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.”
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.”
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.
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.
The randomization process was concealed. NO: The medical teams knew which group they were being assigned too.
The patients were analyzed in the groups to which they were randomized. YES
The study patients were recruited consecutively (i.e. no selection bias). YES
The patients in both groups were similar with respect to prognostic factors. YES
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
All groups were treated equally except for the intervention. YES
Follow-up was complete (i.e. at least 80% for both groups). YES: 94% in the intervention group and 89% in the control group.
All patient-important outcomes were considered. YES
The treatment effect was large enough and precise enough to be clinically significant. UNSURE?
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.
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.
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?”
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.
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