Resus: What is the Impact of Family Presence During Resuscitation?
Case Presentation
Patient was a 55 year old female with a history of diabetes and hypertension, who presented via EMS as full cardiac arrest. Patient collapsed in the field with bystander CPR started shortly after. Upon arrival of EMS at the scene, patient was found to be in PEA arrest and brought to UH emergency department (ED). In the ED, patient continued to be in PEA arrest so ACLS and resuscitative efforts were continued. Patient received several rounds of CPR, ventilation via a bag-valve-mask, defibrillation x2 for transformation to shockable rhythm, and standard ACLS medications. Cardiac activity was monitored using ultrasound during pulse checks. Patient’s husband arrived after 30 minutes and the supervising physician announced to the team that he would bring the husband to the resuscitation room.
What is the impact of family presence during resuscitation?
For someone new to emergency medicine or unfamiliar with this practice, the thought of bringing a family member into the room during a resuscitation may spark surprise, anxiety, or worry. How will the family member react to seeing invasive and intense procedures being done on their loved one? How will this impact the team and overall process of resuscitation?
The practice of “family presence during resuscitation” (FPDR) has been studied and debated for over thirty years. Family presence during resuscitation (FPDR) can be defined as “the presence of family in the patient care area, in a location that affords visual or physical contact with the patient during resuscitation events”[1]. The first study was published in 1987 by Doyle et. al, in which the researchers questioned the fairness of a policy that excluded family members from the treatment rooms of cardiac arrest patients undergoing resuscitation [2]. Through survey data, they found that family members wished to be present during resuscitation efforts and this assisted the grieving process for many. Furthermore, the presence of family members did not interrupt or adversely affect medical efforts [2]. This apparent psychological benefit was supported by a subsequent randomized trial published in 1998. In a trial published by Robinson et. al, family members were given the option to witness resuscitation (treatment group) and were subsequently followed up after 1 month regarding their decision and to assess PTSD-related symptoms such as anxiety, depression, and grief [3]. In the control group, the family members were not offered the choice to witness the resuscitation. This study found no reported adverse psychological effects among those who witnessed resuscitation efforts and all survey respondents were happy with their decision to stay with the patient [3]. The researchers in this study became so convinced of the benefits of FPDR that they terminated the trial prematurely [3]. The results found in these early papers can also be seen in studies published more recently, about fifteen years later.
In 2013, Jabre et. al published a seminal work investigating the psychological consequences among family members given the option to be present during CPR as compared to those who were not offered this option. This was done through a prospective, cluster-randomized controlled trial with 15 prehospital EMS units in France where the tested intervention was the systematic offer of the choice to witness the resuscitation. It is important to note that the intervention involved several in-depth processes including a scripted protocol, designated support assistant charged with explaining the resuscitation process to the family member, and comprehensive post-resuscitation debriefing. The researchers found that offering the choice to families to witness resuscitation can lessen their mental health burden as those who witnessed CPR had less PTSD-related symptoms as compared to those who did not [4]. This apparent psychological benefit held strong at both a ninety day follow-up and a one year follow-up [4, 5]. Furthermore, family witnessed CPR did not affect the resuscitation characteristics, patient survival, or the level of emotional stress in the medical team, and did not result in medicolegal claims [4]. Due to continued concern of FPDR possibly affecting resuscitative processes and outcomes, Goldberger et. al conducted an observational cohort study of 41,568 adults at 252 hospitals across the United States. The exposure was hospital-level policies that allow FPDR and the primary outcomes were ROSC and survival to discharge. They found that hospitals with and without FPDR policies had similar rates of ROSC and survival to discharge. Furthermore, resuscitation quality, interventions, and self-reported systems-level resuscitation errors did not meaningfully differ between hospitals. This was the first large-scale study to conclude that FPDR policies do not negatively affect outcomes or quality of resuscitation processes in the hospital [6].
Reviews of the literature on this topic have found consistent themes in that family wish to be given the option of being present during their loved one’s resuscitation and they often feel like this is beneficial to the patient and themselves [7]. However, critiques of the literature include that most studies are dependent on survey data, leading to potential for bias in the results. The results of randomized controlled trials have been mixed and the results are difficult to generalize to the greater population [7, 8]. Other ethical-focused arguments center on patient autonomy – stating that few patients are asked in advance whether they want family members in the room during a potential resuscitation. Furthermore, it is difficult to apply population or group statistics on the individual, especially with the sensitive and intimate nature of this practice [9]. While these arguments are certainly valid, the current American Heart Association guidelines follow the statement “in the absence of data documenting harm and in light of data that it may be helpful, offering select family members the opportunity to be present during resuscitation is reasonable and desirable” [10].
In conclusion, family presence during resuscitation has been shown to have some potential psychological benefits to the observer without evidence of negative impact on the resuscitation effort, long-term outcome, or frequency of medicolegal claims. When creating and implementing a policy, it is important to consider multiple ethical factors and whether the hospital/ED has the capability of providing enough support to everyone involved in the process.
Case Conclusion:
The attending returned with the patient’s husband and instructed him to sit at the bedside next to the patient. One of the nurses stood close to him and explained what was going on during the resuscitation. The patient continued to receive ACLS interventions for another 20 minutes. As it became evident that the patient would not obtain ROSC, a final pulse check was conducted and the situation was explained clearly to the patient’s husband. It was clearly stated that we would be stopping our resuscitative efforts and the patient’s husband expressed understanding. Time of death was called and a moment of silence was observed.
POST BY: SARAH SERESINGHE (MS4)
FACULTY EDITING BY: DR. COLIN MCCLOSKEY
References
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Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Annals of Emergency Medicine. 1987;16(6):673–5.
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Jabre, P., Tazarourte, K., Azoulay, E. et al. Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive Care Med 40, 981–987 (2014). https://doi.org/10.1007/s00134-014-3337-1
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Brasel KJ, Entwistle JW 3rd, Sade RM. Should Family Presence Be Allowed During Cardiopulmonary Resuscitation?. Ann Thorac Surg. 2016;102(5):1438-1443. doi:10.1016/j.athoracsur.2016.02.011
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McClenathan, BM, Torrington, KG, Uyehara, C. Family Member Presence During Cardiopulmonary Resuscitation A Survey of US and International Critical Care Professionals. Chest. 2002 Dec;122(6):2204-2211. doi: 10.1378/chest.122.6.2204