8/10/2019 4. 2204

1/8

8/10/2019 4. 2204

2/8

resuscitation. They conclude that family membersactually deal with their grief better by witnessing theresuscitation.2,3,6,7,9 They also report that on post-CPR surveys, most family members felt that theirpresence helped and supported their loved onesresuscitation.5,6,9

Many of the health-care professionals who oppose

FWR fear distractions to the CPR team by the family during resuscitation.7,9,10,16,17 Helmer et al17 statethat the resuscitation suite should be free fromdistractions, which includes family members. They compare resuscitation critical task performance topiloting aircraft. To date, no study has demonstratedthat FWR either improves or compromises resusci-tative efforts.

Another argument raised by those opposed toFWR is that allowing the presence of family mem-bers violates patient confidentiality and the patientsright to privacy.17 Helmer et al17 state that we must

first protect the rights of our patient to optimal care,confidentiality and privacy. The needs of family members, as important as they are, must comesecond.

Many health-care professionals also oppose FWRbecause they fear it will increase the risk of litigationand will cause psychological trauma to family mem-bers.7,9,10 However, advocates of FWR state theremay be less legal risk in FWR due to the strength-ening of staff-family bonds.18 They cite a prelimi-nary randomized controlled trial pilot study by Rob-inson et al,12 which demonstrated no adverse

psychological effects to a small number of family members who witnessed resuscitation compared tothose not offered FWR. FWR advocates have spec-ulated that medicolegal risks would actually de-crease, positing that family members increasedknowledge would lower the risks of potential law-suits.18 Opponents of FWR cite one case report, in which a woman sued for nervous shock after witnessing the pain and suffering caused to herhusband and three children after being involved in amotor vehicle accident.19 When surveyed, the Amer-ican Association for the Surgery of Trauma (AAST)

members expressed concern that FWR would in-crease malpractice litigation.17 Neither argument issupported by clinical evidence.

Advocates of FWR state that allowing a family member presence during resuscitation leads to moreprofessional behavior by the CPR team. According toMeyers et al,9 70% of the professionals surveyednoticed modified staff conversations at the bedsideand promoted a more careful choice of words. . . with less black humor. In addition, with family members present, professionals were more apt toconsider the patients dignity, privacy, and need for

pain management.9

While Meyers observations can-

not be refuted, humor provides a psychologicalcoping mechanism enabling health-care profession-als to deal with depressing and dehumanizing situa-tions.20

In May 2000, our institution was confronted with aresuscitation that involved an unsolicited family member presence. This event led to considerable

debate among our health-care professionals andprompted a literature search on FWR, which re- vealed limited data and great controversy amonghealth-care professionals surrounding this new family-centered approach to resuscitation.7,9,10,17,21In response, we developed a survey to evaluatehealth-care professionals for their opinion on family member presence during CPR. In addition, weevaluated the reasons that health-care professionals would oppose family member presence during CPR.

Materials and Methods

An English language survey of six questions covering CPRexperience, opinions on family member presence, as well asdemographic data to determine health-care professionals opin-ions and experiences on FWR was distributed to physicians,nurses, and allied health-care professionals attending the Inter-national Meeting of the American College of Chest Physicians(ACCP) in San Francisco, CA, between October 23 and 26, 2000.The survey was deliberately short to allow its completion in

2 min. All attendees who walked through the main ACCPbooth in the convention exhibition area were offered the oppor-tunity to complete the survey, and survey responses were keptanonymous. One investigator and his spouse distributed allsurveys and briefly explained the purpose of the survey. Consent

to participate in the study was implied by the health-careprofessionals completion of the survey. All responses to thesurvey were handwritten on the questionnaire by individualhealth-care professionals. No remuneration or gift was given forcompleting the survey.

