heart Association have publicly acknowledged the benefits of family presence and advocated that family presence be an option for hospital staff. Step 3: Defining the Opposing Arguments The method of clinical ethical analysis described by Jonsen et al25 (Table 2) provides students a practical and understandable approach to resolving ethical dilemmas in critical care nursing practice. The focus of this method is an analysis of 4 distinct issues that have a bearing on the ethical dilemma under examination: (1) medical indications; (2) patients preferences; (3) quality of life; and (4) social, economic, and health policy issues, defined by Jonsen et al as contextual features. By examining family presence during CPR within the context of these 4 categories, students can gain experience in building arguments that support or reject this practice.
Medical Indications for Offering Family Presence During CPR

Analysis begins with a review of the medical indications that would markedly affect a patients chances of being benefitted or harmed by offering or denying family presence. Medical indications typically focus on treatment goals and the impact the ethical problem has on the achievement of these goals. The review of the literature provides evidence indicating that family presence does not usually interfere with medical interventions with a focus on patients survival. Furthermore, results of research studies indicate that providing family presence can be of great comfort to both patients and the patients families. The

American Heart Association20(pI-19) estimated that less than 15% of all hospitalized patients receiving CPR survive to discharge from the institution where they were resuscitated. Therefore, because of this high mortality rate and patients wishes to be close to their family members at the moment of death, medical indications favor offering family presence. Patients Preferences Patients preferences are key components within the clinical ethical analysis and should be evaluated next. A patient may express certain preferences about medical care directly to his or her family members and/or healthcare providers. If a patients preferences are not specifically known, they may be construed from a review of the patients consents for treatment and advanced directives or determined from the statements of the patients surrogate decision maker. General evidence about patients preferences can also be obtained from the literature. The research indicates that patients and their families prefer having family presence offered as an option and that virtually all patients and families who are offered the opportunity for family presence will accept it.2,5,6,9,11-13,23 Regarding family presence, patients and their families have expressed a desire to be in close contact when facing a lifethreatening situation.12,13 Quality-of-Life Issues The nursing literature describes several qualityof-life concerns expressed by patients and patients families who have experienced family presence during CPR. For many years, healthcare providers have restricted family presence because of concerns

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Table 2 Method of clinical ethics analysis

Medical indications 1. What is patients medical problem? history? diagnosis? prognosis? 2. Is problem acute? chronic? critical? emergent? reversible? 3. What are goals of treatment? 4. What are probabilities of success? 5. What are plans inn case of therapeutic failure? 6. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided? 3. Is patient mentally capable and legally competent? What is evidence of incapacity? 4. Has patient expressed prior preferences, e.g., Advance Directives? 5. If incapacitated, who is appropriate surrogate? Is surrogate using appropriate standards? 6. Is patient unwilling or unable to cooperate with medical treatment? If so, why? 7. In sum, is patients right to choose being respected to extent possible in ethics and law? Quality of life 1. What are the prospects, with or without treatment, for a return to patients normal life? 2. Are there biases that might prejudice providers evaluation of patients quality of life? 3. What physical, mental, and social deficits is patient likely to experience if treatment succeeds? 4. Is patients present or future condition such that continued life might be judged undesirable by them? 5. Any plan and rationale to forgo treatment? 7. What are legal implications of treatment decisions? 6. What plans for comfort and palliative care? 8. Is clinical research or teaching involved? 9. Any provider or institutional conflict of interest?
Reproduced from Jonsen et al,25 with permission of the McGraw-Hill Companies. Copyright 1998 by the McGraw-Hill Companies, Inc.

Patient preferences 1. What has the patient expressed about preferences for treatment? 2. Has patient been informed of benefits and risks, understood, and given consent?

Contextual features 1. Are there family issues that might influence treatment decisions? 2. Are there provider (physicians and nurses) issues that might influence treatment decisions? 3. Are there financial and economic factors? 4. Are there religious, cultural factors? 5. Is there any justification to breach confidentiality? 6. Are there problems with allocation of resources?

about the emotional trauma that witnessing CPR might cause a patients family members. However, patients thought that family presence elevated the patients dignity and status as persons in the eyes of the healthcare team.13 Likewise, family members of patients reported that family presence provided an opportunity for closure and a chance to say goodbye.13 Although the potential danger of emotional trauma

resulting from family presence has been described, most family members indicated that their experiences with family presence did not adversely affect their quality of life.12 Contextual Features The tradition of restricting family presence in hospitals is a significant social and health policy issue that is a contextual feature in the ethical debate associated with this practice. Long-standing opposition to family presence during

CPR is a well-known, social phenomenon within the medical community. Physicians in particular have expressed covert concerns about experiencing increased emotional distress due to the presence of a family member during the code. These concerns stem from an intentional depersonalization of patients by physicians that allows the physicians to remain focused on the required medical interventions and to main-

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tain an objective perspective while directing a code situation. Their distress is compounded by anxiety over possible litigation and even physical assault. The underlying issue appears to be one of control, with nurses more likely than physicians to favor allowing family presence during CPR.12 Healthcare personnel have a fiduciary duty to their patients that requires the personnel to promote their patients interests above their own preferences. Physicians have traditionally recognized the interest that patients family members have in the welfare of the families loved ones, and physicians are therefore obligated to support and shield these patients from harm.25 Thus, the contextual features of the family presence issue support subjugating the desires of healthcare providers in deference to the obligation owed to patients and patients family members.

