Good grief! Should family members be present during prehospital resuscitations?

Good grief! Or at least that is what we hope for when managing end-of-life scenarios as healthcare professionals. When patients are being actively resuscitated, whether in the prehospital environment or inside the hospital, all efforts have traditionally focused on just the patient, including training elements. Despite the family frequently being present or immediately available in the pre- and peri-resuscitation periods, healthcare professionals are rarely trained to cover this affective element of care and, therefore, often neglect to include them or consider their needs during this critical period.

While a resuscitation can be chaotic in a hospital environment, with many more personnel and resources, it can be even more chaotic in the prehospital setting, with variables such as emotionally charged family members, lack of appropriate security, and an austere and unfamiliar environment to EMS clinicians. When combined with a sudden or unexpected illness or death, this can cause a highly complicated grieving process for the surviving family members.

Over the past 30 years, there has been an explosion of research on this affective component of resuscitation, to determine if family presence during resuscitations (FPDR) was valuable and important, affected grief and bereavement, led to PTSD symptoms, or had any impact (negative or positive) on the performance of the healthcare professionals.

Let me cut to the punch line: Routine family presence during resuscitations is generally beneficial for family members and clinicians, and at a minimum, family members should be offered the opportunity to remain with their loved one during the resuscitation.

Advantages of FPDR

First, understand that most of the available literature on this subject is based on surveys and opinions, with a few more scientific trials, including one UK study where 25 families were randomized to either remain with their loved one during resuscitation or were not given a choice and directed to a nearby family room [1]. The study showed such overwhelming benefit to the family being present during resuscitation that it was stopped early.

Another higher-quality study in 2013 randomized 570 relatives of EMS cardiac arrest patients at home to observe the resuscitation or remain nearby but out of sight. Ninety days later, they were interviewed by a trained psychologist, and it was determined that family members were 1.7x less likely to have PTSD-related symptoms and had a statistically significant reduction in anxiety and depression when they were involved in the resuscitation. Furthermore, their presence did not affect the resuscitation characteristics, patient survival, or the level of emotional stress in the EMS clinicians, and there were no medicolegal claims as a result of their presence [2].

In additional studies based on surveys after the resuscitation, it was determined that 94% and 76% of families in two separate studies would have chosen to be present during the resuscitation if they had been given the choice again. In those same two studies, 76% and 64% stated that being present during the resuscitation helped to ease their grief, 60% and 64% believed that their presence helped their loved one, and 100% of families believed that everything appropriate was done for their family [3,4].

Impact on healthcare providers

What about the impact on the healthcare providers? In the same study mentioned above, 97% of the providers agreed that family behavior was appropriate and expressed overwhelming support for continued FPDR [4]. It is believed that many EMS clinicians suffer repeated emotional trauma as they work multiple cardiac arrests over their career, and higher affective competency and advocacy for surviving family members can lead to positive feedback, an improved sense of purpose, and a sense of closure on these calls where the provider may otherwise feel discouraged and empty.

The benefits of FPDR are so widely recognized that many professional organizations now advocate for and endorse FPDR, including the American Heart Association, American Association of Critical-Care Nurses, the Emergency Nurses Association, and the Resuscitation Council (UK) [5-8].

EMS clinicians may wonder about the motivation of family members who want to be present during the resuscitation of their loved one. One EMS study in 2016 sought to determine this very answer, and responses of 75 individuals fell into one of the following four themes [9]:

1. Desire to participate in the resuscitation process or to support their loved one
2. Communicate the patient’s wishes or medical information to the treating EMS clinicians
3. Increased awareness of the critical condition and enhance the perception of the reality of death by observing an unsuccessful resuscitation
4. Seeking a feeling of relief in witnessing excessively heroic treatments

Encouraging FPDR can help the family members to feel as if EMS is seeing the human side of their loved one, rather than just another patient. It can also allow the family members to see that all efforts were being made to resuscitate their loved one and can lead to an earlier sense of closure, which is a very important part of the grieving process in the event of an unsuccessful resuscitation. Additionally, FPDR can lead to improved transparency and communication among EMS clinicians performing the resuscitation and respect the autonomous wishes of the surviving family members.

Challenges and considerations with FPDR

Are there any drawbacks to involving family members during EMS resuscitations? Opponents of FPDR focus on a few different points, but I would argue that these are more areas for consideration rather than contraindications to FPDR.

A representative list includes the following:

