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Benefits and pitfalls of family presence during resuscitation

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In 1995 the RCN, in partnership with the British Association for Accident and Emergency Medicine, recommended that family witnessed resuscitation (FWR) should be fully supported. Despite this it is likely that close family members will still be requested to leave during resuscitation attempts. The rationale for this is the need to protect the relatives from the perceived brutality of the resuscitation attempt (Osuagwu, 1991).

Abstract

VOL: 101, ISSUE: 36, PAGE NO: 24

Rob Harteveldt, BA, DipHe, RGN, EN(G), is cardiac prevention nurse at Stoke Mandeville Hospital, Aylesbury

In 1995 the RCN, in partnership with the British Association for Accident and Emergency Medicine, recommended that family witnessed resuscitation (FWR) should be fully supported. Despite this it is likely that close family members will still be requested to leave during resuscitation attempts. The rationale for this is the need to protect the relatives from the perceived brutality of the resuscitation attempt (Osuagwu, 1991). FWR is now more common (Booth, 2004) although the paternalistic view of protection remains, and many relatives are still being denied access to their loved ones during this time of deep crisis (Blundell et al, 2004). The debate
The last 30 years have seen huge strides in resuscitation techniques and the collaboration of many organisations to increase survival rates following cardiac arrest. This progress has forced the issue of FWR to the forefront of ethical and moral debate. Traditionally the resuscitation room has been a no-go area for relatives. However, in times of disaster - when no such room exists - many people witness the traumatic resuscitation procedures. Some would argue that FWR should not occur because of patient confidentiality. However, while most would agree that the primary responsibility of nursing and medical staff is to the patient, there are conflicting issues when considering what is in the patient’s best interests. The literature
Staff attitudes The are six studies that address the issue of staff attitudes. These obtain qualitative data from their respondents, all of whom had participated in FWR. The sample sizes are relatively small but are elicited from a broad multidisciplinary spectrum. All the studies (Back and Rooke, 1994; Redley and Hood, 1996; Mitchell and Lynch, 1997; Meyers et al, 2000; Booth et al, 2004), report fear of resulting litigation as a common factor among staff who are reluctant to allow family members to be present during a resuscitation attempt. Three studies suggest staff fear their performance would be scrutinised and criticised by relatives, despite having done nothing wrong (Back and Rook, 1994; Mitchell and Lynch, 1997; Meyers et al, 2000). Only one study (Meyers et al, 2000) records that not only were no lawsuits filed for negligence because of family presence, but also that 84 per cent of staff felt their performance had actually improved during resuscitation and they had been able to appreciate that they were dealing with a human being rather than a catastrophic cardiac event. However, some staff believed that such emotional distance was essential for them to concentrate on the task of resuscitation with a clear head. Furthermore, they argued that in some cases the resuscitation attempt was unnecessarily prolonged because of family presence, even if the attempt was obviously futile (Mitchell and Lynch, 1997; Meyers et al, 2000). Others cited unpredictable reactions from family members as a reason why they would not endorse FWR. Fearing that relatives would interfere with defibrillation, for example, was a common finding. Such fears are not unfounded but did appear to have a cultural aspect. One study by Booth et al (2004) arrived at a less elaborate conclusion for why FWR was not offered. In their telephone survey of A&E departments, they found that a possible reason for relatives’ non-attendance at resuscitation was because no one ever approached them to see whether or not they wanted to be involved. It is interesting to note that throughout these studies, the more junior the member of medical staff the less likely they were to agree to FWR. In comparison, however, nurses were more likely than doctors to suggest FWR be offered. Relatives’ experiences If health care professionals feel witnessing the resuscitation of a loved one is distressing for family members, denying FWR is, according to Barrett and Wallis (1998), equally so. They report that even though a woman had seen her husband defibrillated in her living room and again in the ambulance by paramedics, she was stopped from entering the resuscitation room. Meyers et al (2000) cite numerous responses from relatives who have participated in FWR. The majority describe the experience as ‘powerful’ or ‘natural’ and in numerous cases family members stated that they ‘had a right to be there’. Interestingly, all of the respondents felt that viewing the attempt was better than being left alone to wonder and speculate. In resuscitation attempts that were successful Meyers et al (2000) report that relatives had felt connected with their loved one and had felt that they had been able to offer comfort while sharing a powerfully emotive experience. Even in instances where the resuscitation attempt had failed, relatives believed that by being present their worry was decreased and the experience had assisted them in facing the reality, which facilitated grieving in later months (Doyle et al, 1987). Indeed, a study by Robinson et al (1998) substantiated this finding. Relatives who had been involved in FWR showed lower levels of anxiety than those who had not participated. Television programmes such as Casualty portray graphic details of procedures such as resuscitation during peak-time viewing. While it would be naive to imagine that fantasy can prepare us for reality, the advent of such programmes means that intubation and defibrillation are not now as alien to people as the health care professional may believe. In fact, if anything, Blundell et al (2004) found that UK programmes that depicted such procedures were realistic in terms of the frequency of poor outcomes. Barrett and Wallis (1998) imply that too much emphasis has been placed on such procedures. When questioning relatives some months after the resuscitation, few of them could remember what procedures they had seen taking place. This would suggest that family members are much less focused on the technicalities of what is going on around them than on the loved one who is directly in front of them. Practice implications
The main recommendation from all of the studies reviewed (Box 1) emphasises the need for further research into FWR. Indeed, it is important to note that the samples relating to staff attitudes were taken only from those who worked in A&E. This raises the question of whether FWR would be more welcome within a ward area where the relationship between patient, staff and family has developed and has firm foundations. Education and discussion groups to elicit staff concerns and views on FWR should be initiated, and we should endeavour to support junior colleagues who may require support so that they do not feel intimidated by the presence of family members during resuscitation attempts. Having a member of staff who is able to explain to the relative what is happening during the procedures has been recommended by the studies. Some have suggested a senior nurse or even a chaplain could be an appropriate person to fulfil this function. While both of these suggestions have their obvious drawbacks, it is a solution that requires further investigation. One final recommendation would be a call for openness with our clients. If we could discuss the issue of resuscitation with them directly, the debate could be instantly closed. Conclusion
Research into the benefits and pitfalls of FWR is still in its relative infancy with the majority of literature uncovered being anecdotal. The sample sizes of the limited number of studies that are available are small, restricted to specialist areas, and their methodologies and ethical approaches remain questionable. The time lapse between studies and the recurrence of the subject, however, supports the validity of FWR as an area of research. Furthermore, it demonstrates that this issue will not simply fade away and whichever side of the fence you are drawn to the debate into FWR is far from over. This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net

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