What is the role of nurses in witnessed resuscitation? How can they support relatives who wish to be present during an attempt at cardiopulmonary resuscitation on their loved one?
While current resuscitation guidelines explicitly say that relatives should be offered the opportunity to witness a resuscitation attempt made on a family member, the evidence on the benefits and risks is conflicting. Nurses who are in contact with relatives of patients treated in intensive care have a key role in assessing whether witnessed resuscitation may or may not be beneficial. They will be the ones who support relatives throughout the process and liaise with the resuscitation team. This article discusses the issues around witnessed resuscitation and provides nurses with guidance and recommendations.
Citation: Rose S (2018) Supporting relatives who choose to witness resuscitation attempts. Nursing Times [online]; 114: 3, 30-32.
Author: Steven Rose is cardiac clinical nurse specialist, Royal Wolverhampton Trust.
- This article has been double-blind peer reviewed
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Cardiopulmonary resuscitation (CPR) is defined by the Resuscitation Council (UK) as “a procedure which incorporates basic life support along with advanced medical interventions that restores breathing and circulation in a person whose heart has stopped beating” (RCUK, 2016).
Evidence provided by the National Cardiac Arrest Audit shows that from the period 1 April 2011 to 31 March 2013 cardiac arrests accounted for 1.6 per 1,000 hospital admissions in the UK (Nolan et al, 2014). This suggests that, at some point in their careers, nurses will likely be involved in a CPR attempt.
UK and European resuscitation guidelines (RCUK, 2016; Lippert et al, 2010) say that families should be allowed to be present during a CPR attempt in hospital. Some studies show that relatives who witness resuscitation are less likely to develop symptoms of post-traumatic stress disorder (PTSD) than those who do not. However, there is also evidence that relatives who choose to be present may find the experience distressing and develop psychological issues as a result. This article discusses witnessed resuscitation and provides guidance to nurses responsible for caring for relatives.
Position of the RCUK
The idea of supporting relatives to witness resuscitation is nothing new, with research and reports going back to the 1980s (Lippert et al, 2010). In 1996, the RCUK published a booklet called Should Relatives Witness Resuscitation? (McLaughlan et al, 1996). Since then, practice has moved on, but many of the core elements of the booklet are still considered valid today.
In its 1996 booklet, the RCUK suggested that family members who witness the resuscitation process may have a healthier bereavement, as they will find it easier to come to terms with the reality of their relative’s death, and may feel reassured that everything possible has been done. It acknowledged that the reality of CPR may be distressing, but argued that it is “more distressing for a relative to be separated from their family member” at this critical time (McLaughlan et al, 1996). In the latest edition of its Advanced Life Support manual, the RCUK argues that “many relatives want the opportunity to be present during the attempted resuscitation of their loved one” (RCUK, 2016).
The resuscitation team and the nurse caring for the patient have the responsibility of deciding whether to offer relatives the opportunity to witness a resuscitation attempt. The option to witness resuscitation should not be offered if it was believed it would compromise the safety of the patient, relatives or staff members.
Sometimes nurses may decide not to offer relatives the option of witnessing resuscitation; this may be based on their own anxieties rather than on evidence-based practice. “Nurses’ objections revolve around the effects that it may have for family attending either a successful or unsuccessful resuscitation, fear of litigation, and possible disruption of the professionals’ efforts of resuscitation” (Goldsworth and Bailey, 1998).
What do relatives think?
Grice (2003) looked at the attitudes of staff, patients and relatives towards witnessed resuscitation in adult intensive care units. Many staff members who were present during witnessed resuscitation felt that relatives gained certain benefits. Almost all agreed that the views of both patients and relatives should be formally sought before admission to intensive care (Grice, 2003).
More recent work shows both public support for witnessed resuscitation and a desire to be included in the resuscitation process. “Many relatives would like to be present during resuscitation attempts and of those who have had this experience; over 90% would wish do so again” (Lippert et al, 2010).
When a patient is admitted to intensive care the question may be asked by the medical team whether the patient would want CPR or not. This would provide an opportunity for witnessed resuscitation to be discussed with patients and relatives upon admission. The subject would have to be approached sensitively, but ascertaining patients’ and/or relatives’ wishes before an admission to intensive care would certainly help.
What does the literature say?
