Dr. Huang is a senior resident in the Olive View-UCLA Emergency Medicine Residency Program. Dr. Lovato is an associate professor at the David Geffen School of Medicine at UCLA, the ED director of clinical practice at Olive View-UCLA Medical Center, and the co-chair for the Emergency Medicine Best Practices Committee for the Los Angeles County Department of Health Services.
Every ED shift comes with challenges, some of the most difficult related to the humanistic side of medicine. Informing a patient of a serious diagnosis, discussing code status, or notifying family of a patient's death are all difficult scenarios and often conveniently avoided by the best of us.
Family presence during resuscitation is a relatively new idea that is gaining popularity and acceptance, but it can be uncomfortable for physicians and staff to implement. Uncertainty about its benefit adds another barrier for those who might otherwise consider championing the practice. Now, a new study in the New England Journal of Medicine provides new data, perhaps enough to make us re-evaluate the practice.
Family Presence during Cardiopulmonary Resuscitation
Jabre P, Belpomme V, et al
N Engl J Med
Patients generally died at home with their loved ones before cardiopulmonary resuscitation was invented in the 1950s. For better or worse, technological advances and prehospital care have moved patients away from their homes and into the hospital during the last moments of their life. (Crit Care Nurse 2005;25:38.) Now health care providers have the moral and ethical dilemma of being in control of what many consider to be an ethereal, spiritual, even sacred occasion.
Literature on the topic has grown over the past 15 years, but much of it has focused on the effect on hospital staff rather than family. Many studies were limited by small enrollment, use of convenience samples, low rates of participation, and the use of inconsistent and retrospective survey instruments. (Am J Crit Care 2005;14:494.) That made it difficult to draw general conclusions about its benefits or disadvantages.
Opponents of family presence during resuscitation express concern that family may disrupt the process. Codes are unplanned, crowded, noisy, and hectic. Having family present, especially if they are hysterical, can distract staff and fuel the chaos. And it can stressful and intimidating for a provider to be put on the spot. Providers might feel performance anxiety or fear appearing inexperienced or incompetent. Others fear increased litigation risk if mistakes are witnessed. We also might be pushed to “do more” than reasonable when family members are watching, even if the process is futile, potentially prolonging unnecessary suffering for all. HIPAA enforcers might express concern about patient confidentiality because patient wishes regarding family presence are rarely known. Designated staff is often unavailable to support family members in emergency situations.
Proponents of family presence also have their arguments. Families are usually able to control their emotions and witness events without being a distraction, and being present may actually decrease anxiety and help begin the grieving process. Saying goodbye to a dying loved one can be crucial emotionally and spiritually. Family presence during resuscitation helps the family understand the gravity of the clinical situation, limiting unrealistic expectations in preparation for the likely outcome. Family members experience the team's professional effort firsthand, reassured that everything has been done for their loved one and fostering trust that might actually decrease litigation risk. Family presence may challenge providers to rise to the occasion, and may even increase collaboration and professionalism during the resuscitation. Witnessing CPR also may help a family make more informed decisions on future code status for the patient, other loved ones, or even themselves. Acceptance, if not endorsement, is growing in hospital settings, despite the controversy. (J Am Acad Nurse Pract 2011;23:8.)
This is, according to the authors, the first multicenter, prospective, randomized controlled study on the topic. Enrolled were 570 relatives of patients in cardiac arrest who received prehospital CPR. They were randomly assigned to offer family presence (intervention group) or to follow standard practice on family presence (control group). The primary endpoint was the proportion of relatives in each group who had PTSD-related symptoms on day 90. Secondary endpoints were symptoms of anxiety and depression, the effect on medical efforts during resuscitation, the well-being of the health care team, and the occurrence of legal claims. A blinded, trained psychologist asked relatives to answer a structured questionnaire by phone after three months.
The study reported that the frequency of PTSD symptoms was significantly higher in the control group (37%) than in the intervention group (27%) (adjusted OR 1.7; 95% [CI] 1.2 to 2.5; p=0.004). Relatives who did not witness CPR reported anxiety symptoms more frequently than those who did witness the code (24% vs. 16%, p<0.001). Family presence did not appear to affect resuscitation characteristics, patient survival, level of stress on the medical team, or any legal claims.
A few limitations of the study warrant mention. Prehospital CPR was performed in the patient's home, making it difficult if not impossible to generalize these findings to the ED. Resuscitation by numerous ED staff in a cold, unfamiliar environment may have a different effect from witnessing resuscitation at home. Adult members of the patient with various relationships were chosen to participate, and included spouses, parents, offspring, and siblings. Relationship to the patient was not controlled in the study, which brings other questions to mind. Grown children witnessing a parent's resuscitation may elicit a different response from a parent witnessing the resuscitation of a grown child. The study was also performed in France, which not only has a much different prehospital care system but also a much different medicolegal culture from the United States.
But family presence during resuscitation is a growing practice that many institutions have implemented. This study's results and limitations should prompt us to consider the topic and decide if the potential humanistic benefits outweigh the perceived risks. Developing or re-examining formal policies and procedures in the ED might help ensure uniform adoption of family practice during resuscitation, but each of us ultimately must decide if it is an endeavor we are going to embrace and champion or disregard and avoid.
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* Read an abstract of the New England Journal of Medicine article at http://1.usa.gov/119xLSb.
* Read all of Dr. Lovato's past columns at http://bit.ly/JournalScan.
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