Making Ethical Decisions About Family Presence During CPR

The culmination of the clinical ethical analysis occurs when the student group reaches a decision about the merits of restricting or permitting family presence during CPR in critical care units. The tradition of restricting family presence in hospitals was identified in the clinical ethical analysis as a social and health policy issue, or contextual feature, within this ethical dilemma. According to Jonsen et al,25 the fact that this restrictive practice constitutes a contextual feature would normally decrease its overall importance in ethical decision making. However, the medical indications, patients preferences, and quality-of-life issues that would normally exert a more

powerful influence in the final analysis provide little guidance in the case study involving family presence during CPR. In this case study, the key medical indication, the provision of CPR, did not extend the patients survival, the patients preferences about family presence were unknown, and the spouses quality of life could have been affected because she lost the opportunity for closure and the chance to say goodbye to her husband. Thus, the contextual feature, the tradition of restricting family presence during CPR in this hospital, was a pivotal factor in the clinical ethical analysis. In order to effectively resolve the ethical dilemma, a change in policy to remove traditional restrictions on family presence during CPR was needed. In other words, the argument for keeping a restrictive policy because that is the way it has always been done at a particular hospital is not necessarily valid for restricting family presence. Perpetuating restrictions on family presence simply because these restrictions have traditionally been upheld by hospitals (the contextual feature of the family presence debate) is not supported by the clinical ethical analysis. Therefore, from an ethical perspective, hospital policies that globally restrict family presence during CPR should be abolished, and healthcare professionals should develop procedures that at least selectively, or even unconditionally, allow family presence.

Conclusion
During the past decade, nurses have increasingly advocated for family presence. In fact, nurses have been the most frequent authors of studies on family presence. The Emergency Nurses Association is the only pro-

fessional, health-related organization that has published a position paper promoting family presence during CPR.23 As a result of the American Journal of Nursings publication of 2 landmark studies on family presence12,13 and the subsequent publicity about these studies within the popular media, the family presence issue and nurses who support family presence during CPR have gained national attention. Although the issue remains controversial, nurses generally agree that family presence can be beneficial for both patients and patients family members, if patients and their families desire it. Because of this belief, nurses continue to advocate for their patients by attempting to revise policies that restrict family presence in their hospitals. What can nursing students learn from analyzing this case study on family presence? They may realize that situations involving ethical dilemmas in the critical care environment can be resolved in many different ways. Student groups using the case study may gain additional insight by discussing what might have happened if the patients wife had been allowed to stay with her husband during CPR. Students may gain a deeper appreciation for the complexity of ethical issues they will face in the critical care environment. They may even begin to question hospital policies that are based on tradition rather than on specific evidence. Providing the opportunity to discuss and debate an ethical issue and to work through a clinical ethical analysis under the guidance of an informed instructor offers students a valuable experience in dealing with the issues they will undoubtedly face as novices in professional nursing practice.

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Acknowledgments
I thank Anne Young, RN, EdD, and Brenda Haile, RN, DrPH, College of Nursing, Texas Womans University, Houston Center, for sharing their knowledge of clinical nursing ethics. I also thank Rosemary Pine, RN, MSN, CDE, Center for Patient Education, Methodist Hospital, Houston, Tex, Dorothy Kite-Powell, RN, MSN, palliative care, St. Lukes Episcopal Hospital, Houston, Tex, and Amy Calvin, RN, PhD, College of Nursing, University of Texas Health Science Center at Houston, for development of background material for this article and Donna Boyd for her editorial assistance in the preparation of the manuscript. 7. resuscitation room? Accid Emerg Nurs. 1995;3:58-61. Powers K, Rubenstein J. Family presence during invasive procedures in the pediatric intensive care unit. Arch Pediatr Adolesc Med. 1999;153:955-958. Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accid Emerg Nurs. 1996;4:145-151. Rosenczweig C. Should relatives witness resuscitation? Ethical issues and practical considerations. CMAJ. 1998;158:617-620. van der Woning M. Should relatives be invited to witness a resuscitation attempt? A review of the literature. Accid Emerg Nurs. 1997;5:215-218. Meyers T, Eichhorn D, Guzzetta C. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs. 1998;24: 400-405. Meyers T, Eichhorn D, Guzzetta C, et al. Family presence during invasive procedures and resuscitation: the experience of family members, nurses, and physicians. Am J Nurs. February 2000;100:32-43. Eichhorn D, Meyers T, Guzzetta C, et al. Family presence during invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. May 2001;101:48-55. Glidden M. Family presence during resuscitation. Conn Nurs News. SeptemberNovember 2000;73:15. Doyle C, Post H, Burney R, Maino J, Keefe M, Rhee K. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16:673-675. Schwartz T. Family presence: not mine [editorial]. Am J Nurs. May 2001;101:11. 17. Shelton DL. New AHA CPR guidelines favor family presence. AMNews. September 18, 2000. Available at: http://www.ama-assn .org/amednews/2000/09/18/hll20918.htm. Accessed November 16, 2004. 18. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Association; 2001. 19. American Hospital Association. AHA Management Advisory: Ethical Conduct for Health Care Institutions. Chicago, Ill: American Hospital Association; 1992. 20. American Heart Association. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2000;102(8 suppl):I1-I384. 21. American College of Emergency Physicians. Code of Ethics for Emergency Physicians. Dallas, Tex: American College of Emergency Physicians; October 2001. Available at: http://www.acep.org/1,1118,0.html. Accessed November 19, 2004. 22. Villaire M. Interview with Beth Henneman. Beth Hennemans ICU passion is all in the family. Crit Care Nurse. October 1994;14:8895. 23. Emergency Nurses Association. Position Statement: Family Presence at the Bedside During Invasive Procedures and Resuscitation. 4th ed. Washington, DC: American Nurses Association; 2001. 24. Beauchamp T, Childress J. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press; 2001. 25. Jonsen A, Siegler M, Winslade W. Clinical Ethics. 4th ed. New York, NY: McGrawHill; 1998.

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