1. “We must consider the wishes of the patient, who may or may not want their loved one to be a witness to the resuscitation.”
   • Response. Unless this wish was explicitly stated in an advance directive, and with the current understanding about the benefits to the family member, the psychological benefits to the family members would outweigh the risks to patient privacy. Also, the studies were not designed to interview surviving patients of resuscitation to determine if they believed having their family present helped the resuscitation, so it is impossible to make assumptions from the patient’s perspective, and we only have the family member’s perspective to consider in these scenarios.
2. “The literature is mostly based off of survey studies, which is fairly weak evidence in the hierarchy of literature.”
   • Response. True, but the few randomized controlled trials, which are much higher in the hierarchy of evidence, showed statistically significant psychological benefits.
3. “The family can become disruptive to the resuscitation.”
   • Response. While this can be an initial deterrent, most EMS clinicians should be able to do a scene size-up and determine if the family member possesses the emotional stability to remain on scene and not become a danger or hindrance to the resuscitation. A designated team member should remain with the family to explain what is happening in layman’s terms and offer emotional support. Most family members will be more cooperative when the events are communicated to them. This also helps them become an ally to a successful resuscitation by providing history or to understand the degree of efforts put forth to save their family member if the resuscitation should end with termination. If the EMS clinician still feels that the family member would pose a threat, then it’s reasonable to escort that family member away from the scene or involve other personnel on scene to distract the family member away from the primary team performing the resuscitation.
4. “The family member could become harmed or have a bloodborne pathogen exposure.”
   • Response. While this is true for the EMS clinicians as well, the family members may not have the opportunity to be fully informed of the risks prior to agreeing to remain present during the resuscitation. This risk can be mitigated by having the family member remain present with another team member, but not hovering over the patient or placing themselves in danger of a needlestick, accidental electrical shock from the cardiac monitor or AED, or having blood or saliva splashed on them. Personally, I have often allowed family members to hold the hand of their loved one during resuscitations if they prefer, and still able to manage a proper resuscitation without the family member interfering with our resuscitation or being in any danger.
5. “The urban environments and traumatic arrests usually lead to more hostile bystanders and family members, as well as overall negative impact on providers during resuscitations.”
   • Response. There are two older studies addressing this statement, with one study surveying American Association for the Surgery of Trauma (AAST) and Emergency Nurses Association (ENA), demonstrating that AAST members, who were more likely to be older white males practicing significantly longer, took a more paternalistic approach and thought that FPDR was inappropriate, interfered with patient care and increased stress of trauma team members, compared to the ENA members who, although treating the same patient population, took nearly a 3:1 ratio in favor of FPDR [10]. A second study compared urban and suburban EMS clinicians and urban EMS clinicians had a statistically significant increase in feeling threatened by family members or that FPDR interfered with resuscitation, but otherwise no statistical differences between urban and suburban EMS clinicians when it came to feeling uncomfortable with FPDR or believing that it had an overall negative impact on the resuscitation [11].

What does this mean for our EMS clinicians and how should this change your practice?

As EMS focuses more and more on resuscitation on scene to improve patient outcomes, it’s time to consider the family and the importance of their presence during all resuscitations where the scene is conducive to their involvement. Despite not being traditionally trained for this affective component of our work, it is a highly valuable tool to effectively treat the surviving family member(s) and improve the grieving process. These difficult conversations with family members require compassion, transparency, honesty and leadership. These conversations do not come naturally require practice before they feel natural and comfortable.

In summary, when weighing the decision to involve family members during EMS resuscitations, make sure of the following key points:

1. The family member(s) are willing to observe the resuscitation,
2. The family member(s) are not anticipated to interfere with the resuscitation,
3. A designated team member with effective and compassionate communication skills and enough knowledge of the resuscitation can remain with the family member(s) to explain what is occurring and likely future steps, answer questions, liaison between the family and the team, and provide grief support as needed.

Family presence during resuscitations conclusions

Routine family presence during resuscitations is generally beneficial for family members and clinicians, and at a minimum, family members should be offered the opportunity to remain with their loved one during the resuscitation. With practice and continued intentional efforts, EMS clinicians can become just as skilled at this component as they are with management of the resuscitation itself.

References

1. Robinson, S., Campbell-Hewson, G., & Prevost, T. (1998). Effect of witnessed resuscitation on bereaved relatives. The Lancet, 352(9143), 1863.

2. Jabre, P., et al. (2013). Family presence during cardiopulmonary resuscitation. The New England journal of medicine, 368(11), 1008–1018.

3. Doyle, C. J., Post, H., Burney, R. E., Maino, J., Keefe, M., & Rhee, K. J. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16(6), 673–675.

4. Meyers, T. A., Eichhorn, D. J., Guzzetta, C. E., Clark, A. P., Klein, J. D., Taliaferro, E., & Calvin, A. (2000). Family presence during invasive procedures and resuscitation. American Journal of Nursing, 100(2), 32–42.

5. Morrison, L. J., Kierzek, G., Diekema, D. S., Sayre, M. R., Silvers, S. M., Idris, A. H., & Mancini, M. E. (2010). Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3).

6. American Association of Critical-Care Nurses. Family presence during resuscitation and invasive procedures. http://www.ipfcc.org/bestpractices/Family-Presence-04-2010.pdf. Updated April 2010. Accessed May 25, 2021.

7. Emergency Nurses Association. Clinical practice guideline: family presence during invasive procedures and resuscitation in the emergency department.
https://pdfs.semanticscholar.org/db2d/eb0a0f4bb30f91f5fa3ef7fe6d512ba86fcb.pdf . Updated 2012. Accessed January 9, 2018.

8. Bossaert LL, Perkins GD, Askitopoulou H, et al; Ethics of Resuscitation and End-of-Life Decisions Section Collaborators. European Resuscitation Council guidelines for resuscitation 2015: section 11. The ethics of resuscitation and end-of-life decisions. Resuscitation. 2015;95:302-311.

9. De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., Baubet, T., Reuter, P.-G., Javaud, N., Borron, S. W., Vicaut, E., & Adnet, F. (2016). Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial. PLOS ONE, 11(6).

10. Helmer, S. D., Smith, R. S., Dort, J. M., Shapiro, W. M., & Katan, B. S. (2000). Family Presence during Trauma Resuscitation: A Survey of AAST and ENA Members. The Journal of Trauma: Injury, Infection, and Critical Care, 48(6), 1015–1024.

11. Compton, S., Madgy, A., Goldstein, M., Sandhu, J., Dunne, R., & Swor, R. (2006). Emergency medical service providers’ experience with family presence during cardiopulmonary resuscitation. Resuscitation, 70(2), 223–228.