Family presence during cardio pulmonary resuscitation is always a debatable issue among health care professionals. However, the family plays a very critical role in providing supportive care and has the most stakes in the patient’s survival, progress and outcome. This paper reviews the literature and highlights the benefits and consequences of the family presence during CPR.
Benefits of family presence during CPR includes, providing value to patient’s preference and dignity, supporting each other in the grieving process and reducing risks of medico legal divergence. On the other hand, consequences of family presence include neglect of patient’s right to autonomy, breach of confidentiality, emotional trauma to the family and possible law suits. Therefore we, as health care professionals, play a pivotal role in easing the patient’s distress by providing psychological support during CPR through family contribution.
Key words: Cardio pulmonary resuscitation, grieving, medico legal divergence, autonomy
Many years ago, mortality was a family unit matter, with family members providing emotional support to the dying person. Medical breakthroughs and technological advances like Cardio-Pulmonary Resuscitation (CPR) have made it possible to prolong a dying person’s life. Cardiopulmonary resuscitation (CPR) is an emergency procedure that is often employed after cardiac or respiratory arrest (1).
To avail this advance technology, families started transporting their loved ones more frequently to the hospitals with the desire of their survival. However, in the past, hospitals had adopted the practice of not allowing family members to witness the procedure of CPR, (3,12) despite the fact, that families play a very critical role in patients’ access to medical care in such emergencies. They are the one’s who serves the most in the patient’s survival, progress and outcome (10). The practice of family presence during CPR first emerged in the 1980s from the Foote Hospital in the United States, and since then the concept has gained momentum (2). The presence of patient’s immediate family member during CPR is an ethical, moral, and legal dilemma among healthcare professionals (2,10). This paper will highlight the benefits and the consequences of the family’s presence during CPR.
Benefits of family presence during CPR include, providing value to patient’s preference and dignity, supporting family in the grieving process and reducing risks of medico legal divergence (2) . Most of the patients prefer presence of family members when they are in distress. As Meyers, Eichhorn, Guzzetta and Klein (2000) have emphasized that if patients were provided opportunity to decide the presences of their family members, when they are struggling to survive, they will accept it (3). So loved ones, who were always the source of happiness and strength, need to be present when the patient require them the most; the patient may feel secure and less frightened with their family’s presence. It is estimated that only 10% to 15% of patients who receive CPR in the hospital survive and get discharged (2). Therefore, because of the high mortality rate and patients’ desire to be close to their family at the moment of death, it is the ethical and moral responsibility of the health care provider, to work as an advocate for patients’ dignity by allowing family during CPR. As Snoby (2005) found that “60% to 80% of the public believe that family members should be permitted to be with their loved one during resuscitation”(4).
Family presence during CPR facilitates family in the grieving process (10,12 ) and helps to meet their emotional and psychological needs. While working in an emergency department of a private tertiary care hospital, one of the authors (of this article) primary author of this manuscript came across a patient’s family who were provided the opportunity to be with the patient during CPR. The family members later expressed that it allowed them the possibility for closure and gave them a chance to say goodbye to their loved one . Family members who were at the bedside during CPR process expressed that their presence had helped them to face the reality of the situation and also facilitated in their grieving process. (5,12). Hanson and Strawser (1992), referring to his study, stated that “76% believed their adjustment to the death of their love one and 64% believed their presence was beneficial to the dying person”(1). Thus, family presence during CPR facilitates grieving with subsequent death and therefore,the health team should support family presence during CPR.
In addition, family presence during CPR may alleviate the uncertainty which may lead to possible lawsuits. Beside this argument, family presence during CPR enhances communication which facilitates the understanding between the medical staff and the family. A study conducted at the Parkland Health and Hospital system reveals that 95% of the family members who were present during resuscitation, verbalized that it helped them to understand the patient’s grave condition and efforts that were made by health care team members to save the life of their loved ones(3). Hence, family presence eliminates uncertainties about the procedure and efforts made for patient survival.
On the contrary, consequences of family presence may present certain issues such neglect of patient’s right of autonomy, breach of confidentiality (10), emotional trauma to the family and possible law suits. (2, 9,10)). Several healthcare professionals views that by allowing the family to be present during resuscitation, violation of the patients’ rights to autonomy and disregard to his/her confidentiality. Allowing immediate family without patient’s consent contravenes his or her autonomy, privacy and confidentiality. Often exposing patient in front of family members may also cause discomfort for the survivors of CPR. As Nibert declares that some patients choose to face death alone and do not allow their relatives to invade their privacy(6).
It is also argued in literature that relatives should not be present at resuscitation as it creates more psychological difficulties throughout their bereavement (11). It might be challenging for the family members to deal with the memories of blood loss, needles, body fluids, intubation process, chest compressions and defibrillation procedures performed on their loved one. Many people are sensitive to see their dear ones in distress; therefore it has been observed that the family becomes emotionally traumatized during CPR. As Morse and Pooler allege that family members who remain with the patient have crumpled during relatively minor procedures, and were required to seek medical assistance and care for themselves (7). In one CPR procedure performed at a hospital, one of the authors of this manuscript experienced the distress of a family member. The brother of the patient had chosen to be present and was allowed to do so. During the procedure the brother broke out in tears and left the room. Later he reported that he could not bear to see his brother suffering.
It has also been asserted that the presence of family member during CPR may lead to lawsuits. Hospital management may have fears that family members can notice errors and take them to the court. As Rattrie pointed out that, ” The nurses and health professional are at risk of legal claim for the compensation of negligence (8). This argument leads to the major concern for the health care professionals for continuation of their profession and their career growth. Fear may be due to lack of confidence or lack of skills of the health team members in the CPR procedure (2).
Health teams may not prefer presence of family members as they could interrupt the procedure (11) by asking either to prolong or to discontinue prematurely. Similarly, medical staff may feel that family presence and their emotional reactions can cause constraints during the CPR procedure. Furthermore, considering the poor understanding of the CPR procedure by untrained family members who may consider it an offence, the resuscitation team may end up with an argument by the family during the procedure (10).
In one CPR procedure in a private tertiary care hospital, it was experienced by one of the author (of this article), that a parent requested doctors to stop CPR on their 12 year old chronically ill child. In contrast, it is also observed by another author (of this article) that the family insisted to prolong CPR even though the patient was clinically dead.
In conclusion, we, as health care professionals, are at prime position to ease patient’s distress by providing psychological support during CPR through family contribution. However their presence during the procedure remains debatable. The health care team has an ethical and moral accountability to provide liberty for family presence during CPR, rather than considering health care professionals comfort, preference (6) and fears. Further studies on the experiences of the survivors of the CPR and their family can give further insight to the phenomenon. Development of comprehensive guideline, based on such experiences and expert opinions, can facilitates the decision making and support the needs of patients’ family members and health professionals in this critical time (10) This may produce a more integrated and consistent approach to this sensitive aspect of clinical practice.(10)