Family presence during cardiopulmonary resuscitation: an opportunity for meaning-making in bereavement
The practice of allowing family members to be present during invasive procedures or cardiopulmonary resuscitation (CPR) of their relative has been debated for decades. With the rise of family-centered care (FFC), family input into health care decisions has increased and strict visitation policies in the intensive care unit (ICU) have relaxed, even including family member participation in simple care activities (aspiration of secretions, changing the patient’s position).
But what is patient- and family-centered health care exactly? The Institute of Patient and Family Centered Care states that “Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It redefines the relationships in health care” (http://www.ipfcc.org/). In this approach, health care practitioners (HCPs) recognize the vital role that families play in ensuring the health and well-being of the patient. They acknowledge that emotional, social, and developmental support are integral components of health care.
The greater prominence of FCC within critical care medicine adds a new context to the conduct and interpretation of family presence during CPR—a source of considerable controversy for nearly 20 years . Some have argued that family presence should be discouraged to protect the family from the perceived brutality of the resuscitation attempt  as well as HCPs’ fear of litigation, greater prolongation of resuscitation, and family interference [3, 4]. Yet others have described the possible benefits of family presence: viewing the attempt is better than being left alone to wonder and speculate; being present decreases worry and helps relatives face the reality [5–7]. The multicenter, randomized trial by Jabre and colleagues in the New England Journal of Medicine  provided powerful evidence that the naysayers should reconsider. In this study, relatives who were allowed a chance to witness resuscitation (some did not do so even though they had the option) experienced fewer symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD) at 3 months than those who were not allowed to witness CPR. The study also showed that family presence during CPR did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts.
The 1-year follow-up of these family members was described in a recent issue of Intensive Care Medicine . Similar to the trend at 3 months, those who were offered the opportunity to be present during CPR had fewer PTSD-related symptoms and were less likely to have developed complicated grief symptoms. How could family presence during CPR be operationalized? As debates have shown, presence of family during CPR is not simple: family participation requires education. In the study by Jabre and colleagues, HCPs participating in the trial received guidance as to how to communicate with relatives in this emotionally and medically difficult context—perhaps, in fact, an element that contributed to the benefits experienced. If one is to offer relatives the possibility of witnessing CPR, a clinician must be available to prepare them, give them clear information, and handle their emotions and reactions. Relatives cannot be left alone to cope with this experience and staff cannot be torn between caring for the patient and tending to the family’s needs  during this very stressful performance .
What could be the mechanisms of benefit for witnessing CPR? Social scientists and ethicists often blame the increased use of advanced medical technologies for the undignified character of contemporary dying. On the basis of ethnographic material and in-depth interviews with HCPs, the sociologist Timmermans reported that witnessing resuscitative efforts may help relatives provide meaning to the process of dying by different means: first, by providing temporal reprieve for relatives to come to terms with sudden death (communication with physician, hope during resuscitative efforts); second, by showing that everything has been done for the patient, thereby easing their guilt and aiding their understanding about the event; third, by showing that the patient was treated with respect and dignity; fourth, by facilitating transition from life to death; and last, by offering an opportunity for closure and appropriate grieving . A collaborative approach in which relatives can choose to witness resuscitative efforts may therefore allow those who care the most for the patient to be a part of a life transition and broadens the purpose of resuscitation practice to not only possibly save lives but also an opportunity for relatives to give additional meaning to death. This may ease the grieving process. Most studies  show that relatives who were present during resuscitation stated that they would do so again in the future. Just as families want a more active role in end-of-life decision-making , they feel that it is their right to be present during CPR and want to be offered the opportunity to be present even if they might not accept it . When HCPs who have experience with family presence during CPR are asked, they too, overwhelming would continue the practice into the future . There is, however, legitimate concern that not all people of all cultures may desire or benefit from family presence during CPR and further research is needed to better understand this cultural variation .
Three major points must be put forward. Most importantly, family presence during CPR must remain an option and never an obligation. Furthermore, education of HCPs is needed to ensure that they can attend to family needs (procure comfort, answer questions, clarify procedures, and ensure safety) and to ensure that they themselves feel confident with family presence. Lastly, the emergency response system needs to include a family liaison whose position it is to deal with family needs while other HCPs are resuscitating the patient.
So what comes next? More research is needed to confirm the beneficial results of family presence during CPR, such as those published by Jabre and colleagues. Since all HCPs are likely unprepared to systematically adopt this practice, further research is also needed to help understand the barriers to implementation of family presence during CPR and to test strategies to overcome them. Last, education and structured support are needed for HCPs through the transition to adopt family presence.
Conflicts of interest
Authors have no conflicts of interest to declare.