The data were compiled and transferred to a standard work-sheet (Excel 2000; Microsoft Corporation; Redmond, WA). 2

analysis (JMP Statistical Software; SAS Institute, Inc; Cary, NC)or the Fisher exact test (Number Crunching Statistics System, version 6.0; Statistical Solutions; Saugus, MA) were used tocompare the proportions of those in favor of FWR for variousdemographic groups, depending on whether the sample sizes of the demographic subgroups were large ( 2 test used) or small(Fisher exact test was used if the number in an individual data

cell was

10). The level of statistical significance was set atp 0.05. For the analysis of regional variations, the UnitedStates was divided into the northeast, midwest, south, and westregions using the US Census Bureau methodology 22 (Fig 1).

Results

A total of 592 surveys were completed. Ten sur- veys were internally inconsistent and were not in-cluded in the analysis. Of the remaining 582 survey participants, 28 indicated that they had never beenpresent during an attempted resuscitation. Thus,

these respondents were excluded from further anal-www.chestjournal.org CHEST / 122 / 6 / DECEMBER, 2002 2205

8/10/2019 4. 2204

3/8

ysis as their lack of experience made their opinionsuninformed, leaving 554 surveys to be analyzed.Although many surveys had incomplete responses,

the data were recorded and analyzed as long as they were not contradictory.Four hundred ninety-four of the 543 people that

listed an occupation, indicated that they were physi-cians, which represented approximately 15% of thephysicians who attended the ACCP InternationalConvention. Twenty-eight nurses and 21 other alliedhealth-care workers were surveyed, which repre-sented approximately 8% of the nurses and otherallied health-care professionals at the ACCP Inter-national Convention. Sixteen survey participants didnot describe their professional training.

Gender analysis of the survey participants showedthat 394 (71%) were male physicians. Of the remain-ing 29%, there were 73 female physicians, 25 femalenurses, 12 female allied health-care providers, 9male allied health-care providers, and 2 male nurses.Seven individuals (5 men and 2 women) did not listtheir occupations. Participants identified their eth-nicity as follows: white, 293; Asian, 101; Hispanic, 24;African, 10; other, 59; and not specified, 67. Neithergender nor ethnicity influenced participants survey responses.

Among the 494 physicians surveyed, the following

specialties were represented: pulmonary, 388 physi-

cians; critical care, 283 physicians; pediatrics, 20physicians; sleep, 19 physicians; cardiothoracic sur-gery, 18 physicians; cardiology, 9 physicians; allergy,

5 physicians; other, 26 physicians; and not specified,28 physicians. Many physicians indicated that they are certified in more than one specialty. Subgroupanalysis by specialty failed to show significant differ-ences among the groups.

The mean ( SD) age of participants was43.6 10 years, and there was no significant differ-ence in survey responses based on age. The averagenumber of years since the completion of training was11, and the number of years since training did notinfluence opinions on FWR. Also, there was nosignificant difference of opinions based on the size or

type of the hospital in which the participant prac-ticed.Regardless of occupation, the majority (78%) of all

health-care professionals surveyed opposed FWR foradults. In examining opinions per occupation (Fig 2),a greater percentage of physicians (80%) than nursesand allied health-care professionals combined (61%;p 0.0037 [ 2 test]) or nurses alone (57%;p 0.0066 [ 2 test]), disapproved of FWR. Theopinions of all participants regardless of occupationalso showed that a great proportion (85%) were notin favor of FWR when resuscitation involved a child.

The responses, by occupation, showed that even

Figure 1. Regional variations in FWR opinions among health-care professionals. US Census Bureaumethodology was used to separate the United States into four regions. FWR opinions were comparedbetween each region and the rest of the United States. * statistically significant regional difference(p 0.05).

2206 Special Reports

8/10/2019 4. 2204

4/8

fewer physicians (14%) would allow family membersto be present during pediatric CPR compared to20% allowing family member presence during adultCPR (p 0.037 [ 2 test]). This tendency also wasseen in nurses, as only 17% endorsed FWR duringpediatric resuscitation compared to 43% endorsingadult resuscitations, although this difference was notstatistically different (p 0.069 [Fisher exact test]).

