The Case

A 72-year-old man is brought in by emergency medical services in full cardiac arrest. He was found at home by his wife, with an unknown down time. Resuscitative efforts, including CPR, bag-valve-mask ventilation, defibrillation, and multiple rounds of advanced cardiovascular life support (ACLS) medications, by prehospital providers were unsuccessful. The nurse alerts you that the wife has arrived to the ED waiting room.

Should you invite her into the resuscitation room?

Background and Evidence

Family-witnessed resuscitation (FWR) has been controversial for many years. On the one hand, family members are at high risk for psychological trauma and may distract the providers, who may fear family response to termination of resuscitative efforts or subsequent litigation. On the other hand, FWR may give patients’ family members one last moment to say good-bye and allow them to see the level of effort that went into the resuscitation.

The evidence behind the practice of FWR generally supports its use but within a specific set of circumstances. Clinical investigation started with small observational studies, which found that while health care providers’ initial opinions about family member presence were mixed, most participating family members would choose to be present again and believed it aided their grieving and was beneficial to their dying family member.^1–3 Furthermore, when surviving patients were interviewed, most expressed a desire to have family members present.⁴ Providing loved ones a last opportunity to say good-bye is a natural extension of the ACEP Code of Ethics Principle 7, which states, “emergency physicians shall work cooperatively with others who care for, and about, emergency patients.”

These initial studies called for greater research to better elucidate what harms and benefits might exist. The first randomized, prospective trial of FWR was terminated early after just 25 enrolled subjects, without any reported psychological harms to family members, when investigators feared protocol violations by participating providers who became convinced of its benefits and resisted randomization to non-^FWR.5

Those preliminary pilot studies were followed by the randomized, prospective trial of 570 patients conducted by Jabre et al, who found that FWR was associated with psychological benefits without any corresponding increase in provider stress or medical-legal conflict.⁶ It is important to emphasize, however, that family members in the Jabre et al study were all offered a choice to participate and were always accompanied by a chaperone offering emotional support and informative explanation, and the trial involved trained personnel following a scripted protocol.⁷ Underscoring the importance of provider training and guidelines is a study examining the impact of health care provider education about FWR combined with departmental guidelines, which resulted in more positive perception of family presence by health care providers and greater participation in its practice.⁸

Barriers and Pitfalls

While aforementioned concerns about FWR-induced traumatic memory and litigation are largely unfounded, other pitfalls may prevent a positive family experience during resuscitative efforts. First, it is important to set expectations for family members, whose expectations for resuscitation might come from television shows such as ER or Grey’s Anatomy. Many people do not have an accurate perception of what occurs during resuscitative efforts, and some advocate that more education is needed to prepare families to attend resuscitative efforts. There is also concern that families will have a traumatic reaction or negative memories from witnessing a resuscitation. Opponents of family presence also have concerns with potential disruption of the resuscitative efforts, performance anxiety of the providers, more aggressive resuscitation efforts when family members are present, and the potential risk of litigation.⁹

First, it is important to set expectations for family members, whose expectations for resuscitation might come from television shows such as ER or Grey’s Anatomy. Many people do not have an accurate perception of what occurs during resuscitative efforts, and some advocate that more education is needed to prepare families to attend resuscitative efforts.

Despite these concerns, the evidence demonstrates that the overwhelming majority of family members who were present during resuscitative efforts confirm that they would repeat the experience given the choice. Resistance to family presence seems to come primarily from providers, physicians more than nurses. Overall, avoiding negative experiences can be easily achieved by increasing awareness of the benefits to both providers and families, creating a universal protocol that guides families through this experience, and allowing staff as well as family to reflect upon these difficult scenarios.¹⁰

Practical Guidelines

Staff education and preparation are critical to successful family presence during resuscitations. It is important to develop an institutional policy or structured guidelines that will formalize the process and optimize the experience.¹¹ Currently, few institutions have such specific policies or guidelines.¹² A protocol may include guidelines regarding family assessment, preparing the family, the facilitator’s role, postevent family support, and postevent staff support. Development of institutional guidelines should include clinicians, advanced practice providers, nursing staff, pastoral care, social services, and patients. Following policy development, staff education and preparation is essential. Training may include facilitator-training workshops to employ simulation with mannequins and/or actors portraying patients and families.^13–15 A designated supportive staff member (SSM) is important for a successful experience for families. The SSM may be a social worker, nurse, chaplain, or other dedicated personnel. The SSM should be trained and committed to the supportive process during resuscitative efforts. The SSM should initially communicate with family members prior to entering the resuscitation area. Family members should be given the option to be present and prepared for the visual and emotional stress of the clinical scenario. They should be instructed where to stand at the bedside to be close to their family member without interfering with the delivery of care. If there is uncertainty about crowd control or ability to function appropriately, or if there is suspicion of abuse, it may not be appropriate for family to be present. Ideally, there should be a designated area that provides adequate seating for the family as well as a direct line of vision to the patient and the delivery of care. Family members should be allowed to leave and reenter the room if they become uncomfortable with the situation. The SSM should be solely dedicated to the family throughout the resuscitative efforts and should provide appropriate education and communication regarding clinical status and medical interventions. Following unsuccessful resuscitative efforts, support of family through the bereavement process is essential. The health care team and the SSM should facilitate compassionate communication and support, which may include spiritual support, psychosocial support, and open dialogue about the events of the resuscitative efforts.

Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio. Dr. Jesus is assistant professor of emergency medicine at Christiana Care Health System in Newark, Delaware. Dr. Phillips is chief resident in the department of emergency medicine at George Washington University Hospital in Washington, D.C. Dr. Larkin is Lion Foundation professor and chair of emergency medicine at the University of Auckland in New Zealand.

References

1. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16(6):673-675.
2. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18(2):104-106.
3. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122(6):2204-2211.
4. McMahon-Parkes K, Moule P, Benger J, et al. The views and preferences of resuscitated and non-resuscitated patients towards family-witnessed resuscitation: a qualitative study. Int J Nurs Stud. 2009;46(2):220-229.
5. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352(9128):614-617.
6. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368(11):1008-1018.
7. Kramer DB, Mitchell SL. Weighing the benefits and burdens of witnessed resuscitation. N Engl J Med. 2013;368(11):1058-1059.
8. Edwards EE, Despotopulos LD, Carroll DL. Changes in provider perceptions of family presence during resuscitation. Clin Nurse Spec. 2013;27(5):239-244.
9. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005;14(6):494-511.
10. Boudreaux ED, Francis JL, Loyacano T. Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research. Ann Emerg Med. 2002;40(2):193-205.
11. Bradley C, Lensky M, Brasel K. Implementation of a family presence during resuscitation protocol #233. J Palliat Med. 2011;14(1):98-99.
12. 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;29:208-221.
13. Browning DM, Meyer EC, Truog RD, et al. Difficult conversations in health care: cultivating relational learning to address the hidden curriculum. Acad Med. 2007;82:905-913.
14. Meyer EC, Sellers DE, Browning DM, et al. Difficult conversations: improving communication skills and relational abilities in health care. Pediatr Crit Care Med. 2009:10;352-359.
15. Meyer EC, Brodksy D, Hansen AR, et al. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinatol. 2011;31:212-219.
16. Henderson DP, Knapp JF. Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures. J Emerg Nurs. 2006;32:23-39.