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SGEM#59: Can I Get A Witness (Family Members Present During CPR)

SGEM#59: Can I Get A Witness (Family Members Present During CPR)

Podcast Link: SGEM59
Date:  January 12, 2014

Guest Skeptic: Darin Abbey is a clinical nurse educator for the emergency department in Nanaimo, British Columbia.

Case Scenario: You are working in a busy ED when a young new paramedic crew brings in a post cardiac arrest that they are resuscitating. They tell you that the patient collapsed at home during a family event and that a family member immediately started CPR while the rest of the family bore witnesses.  The family is now en route to the ED and the paramedics are concerned that they did the wrong thing by allowing the family to watch.

Questions: Does offering a relative the choice of observing cardiopulmonary resuscitation (CPR) reduce the likelihood of PTSD-related symptoms? Does family presence during CPR affect medical efforts at resuscitation, or well-being of the health care team? Does family presence change the occurrence of medico legal claims?

Background: The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial. The risks and benefits have been debated in the medical literature since the 1980’s.

While on one hand there are suggestions that it may help family members bring closure to the event by allowing them to see the efforts of the resuscitation team and perhaps afford them the opportunity to say a final goodbye to a loved one. This perspective is often outweighed by fears of increased stress and emotional burden placed not only on the families themselves, but also on the health care providers.

Prior to this publication available data has come from simple feedback or small observational studies. There has only been one RCT on the issue and it was terminated after only enrolling 25 patients. Nonetheless the authors note that “major international guidelines for CPR state than available evidence support family witnessed resuscitation and this action is considered reasonable and generally useful.”

CPR Real Life

Reference: Jabre, P. et al. (2013). Family Presence During Cardiopulmonary Resuscitation. NEJM. 368;11. 1008 – 1018.

  • Population: Cluster randomized trial of 570 patient’s family members when the patient was receiving CPR. The study was conducted from15 different pre-hospital emergency medical services (EMS) in France. Situated in France, the population studied were adult family members of adult patients in cardiac arrest occurring at home. Exclusion criteria were communication barriers with the relative and cardiac arrest cases in which resuscitation was not attempted. These events were attended by one of fifteen pre-hospital emergency medical service [EMS] units consisting at a minimum of an ambulance driver, a nurse and a senior emergency physician.
  • Intervention: The intervention consisted of eight out of 15 EMS units following a communication guide to ask family members if they wanted to be present during the resuscitation, to introduce the relative to the scene and if required to help with the announcement of death. In contrast physicians in the control group interacted with families in a standard manner, in that the option to attend was not routinely offered and instead relatives who chose not to attend the CPR event were taken to another room.
  • Comparison: The other seven out of 15 EMS units provided standard practice regarding family presence when CPR was being administered. The standard practice was at the desecration of the physician team leader.
  • Outcome: The primary outcome was the proportion of relatives with post-traumatic stress disorder (PTSD) symptoms on day 90. This was determined by the Impact Event Scale (IES). The IES is a reliable tool that has been used for many years to evaluated traumatic experiences. It consists of 15 items, which are scored from 0-5. A score of zero is no PTSD and max score of 75 is severe PTSD. A secondary outcome was anxiety and depression symptoms. These were measured on the Hospital Anxiety and Depression Scale (HADS). The HADS is two scales in one. There is a seven-part section, which evaluates anxiety, and another seven-part section, which evaluates depression. The result can range for zero to a maximum of 21. A score of >10 indicate moderate-to-severe symptoms of anxiety or depression. Other secondary outcomes included effects on medical efforts at resuscitation (measured on a visual analogue scale), well being of the health care team, and the occurrence of medico legal claims.

Authors Conclusions“In conclusion, our results show that the presence of a family member during CPR of an adult patient, performed in the home, was associated with positive results on psychological evaluations and did not interfere with medical efforts, increase stress in the health care team, or result in medical legal conflicts.”

Quality Checklist:

  1. The study population included or focused on those in the ED. YES/NO: They have a different system in France. The RN and Emergency physician are in the ambulance. So they are running the code but in the pre-hospital setting.
  2. The patients were adequately randomized. YES/NO: There were randomized but it was not completely randomized. They took the 15 EMS units and randomly assigned 8 to have the intervention and 7 to be the control group.
  3. The randomization process was concealed. NO: The medical teams knew which group they were being assigned too.
  4. The patients were analyzed in the groups to which they were randomized. YES
  5. The study patients were recruited consecutively (i.e. no selection bias). YES
  6. The patients in both groups were similar with respect to prognostic factors. YES
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. NO: The paramedics, nurses and doctors knew which group they were allocated. But the trained psychologist doing the structured questionnaire by telephone was unaware of group assignment
  8. All groups were treated equally except for the intervention. YES
  9. Follow-up was complete (i.e. at least 80% for both groups). YES: 94% in the intervention group and 89% in the control group.
  10. All patient-important outcomes were considered. YES
  11. The treatment effect was large enough and precise enough to be clinically significant. UNSURE?