There were significant differences in opinionsregarding FWR based on the regional location of thehealth-care professionals practice (Fig 1). Health-care professionals practicing in the northeast United

States were less likely to allow family presenceduring an adult or pediatric resuscitation (12% and5%, respectively) compared to health-care profes-sional in the rest of the nation (25% and 21%,respectively; p 0.016 and p 0.001, respectively [Fisher exact test]). Midwest health-care profession-als (37%) were more likely to allow family memberpresence during an adult resuscitation than those inthe rest of the nation (18%; p 0.002 [Fisher exacttest]). Midwest health-care professionals were alsomore likely to favor FWR in the pediatric patientcompared to health-care professionals in the rest of

nation, but this was not statistically significant. Of those participants who indicated whether their prac-tice was in the United States or in another country,there were no differences in opinions between inter-national (n 96) and US participants (n 341)concerning either adult or pediatric resuscitation.

Of the 554 participants who had previous resusci-tation experience, 22% would allow family presenceduring an adult resuscitation. In contrast, 42% of those with no previous resuscitation experience(n 24), who were eliminated from the above anal- yses, would allow family presence during an adult

resuscitation attempt (p 0.043 [Fisher exact test]).

Three hundred forty-three participants (59%) hadpreviously been involved in FWRs. Of the 343 withFWR experience, only 136 (40%) would allow FWRagain.

Respondents who disapproved of family memberpresence during resuscitation listed various reasons.The most common reason chosen was a concern forthe psychological trauma to the witnessing family members (79%). Other reasons listed were medico-legal concerns (24%) and performance anxiety af-fecting the CPR team (27%). Forty-eight respon-dents (9%) noted additional reasons, beyond those

listed on the survey, for why they would not allow FWR. The most common additional reason (26respondents) was fear that family members would bea distraction to the resuscitation team. Respondents were allowed to list multiple reasons if they chose todo so.

Discussion

In our survey, as well as other surveys of staff members,2,4,7 10,17 one common reason for not allow-

ing family member presence during CPR was a fearof distracting the CPR team. In the largest survey of physicians prior to our study,17 AAST membersbelieved strongly that the presence of family mem-bers in the resuscitation bay would interfere withpatient care. Representative comments from oursurvey participants include some family membersfainted, their presence slowed the needed stepsdown, families become hysterical and distract usfrom doing our job, spouse had an altercation withthe chaplain at the bedside, the family becomes sodistressed that we have to resuscitate them, dis-

traction for communication, possibly delay treat-

Figure 2. Variations in FWR opinions by occupation. * physician opinions differed significantly from nurses and other allied health-care professionals (p 0.05); opinions on adults and children were significantly different (p 0.05).

www.chestjournal.org CHEST / 122 / 6 / DECEMBER, 2002 2207

8/10/2019 4. 2204

5/8

ment or interfere, family disrupts the normal flow,reduces effectiveness, interrupts efficient care,interference by family during rapid delivery of treatment, too many in room, dont have time toexplain, would distract from at least one memberof the team who would have to explain to the family.Hanson and Strawser3 presented an opposing view in

their 9-year retrospective study, which reported notone instance of actual interference with the resusci-tation when family members were present. Similarly,Meyers et al9 reported no actual interferences by family members. The discordance between our sur- vey of critical care physicians and the results pub-lished in the literature demonstrates that prospectivestudies in ICUs are needed to assess the likelihood of family member interference during FWR.

A major concern of professionals who are opposedto FWR is the fear of psychological trauma to family members who witnessed the resuscitation. In our

survey, as well as other surveys of staff,9,12,23

physi-cians, more often than nurses, were afraid of psycho-logical trauma to those witnessing CPR. In fact,nearly 79% of the professionals in our survey cited afear of psychological trauma to family members as acause for excluding family members.

