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Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA
The upper gastrointestinal bleed patient that I had been following since admission was in cardiac arrest in the intensive care unit. The resuscitation effort was routine; however, the presence of his family at bedside was new to me.
One initial concern lay with the patient’s observing family members in regards to the possibility of psychological trauma due to a limited capacity to understand or comprehend the resuscitation events. These concerns have been documented among the medical community and further include the potential for family member disruption and delay of resuscitation efforts, which may directly or indirectly influence treatment outcomes, and the notion of an increased frequency of litigation following family presence during resuscitation (FDPR).[1-3] However, little evidence substantiates these concerns.[1] Current literature suggests FDPR during both out-of-hospital and in-hospital cardiac arrest confers psychological benefits for family members regardless of treatment outcome.[4, 5] What’s more, multiple cohorts of surveyed patients wished their family member(s) to be at bedside should they need to be resuscitated.[6, 7]
In 2013, the New England Journal of Medicine published a large-scale French study addressing out-of-hospital FPDR.[4] Patients’ family members were divided into two groups: those offered the opportunity to observe cardiopulmonary resuscitation (CPR) of their family member and those who were not offered the opportunity, but could independently elect to be taken to the room were cardiopulmonary resuscitation (CPR) was being preformed. Among those offered the opportunity, 79% chose to witness CPR in comparison to 43% in the latter group. Endpoints included the proportion of family members with post-traumatic stress disorder (PTSD) related symptoms, and the presence of anxiety and/or depression symptoms. Among those who did not witness CPR, these family members were 60% more likely to experience symptoms of PTSD in comparison to those who chose to witness CPR. Those who did not witness CPR efforts also experienced an increased frequency of anxiety and depression.
The reduced incidence of PTSD symptoms, anxiety, and depression among family members after witnessing CPR preformed on their loved one, regardless of outcome, is likely multifactorial in nature. Surveys reveal that FPDR may facilitate a better comprehension of the overall condition of their family member and a greater sense of closure, in turn, minimizing denial and contributing to an understanding that everything possible was done. The wife of a patient was quoted; “Seeing them work on him was painful, but it also helped me accept what was going to happen to him.”[8] Her husband had expired after cardiac arrest.
Additionally, in 2015, an American study published in Circulation assessed patient outcomes following in-hospital cardiac arrest in institutions with and without a formal FPDR policy.[5] No significant differences were noted in patient outcomes, resuscitation quality, and pharmacological and non-pharmacological interventions delivered to patients between hospitals with and without a formal FPDR policy.
Despite the documented benefits of FPDR for family members and lack of significant impact on patient outcomes, a 2003 survey of 3000 critical care and emergency nurses noted that only 5% worked at institutions with a formal FPDR policy.[9] In 2015 a review of 252 United States hospitals noted only 32% with a formal policy regarding FDPR.[5] Physician and staff hesitation is likely a true obstacle surrounding widespread implementation of formal FPDR policies.
Despite their obvious pain and sadness, the two adult children and wife of my patient chose to stay for the entirety of the resuscitation effort. He was pronounced after running the code for 30 minutes.
1. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
2. Itzhaki M, Bar-Tal Y, Barnoy S. Reactions of staff members and lay people to family presence during resuscitation: the effect of visible bleeding, resuscitation outcome and gender. J Adv Nurs. 2012 Sep;68(9):1967-77.
3. Newton A. Witnessed resuscitation in critical care: the case against. Intensive Crit Care Nurs. 2002 Jun;18(3):146-50.
4. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013 Mar 14;368(11):1008-18.
5. Goldberger ZD, Nallamothu BK, Nichol G, Chan PS, Curtis JR, Cooke CR. Policies allowing family presence during resuscitation and patterns of care during in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 2015 May;8(3):226-34.
6. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-3.
7. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
8. Post H. Letting the family in during a code. Nursing. 1989 Mar;19(3):43-6.
9. Maclean SL, Guzzetta CE, White C, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. J Emerg Nurs. 2003 Jun;29(3):208-21.