Results:

  • Resuscitation outcome: Of the 570 family members, 60% witnessed resuscitation. Only 4% of patients that were resuscitated were alive at day 28, this was consistent between both witnessed and un-witnessed groups. Resuscitation metrics did not differ between groups (duration of resuscitation, type or amount of infused medications or number of shocks delivered).
  • Psychological Outcome: The frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (OR 1.7; 95%CI 1.2-2.5 p=0.004) and also higher in the family members that did not witness CPR (OR 1.6; 95%CI 1.1-2.5 p=0.02). The frequency of symptoms of anxiety were also higher in the control group versus the intervention group, and again higher in family member that did not witness CPR (p<0.001 for both comparisons).
  • Interference by Family Members: Less than 1% of the family members were aggressive or in conflict with the medical team. Of the family members who did not witness CPR 12% expressed regret at having been absent as compared to 3% of relatives who witnessed CPR and regretted being present.
  • Stress Assessment of Medical Teams and Medical Legal Conflicts: There was no significant difference in stress levels according to family presence, and with a mean 20-month follow up there were no claims for damages from any participating family members and there were no medical legal conflicts.

Screen Shot 2014-01-12 at 11.19.11 AM

EBM Comments: Odds Ratio (OR) can be hard to understand. The OR is a ratio of the odds an outcome will occur in one group divided by the odds of the outcome will occur in the other group. The OR tends to exaggerate effect size compared to relative risk (RR), especially for common outcomes. Here are some links for additional reading on OR and RR in the BMJ.

BEEM Commentary: There is potential measurable benefit in providing families the opportunity to witness CPR, but this study only permits us to comment on the pre-hospital environment in France. This system has some similarities to the ED, i.e. the presence of nursing and a physician in the pre-hospital setting, but application to the ED can only be inferred. We also need to be careful about the medical legal conclusions made by the author. The North America and in particular the USA litigation environment may be much different than France. It is reassuring that witnessed resuscitations were not affected in terms of outcomes and family interference was very rare (<1%). This may alleviate fear of family members in the resuscitation.

The Bottom Line: Having family members present during resuscitation (or at least offering them the opportunity) may reduce long-term stress effects and will not likely increase provider stress, create conflict or affect resuscitation outcomes. Medicolegal conclusions would be applicable to European healthcare systems.

Unknown

Case Resolution: The patient survives to hospital admission but like the majority of patients does not survive to hospital discharge. You reassure the paramedic that they did the right thing by allowing the family to witness the resuscitation.

Star Trek II Wrath of Khan: Captain James T. Kirk “And how we deal with death is at least as important as how we deal with life, wouldn’t you say?”

Additional References:

  • J Med Ethics. 2013 Apr 10. Family presence during cardiopulmonary resuscitation: who should decide?
  • Evid Based Med. 2013 Jun 14. Presence during cardiopulmonary resuscitation is beneficial to family members in the out-of-hospital setting.
  • Emerg Med J. 2013 Mar 14. Emergency care staff experiences of lay presence during adult cardiopulmonary resuscitation: a phenomenological study.
  • J Trauma Nurs. 2012 Jul-Sep;19(3):190-4. doi: 10.1097/JTN.0b013e318261d041. Challenges in conducting research after family presence during resuscitation.
  • J Adv Nurs. 2013 Oct 24. doi: 10.1111/jan.12276. Integrative review: nurses’ and physicians’ experiences and attitudes towards inpatient-witnessed resuscitation of an adult patient.
  • NEJM Appendix. 2013 March. 368;11. 1008 – 1018. Family Presence During Cardiopulmonary Resuscitation.

KEENER KONTEST: Listen to the SGEM podcast to hear the keener question. If you know the answer send an email to TheSGEM@gmail.com with Keener Kontest in the subject line. The first person with the correct answer will win a cool skeptical prize.

BEEM Conferences: SkiBEEM, SteelBEEM, SweetBEEM and PrairieBEEM

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’ Guide to Emergency Medicine.