Most of the evidence comes from informal feedback and small observational studies, and not all authors come to the same conclusions. Robinson et al (1998) demonstrated a reduced risk of psychological problems for bereaved family members who chose to witness the resuscitation attempt on their relative: seven out of the eight participants in the study who had witnessed the CPR attempt felt that the grieving process had been eased, as they were able to be with their loved one until the end.
Terzi and Aggelidou (2008) produced evidence showing that relatives who had been briefed and given the choice to be present during resuscitation and subsequently witnessed the resuscitation attempt had gained benefits in terms of an easier grieving process.
Compton et al (2009) conducted a study involving 54 participants, out of which 34 had witnessed out-of-hospital resuscitation and 20 had not. The aim was to assess whether witnessing an unsuccessful out-of-hospital CPR attempt was associated with PTSD symptoms in family members. The outcomes suggested that relatives who had witnessed a failed CPR attempt could display symptoms of PTSD. Compton et al acknowledged that their study had limitations, such as a small sample size, and commented that out-of-hospital CPR is less controlled than in-hospital CPR.
Jabre et al (2014) followed up 570 family members for one year to compare psychological outcomes in those who had been given the option to be present during resuscitation (n=239) and those who had not. The authors found that there was no difference between those who had witnessed resuscitation and those who had not in terms of depressive symptoms. They also found that family members who had not witnessed resuscitation displayed significantly more PTSD symptoms than those who had.
Beneficial or detrimental?
So, is witnessed resuscitation beneficial or detrimental for relatives? Are they more or less at risk of PTSD, depression and prolonged grief? Some of the evidence described in this article shows that the outcomes for relatives who are not present during resuscitation are worse than for those who are present, and that those who do witness resuscitation cope better with grief and bereavement. However, some of the evidence shows the contrary. There is also evidence suggesting that witnessing resuscitation does not make a significant difference to the outcomes for relatives.
The decision regarding whether to be present during resuscitation should be left to the individual person. Nurses need to gauge whether witnessed resuscitation would have benefits for the patient and/or the relatives, which can only be done through a holistic assessment of the specific situation at the time (Guzzetta et al, 2007).
Role of nurses
Witnessing resuscitation can be traumatic for family members, so it is important that health professionals provide support and explain everything that is being done (Guzzetta et al, 2007). A member of the nursing team, ideally the nurse caring for the patient in cardiac arrest, should be designated for that role and remain with the family during the whole process.
If witnessed resuscitation is to be offered, nurses need to discuss the wishes of the patient and/or relatives as soon as possible to act in the best interests of both (Guzzetta et al, 2007). Nurses should explain what resuscitation is and what it involves. Questions to discuss with relatives relate to their perception of resuscitation and their willingness to witness it (Meyers et al, 2000).
In accordance with the Nursing and Midwifery Council code (2015), nurses need to remain non-judgemental whatever the relatives decide, whether they choose to be present or not, and support them in making the decision.
Once it has been established that relatives want to be present, nurses should inform the resuscitation team leader, seek their approval and ask them when the relatives should enter the resuscitation area. As clarified by Guzzetta et al (2007), “The team who are providing direct care retains the option to request that the family be escorted away from the bedside and/or out of the room if deemed appropriate.”
Before family members enter the resuscitation area, they must be informed, in clear language understandable to non-clinicians, of their relative’s clinical condition and of the procedures taking place place. Nurses need to discuss what is happening to a patient during a resuscitation attempt and the importance of the witnessing family’s role in providing comfort and reassurance to the patient when appropriate (Moons and Norekvål, 2008).
There may be circumstances that preclude family presence; for example, if the privacy and dignity of the patient needs to be protected; or if during a resuscitation attempt all members of staff are fully occupied and there is no one available to support the family.
There may also be circumstances when relatives will need to be escorted out of the room; for example, if they disrupt the work of the resuscitation team through uncontrolled manifestations of grief (Doolin et al, 2011), lose self-control, exhibit violent and/or aggressive behaviour (Guzzetta et al, 2007) or try to become physically involved in the CPR attempt. Situations where the presence of relatives could negatively affect the team’s work should be considered when assessing the situation holistically (Guzzetta et al, 2007).
Post-resuscitation, the nurse who is supporting the family can point towards chaplaincy services for meeting the spiritual needs of the patient and/or relatives (Harteveldt, 2005), as well as towards bereavement support services. The nurse should participate in staff debriefing, which is an opportunity for the team to identify issues, reflect on them and initiate appropriate actions (Halm, 2005).