Others have expressed this concern. For example,Osuagwu16 stated that FWR was nontherapeutic,regretful, and traumatic enough to haunt the surviv-ing relative for as long as he or she lives. However,FWR advocates argue that the medical professionencourages lay people to be trained in basic life

support and CPR to help their loved ones survive inthe case of an accident or emergency. Furthermore,many family members are the first responders tothe scene and initiate CPR, only to be ejected fromthe resuscitation room once they arrive at the hos-pital. Others suggest that most people know what toexpect during CPR due to frequent depictions of resuscitation and CPR on television programs suchas ER and St. Elsewhere.24 Van der Woning24 statesit seems a natural progression that the majority willsoon no longer accept the traditional exclusion of themselves from the resuscitation of a family mem-

ber. The veil of mystery and heroism has been liftedthrough TV, and for the general public resuscitationis a frequent and procedural event for the medicalteam. It is an event from which the general publicneed not be shielded anymore.24 However, weagree with Osuagwu16 and contend that the invasive-ness and poor outcomes of real-life CPR attemptsdiffer markedly from televisions almost universally successful and bland depictions.

In a small randomized, controlled pilot study,12the data showed no adverse psychological effects, with a trend toward lower degrees of intrusive

imagery, posttraumatic avoidance behavior, and

symptoms of grief among relatives who witnessedresuscitation as measured by five different psycho-logical tests administered at 3 and 9 months after theattempted resuscitation. Although most physicians worry about psychological trauma to family members who have viewed a resuscitation, family members donot share this concern.2 6,9 These small published

studies suggest that health professionals concernsabout psychological trauma following FWR may beunsubstantiated.

Most advocates of FWR, including those whopioneered the idea, recommend family memberpresence in the resuscitation suite only after allinvasive lines and tubes, such as central venouscatheters, arterial lines, and endotracheal tubes, havebeen placed.3 Exceptions to this standard are theENA resolution15 and the FWR policy at ParklandMemorial Hospital, Dallas, TX.9 The CPR Guide-lines 2000 of the American Heart Association do not

describe the time during resuscitation when it isappropriate for family members to enter the resus-citation suite. We believe that health-care profes-sionals would be more likely to accept family pres-ence after invasive procedures have been completed,as this would afford a more controlled environmentfor the CPR team.

Many health-care providers have had previousexperience with FWR. In our study, 307 physicians(61% of those surveyed) had previous experience with FWR. Only 119 (39%) would allow FWR again.Thus, 60% of physicians considered FWR to be a

negative experience. This parallels the sentiments of AAST members. Almost 75% of those physicians who had experience with FWR characterized theirexperience as negative.17 Contrary to this, only 47%of the nurses in our survey considered their FWRexperience as having been negative. This is in agree-ment with the survey by Helmer et al,17 who foundthat only 36% of ENA members surveyed consideredtheir previous FWR experience to have been nega-tive.17

While staff members2 4,7 10,17,25 and family mem-bers2 6,9,11,12,26 have been surveyed about FWR,

there has been little research on what the patient would have wanted. Anecdotal cases of patients whohave survived resuscitation have been reported.4,12Of those, most support FWR. For example, Belangerand Reed4 have reported the case of a 60-year-oldman, status post-massive myocardial infarction, who was aware of his wifes presence during an extendedresuscitation. Afterward, he stated that her presence was sufficient encouragement to continue his fightfor survival.4 Opponents of FWR argue that dyingpatients may prefer loved ones to remember themas they were, and not the sight of nurses and doctors

gagging their throats and stamping their chest during2208 Special Reports

8/10/2019 4. 2204

6/8

8/10/2019 4. 2204

7/8

8/10/2019 4. 2204

8/8

relatives and friends during resuscitative efforts. Sch InqNurs Pract 1997; 11:153168

26 Boie ET, Moore GP, Brummett C, et al. Do parents want tobe present during invasive procedures performed on theirchildren in the emergency department? A survey of 400parents. Ann Emerg Med 1999; 34:7074

27 Osuagwu CC. More on family member presence in theresuscitation room [letter]. J Emerg Nurs 1993; 19:276277

28 Walker WM. Do relatives have a right to witness resuscita-tion? J Clin Nurs 1999; 8:625630

29 Back D, Rooke V. The presence of relatives in the resuscita-tion room Nurs Times 1994; 90:3435

www.chestjournal.org CHEST / 122 / 6 / DECEMBER, 2002 2211