  • Awkward A

    A few years ago, I met a woman who had witnessed EMS attempt to resuscitate her husband. The detail in which she could recall the event, and her lack of understanding of what had occurred (she was a well educated woman, with some medical background) shocked me. I was able to explain to her what had likely happened, thanks to her detailed description. After an hour or so, she felt more comfortable with what she had seen, but it didn’t lessen the replay for her at all. Her husband died more than 10 years prior to our meeting.
    After that, I started to look at my VSA calls a bit differently. I now try to keep the family from witnessing what we do. It’s violent, fast, and can been seen as showing little respect for their loved one (we cut their clothing off, move them around roughly, crack ribs, shove things down their throats, etc), and due to the nature of the call, we have very little time to explain what we’re doing and why we’re doing it. No one would resuscitate a mother in front of their 10 year old child–it’s scarring, and scary. So why would we do so in front of any child, partner, or parent? They have the same reaction.
    I’ve had a chance to talk to a few family members a few days, or months, after my calls (benefit of living & working in a rural community, I guess), and their memories of the event are just as clear as the woman mentioned above–even the ones I had move to another room. But the later couldn’t describe what we had done to their loved one, but didn’t have any more questions than the others about whether or not something more could have been done.
    So, in closing, I suggest you look at these events as someone without any medical knowledge. How would you feel watching what we do, seeing your loved one like that in your memory forever? It’s bad enough that when people die, they look nothing like what they did in life, but adding the violence, and seemingly lack of respect we give the patient seems like a disservice to the family–who are not bystanders, but closer to patients themselves.

    • TheSGem

      Thank you for sharing your experience with others. There are difficulties with anecdotal cases like you describe. We are all susceptible to many forms of bias. Having stories like you report can distort the lens we look through at future events.

      That is one reason it is important to have these types of trials to remove as much bias as possible. It appeared in this study that the intervention made an overall positive experience. While it might not have been positive for everyone only 3% reported regretting their decision. Perhaps your case is one of those 3%
      Four times as many people (12%) regretted not witnessing.
      It also had an overall decrease in PTSD from a validated assessment tool. Their secondary outcomes were also better.

      One of the key points and perhaps we did not emphasize it enough in the podcast was the extra training the staff got on how to approach people in these situations. It was not just inviting people into witness the event. They were specially trained on how to do it effectively. Perhaps this limited some of the negative concerns you expressed.

      It is certainly a difficult time for family. Watching what we do can be scary. However, the consensus seems to be in favour of offering people the option.

  • http://roguemedic.com/ Rogue Medic

    We continue to make excuses for protecting others from the same things that we experience.

    We are not there to decide what the family may witness.

    We are there to provide medical care.

    As a paramedic, patients invite me into their home to provide care to them/their family members.

    We should spend more time explaining what we do to family, especially since we may find out more about the patient when we state what we think is going on.

    We may be afraid of death, but we should not project our anxieties on our patients, especially on one of the worst days of their lives.

    Imagine if we were to try to explain information for obtaining informed consent for the treatments that are recommended in cardiac arrest.

    None of the following ACLS recommended treatments have evidence of improved outcomes for cardiac arrest patients – ventilations, airways, epinephrine/adrenaline, vasopressin, norepinephrine, pseudoephedrine, amiodarone, lidocaine, procainamide, magnesium, prehospital therapeutic hypothermia.

    How do we get family to consent to a treatment that is more likely to produce a worse outcome?

    In the absence of evidence of benefit, we should assume harm. Any other interpretation is disingenuous.

    Most of what we do in cardiac arrest treatment is for our benefit, not for the benefit of the patient.

    I give epi and get a pulse back more often. I am a God!

    The reality is that if I give epi, I do get a pulse back more often, but the patient appears to be less likely to leave the hospital with a working brain. This is not a positive patient oriented outcome.

    Would it be different from France? I do not speak with an outrageous French accent, so that would be different. Is death different in France? Is the reaction to death different in France?

    Is there something magical about protecting people from dealing with reality?

    Do we need evidence to discourage imposing paternalism through our jobs?

    We need to grow up and stop blaming others for our anxieties.

    Concerns about being sued need to be supported by evidence.

    How incompetent do we have to be to be more likely to be sued for allowing family members to witness resuscitation.

    Where is the evidence that hiding what we are doing discourages law suits?

    We arrive, have the family stop CPR, and kick them out of their home in order to protect them from having to see what we do.

    This is not ethical or logical. This is what I would expect from a quack.

    .

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