Every situation is different, so an individualised and holistic approach is needed, while trust policies and procedures need to be adhered to at all times. The recommendations summarised in Box 1 will help nurses involved in witnessed resuscitation. It is essential that relatives of patients who are to receive CPR be given the option of being present and that they are supported throughout the process by appropriately trained staff. However, the patient’s welfare and dignity should remain nurses’ the utmost priority.
Box 1. Recommendations for nurses
- Approach relatives, introduce yourself and give them a clear and honest explanation of what has happened and what will happen next
- Give them the choice to be present during resuscitation
- Explain what they can expect to see – particularly the procedures they may witness
- Explain how many of them may enter the room at one time
- Explain to them where to stand in the room
- Explain to them when they will be able to approach the bed or trolley and that they will be allowed to touch the patient when it is safe to do so
- Inform them they will be able to leave the room and re-enter it at any time, and will always be accompanied
- Ask them not to interfere with the procedures
- Inform them that they may be escorted out of the room if they become overwhelmed by grief or disturb the resuscitation efforts of the team
- Depending on the patient’s condition and the interventions being used, inform relatives that there may be other situations when they may be asked to leave the room
- Gain the agreement of the resuscitation team before bringing relatives into the resuscitation area
- Ask the resuscitation team at what time the relatives should enter the area
- Explain to relatives the procedures step by step as they occur
If resuscitation is unsuccessful:
- Advise relatives that there will be a brief interval during which equipment will be removed and that they will then be able to be with the deceased in private
- Give them as much time as they need
- Give them an opportunity to ask questions
- Let them know that chaplaincy services and bereavement support are available
- Guidelines say that relatives should be allowed to be present during cardiopulmonary resuscitation (CPR) in hospital
- Nurses will likely be involved in witnessed resuscitation at some point in their careers
- Research to date does not demonstrate for certain whether witnessed resuscitation is beneficial or detrimental for relatives
- Relatives should be given the option of being present and receive support to make the decision
- Relatives who choose to witness resuscitation need information and support before, during and after the procedure
Compton S et al (2009) Post-traumatic stress disorder symptomology associated with witnessing unsuccessful out-of-hospital cardiopulmonary resuscitation. Academic Emergency Medicine; 16: 3, 226-229.
Doolin CT et al (2011) Family presence during cardiopulmonary resuscitation: using evidence-based knowledge to guide the advanced practice nurse in developing formal policy and practice guidelines. Journal of the American Academy of Nurse Practitioners; 23: 1, 8-14.
Goldsworth JE, Bailey M (1998) Your patient is undergoing resuscitation. Where’s the family? Nursing; 28: 9, 52-53.
Grice AS (2003) Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units. British Journal of Anaesthesia; 91: 6, 820-824.
Guzzetta CE et al (2007) Presenting the Option for Family Presence. Des Plaines, IL: Emergency Nurses Association.
Halm MA (2005) Family presence during resuscitation: a critical review of the literature. American Journal of Critical Care; 14: 6, 494-511.
Harteveldt R (2005) Benefits and pitfalls of family presence during resuscitation. Nursing Times; 101: 36, 24.
Jabre P et al (2014) Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive Care Medicine; 40: 7, 981-987.
Lippert FK et al (2010) European Resuscitation Council Guidelines for Resuscitation 2010 Section 10. The ethics of resuscitation and end-of-life decisions. Resuscitation; 81: 10, 1445-1451.
McLaughlan C et al (1996) Should Relatives Witness Resuscitation? London: Resuscitation Council (UK).
Meyers TA et al (2000) Family presence during invasive procedures and resuscitation. American Journal of Nursing; 100: 2, 32-42.
Moons P, Norekvål TM (2008) European nursing organizations stand up for family presence during cardiopulmonary resuscitation: a joint position statement. Progress in Cardiovascular Nursing; 23: 3, 136-139.
Nolan JP et al (2014) Incidents and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation; 85: 8, 987-992.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Resuscitation Council (UK) (2016) Advanced Life Support, 7th edn. London: RCUK.
Robinson SM et al (1998) Psychological effect of witnessed resuscitation on bereaved relatives. Lancet; 352: 9128, 614-617.
Terzi AB, Aggelidou D (2008) Witnessed resuscitation: beneficial or detrimental? Journal of Cardiovascular Nursing; 23: 1, 74-78.