Essay: Family presence during CPR (cardiopulmonary resuscitation)

In a pre-hospital setting, there are few moments that are as intense as the events that take place when trying to save a life. Family presence during these resuscitation efforts has become an important and controversial issue in health care settings. Family presence during cardiopulmonary resuscitation (CPR) is a relatively new issue in healthcare. Before the advent of modern medicine, family members were often present at the deathbed of their loved ones. A dying person’s last moments were most often controlled by his or her family in the home rather than by medical personnel (Trueman, History of Medicine). Today, families are demanding permission to witness resuscitation events. Members of the emergency medical services are split on this issue, noting benefits but also potentially negative consequences to family presence during resuscitation efforts.
A new study has found that family members who observed resuscitation efforts were significantly less likely to experience symptoms of post-traumatic stress, anxiety and depression than family members that did not. The results, published in an online article in The New England Journal of Medicine, entitled ‘Family Presence during Cardiopulmonary Resuscitation,’ were the same regardless of the survival of the patient. The study involved 570 people in France whose family members were treated by emergency medical personnel at home. These EMS teams were unique in that they were comprised of a physician, a nurse trained in emergency medicine, and two emergency medical technicians. The study found that the presence of relatives did not affect the results of CPR, nor did it increase the stress levels of the emergency medical teams. Having family present also did not result in any legal claims after the incidents occured. While the unique limitations of the study warrant consideration, the results show a definite benefit in having families stay during CPR (Jabre Family Presence).
Historically, although parents of children have been allowed to be present for various reasons, relatives of adult patients have not. As medical practices change to increasingly involve family in the care of patients, growing numbers of emergency medical practitioners say that giving relatives the option of watching CPR can be a good idea. Several national organizations, including The American Heart Association, have revised their policies to call for giving family members the option of being present during CPR (AHA Guidelines for CPR). Witnessing CPR, say some emergency medical experts and family members, can take the mystery out of what could be a potentially terrifying experience. It can provide reassurance to family members that everything is being done to save their loved ones. It also can offer closure for relatives wanting to be with their family members until the last minute (Kirkland Lasting Benefit). Another benefit is that it shows people why reviving someone in cardiac arrest is much less likely than people assume from watching it being done on television (Ledermann Family Presence During). Family members who can truly understand what it means to ‘do everything possible’ can go on to make more informed decisions about end-of-life care for themselves or their families.
There are three perspectives on this issue- that of the emergency medical personnel providing care, the family, and the patients. The resistance on the part of the medical community to family presence during CPR stems from several different concerns. The most common concern among these is that family members, when faced with overwhelming fear, stress and grief, could disrupt or delay active CPR. Another concern raised by emergency medical personnel is that the realities of CPR may simply be too traumatic for loved ones, causing them to suffer more than they potentially would have if they had never witnessed the event. Some families share this view, citing the potential for extreme distress as a main reason for not wanting to witness resuscitation (Grice Study examining attitudes). Many emergency medical personnel also fear an increased risk of liability and litigation with family members present in the room (Fullbrook the Presence of Family). The worry is that errors can occur, inappropriate comments may be made, and the actions of the personnel involved may be misinterpreted. In an already tense situation, the awareness of the family could increase the anxiety of the personnel and create a greater potential for mistakes.
Another complication that arises from having families present during resuscitation attempts is that of patient confidentiality. The patient’s right to privacy should not be circumvented with implied consent. There is always the possibility that medical information previously unknown to the family may be revealed in the chaos of resuscitation. In addition, patient dignity, whether physical or otherwise, may become compromised (Fullbrook the Presence of Family). Beyond moral considerations, legal concerns regarding revealing patient information are real. This could become an even larger issue if there is no one available to screen witnesses, which could result in unrelated people gaining access to personal information. Eventually, a breach in confidentiality can lead to a breach in the confidence that the public has gained in pre-hospital emergency care.
Family presence during CPR in a pre-hospital setting remains a highly debatable topic. This could be largely due to the fact that the needs of the emergency medical providers and the rights of the patients can be at odds with the wishes of the family members. Although there are several possible reasons why family presence is not being welcomed into daily practice, one of the major reasons could be the lack of formal written policies that define the roles of families and providers placed into this situation. Bringing family members into a situation where CPR is being performed on a loved one should not happen haphazardly. It should happen with careful concern and support for everyone involved. Policies and protocols, defined by experienced personnel, can provide legal and emotional support. They can also potentially help ease anxiety by defining expectations and placing responsibility in the hands of people who are experienced enough to know how to handle the situation appropriately. The policies and protocols should address the basic needs of all people involved. Five basic needs should be addressed:
1. The number of people allowed to be present
2. Which relatives should be allowed to be present (age, relationship, etc.)
3. The role of the family members present and what is expected of them.
4. The place where the family should remain during the duration of CPR.
5. The formal wishes of the patient- written as a directive like a living will.
An important component of this is available, trained staff that can prepare the family members for what they will witness, support them through the event, and then direct them after the event’s conclusion.
The American Heart Association states that the goals of cardiopulmonary resuscitation are, ‘to preserve life, restore health, relieve suffering, limit disability, and respect the individual’s decisions rights and privacy’ (AHA Guidelines for CPR). The practice of offering family members the opportunity to be present during CPR is a controversial ethical issue in emergency medical services. While the results of the study published on this topic in The New England Journal of Medicine clearly show no negative side effects from having families present during resuscitation attempts, the limitations of the study lend to the need for more research before it could be universally accepted.