Family presence during resuscitations…the debate continues

For those of us involved in acute care medicine, you’ve likely faced the question

“should we invite the family to be present during the resuscitation?”

More than likely you also have an opinion on the matter. In fact, as I’ve started to look at the literature, people have very strong opinions about this subject! For those with short attention spans…check out a recent New England Journal of Medicine article for further evdience! 

I’ll be candid – I support the practice of having families present for the resuscitation, or at least inviting them to be present. I understand some families will decline which is entirely their choice but importantly other families will find this important to be present.

The last time I invited a family to observe was in an ICU setting where we were in the process of resuscitating a young person who had suffered cardiac arrest. The patient was extremely unstable with episodes of CPR and increasing pressor requirements.  I knew the family was waiting in the family room so I handed over the role of team leader to another colleague and visited with the family. Before leaving, however, the entire team was made aware of the plan to have the family present. Everyone was in agreement with the plan. I invited all family members to be present though only 3 of 5 requested to observe. Before entering, I outlined that they would see their loved one with a “breathing tube” and that “CPR” may be in process. We had our most senior ICU nurse with the family throughout the resuscitation to explain exactly what was happening. Never once were they left alone, however, we did encourage if they wished to hold their loved ones hand. We had planned our equipment prior to allow for this. Unfortunately the patient died but the family expressed their gratitude to the entire team for their efforts. Furthermore, they thanked us for allowing them to be with the patient during the final moments of her life. I can’t speak to why the family chose to be present, but they expressed nothing but gratitude for the invitation.

Detractors will say that family presence may have hindered the teams performance and perhaps led to psychological harm to the patient’s family. I also can’t speculate on the long term consequences for observing this potentially traumatic event. However, our team unanimously decided it would be appropriate and we proceeded accordingly.

Importantly, our team had a short de-brief afterwards where any concerns, comments and opinions were heard. There was no disagreement among team members that what was done was appropriate.

I recalled this story after reading this week’s NEJM which published a pre-hospital trial which randomized family members to observation of CPR compared to standard practice. The primary outcome was the proportion of relatives with PTSD related symptoms. Impressively, those family members who observed the resuscitation had significantly lower frequency of PTSD related symptoms than those who did not witness the resuscitation. There was no affect on resuscitation characteristics, patient survival and none resulted in medicolegal claims.

In conclusion, the authors stated that:

“family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team or medicolegal conflicts”

Some will argue that this study applies only to the pre-hospital setting since in-hospital situations are very different. In this study setting, many may have witnessed the actual collapse which differs from the hospital. So in the pre-hospital setting, maybe this is sufficient evidence to proceed with offering family presence? I can’t imagine there’s going to be another randomized trial any time soon. This is likely the best evidence we’ll get…at least out of hospital.

There is a vast array of highly opinionated individuals who have posted replies to this topic and I believe these warrant reading. Its amazing how strong the opinions are despite the lack of evidence. There have been several studies that have evaluated ED personnel opinion – these show equipoise…in one study it was 50.9% who supported family presence.

As many who are against the practice have pointed out, lack of support and communication during the resuscitation are detrimental and counterproductive. There must  be a designated individual who can provide perspective and explanation to the family. Furthermore that individual must recurrently reassess the emotional state of the family. While some feel this is a pandora box that should NEVER be opened, I would disagree. One of the editorialists for the NEJM article summaries the situation quite well:

“Part of our job as physicians is to help patients and families establish goals of care, process life-threatening events, and, at times, orchestrate the best death possible.”

 

What is most important as acute care clinicians is that we continue the discourse and encourage future study. There is clearly no definitive answer and to argue in one direction or the other without acknowledging the lack of evidence is ignorant. We have multiple surveys that report equipoise among clinicians followed by anecdotal reports of success with family observation.  Interestingly, several large guidelines have endorsed family presence including those from the AHA.

Based on this emerging evidence, it certainly doesn’t discourage me from further pursuing family presence. I will continue to invite families into the resuscitation room, however, before this occurs I will ensure the following:

  1. Discuss with the team so that everyone is aware that the family will be entering 
  2. Offer to the family the opportunity to be present
  3. Prepare the family for what they may see and that the resuscitation may be stopped during their present
  4. Ensure there is a well experience clinician (either RN or MD) with the family throughout the resuscitation
  5. Debrief the resuscitation team afterwards

 

What should be encouraged is similar situations be incorporated within simulation training. Before we fully integrate family presence, just like any other high-risk procedure, we should practice it and be competent. The entire team should be aware and understand the implications.

For those wishing to read more, I highly recommend a critical review of the literature published in 2005. While it’s a bit older, it is quite helpful! At that time there was little evidence to support many of the concerns expressed by those do not support family presence…

 

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