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The relationship between the hospital setting and perceptions of family-witnessed resuscitation in the emergency department
Resuscitation (2006) 70, 74—79
CLINICAL PAPER
The relationship between the hospital setting and perceptions of family-witnessed resuscitation in the emergency department夽 Cheryl Macy a, Emily Lampe a, Brian O’Neil a,b, Robert Swor a,b, Robert Zalenski a, Scott Compton a,∗ a b
Wayne State University, Department of Emergency Medicine, Detroit, Michigan, United States William Beaumont Hospital, Department of Emergency Medicine, Detroit, Michigan, United States
Received 12 September 2005 ; received in revised form 4 November 2005; accepted 4 November 2005 KEYWORDS Cardiopulmonary resuscitation; Witnessed resuscitation
Summary Objective: To compare the support for, and perceptions of, family-witnessed resuscitation (FWR) in urban and suburban emergency departments (ED). Methods: A convenience sample of ED personnel from two urban and two suburban midwestern hospitals in the United States were surveyed. Survey questions assessed respondents’ opinions and experiences regarding the presence of family members during a resuscitation attempt. Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and 2 tests. Results: There were 218 respondents to the survey (108 urban, 110 suburban) of which the majority (63.3%) were female, and a mean (S.D.) age of 36.9 (10.2). The majority [131 (60.1%)] were health care providers (i.e. physicians, nurses, and physician assistants) while the remainder included support staff (i.e. security, pastoral care, and social workers). Half (50.9%; 95% CI: 44.3—57.6) of all ED personnel felt it was appropriate for an escorted family member to be allowed to be present during a resuscitation attempt. However, ED personnel of urban settings were less likely to support FWR (38.9% urban versus 62.7% suburban; p < 0.001). Likewise, fewer urban than suburban personnel thought that the psychological impact of witnessing a failed resuscitation attempt would be beneficial for a family member (37.6% versus 61.7%; respectively, p = 0.001). Of note, a minority, yet substantial percentage of all ED personnel believed that the practice would increase the potential for malpractice litigation (28.7% urban versus 21.8% suburban; p = 0.242).
夽
A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2005.11.013. ∗ Corresponding author at: Wayne State University, 4201 St. Antoine, UHC-6G, Detroit, MI 48201, United States. Tel.: +1 313 745 4238; fax: +1 313 993 7703. E-mail address: [email protected] (S. Compton). 0300-9572/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.11.013
Hospital setting and perceptions of family-witnessed resuscitation
75
Conclusion: Overall, there is divided support among ED personnel for FWR. The hospital setting appears to influence this support strongly, as well as the perceived benefit of FWR. © 2005 Elsevier Ireland Ltd. All rights reserved.
Introduction The International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care advocated family member presence during cardiopulmonary resuscitation. The support for this practice is based on previous studies that suggested there were benefits to the family member as a result of witnessing a loved one’s failed resuscitation attempt. These benefits are thought to include the removal of doubt that everything possible was done, a reduction of overall fear and anxiety, a higher sense of connection and bonding with the patient, and a greater feeling of closure.1—6 Additionally, one study showed that greater than three quarters of families felt their grieving process was improved by witnessing the resuscitation attempt.5 However, the same evidence that has led the AHA to recommend family-witnessed resuscitations has been insufficient for many emergency department personnel to remove their doubts about its logistical limitations, and the potential negative affect it may have on the family member. In a large study of emergency personnel from a single institution, many nurses and physicians were described as not supportive of family-witnessed resuscitations (FWR).7 Hesitations stem from concerns related to the psychological trauma to family members, the fear of distraction or performance anxiety affecting the CPR team, and an increased potential for malpractice litigation.7 In addition, staff have reported concerns that the resuscitation may continue beyond the recommended length of time when family members are present.8 These findings suggest that despite the recommendation for implementing family-witnessed resuscitations, the evidence is not enough to convince many emergency personnel of its value. These perceptions may be influenced by several factors. For example, it is possible that many emergency department personnel are not familiar with the literature regarding family-witnessed resuscitations. Additionally, it is also possible that clinical and environmental factors play a significant role in the personal perception of the logistical feasibility and value of instituting the practice—–a fact that would not be identifiable by surveys conducted at a single institution. Urban centers participate in traumatic resuscitations with younger patients more
frequently, who have no prior illness or expectation of a life-threatening event. Environmental factors may include the hospital setting (urban versus suburban) and the cross-racial identity of patient and ED personnel. This assertion would seem to be supported by a recent study of emergency medical service (EMS) personnel from urban and suburban settings.9 This study showed urban providers reported more often that they felt threatened by family members and that family interfered more often with their ability to attempt resuscitation in a pre-hospital based environment. These environmental factors may have important implications in an emergency department setting, but as of yet there has been little research in this area. Therefore, this study was conducted to compare the perceptions, experiences, and attitudes toward family-witnessed resuscitations between urban and suburban emergency department personnel.
Methods A survey of a convenience sample of urban and suburban emergency department personnel employed by four large midwestern hospitals (two urban and two suburban) was conducted to determine perceptions, experiences, and attitudes regarding familywitnessed resuscitation. The two urban hospitals were Sinai-Grace Hospital (approximate annual ED census: 55,000) and Detroit Receiving Hospital (approximate annual ED census: 80,000). Both are located in Wayne County, Michigan, and are core members of the Detroit Medical Center, which is affiliated with the Wayne State University School of Medicine. The patient populations of these urban hospitals are primarily African—American and underinsured. The two suburban hospitals were William Beaumont Hospital-Royal Oak (approximate annual ED census: 115,000) and William Beaumont Hospital-Troy (approximate annual ED census: 55,000). Both are located in Oakland County, Michigan, which is one of the wealthiest counties in the United States. The patient population is predominantly white, and the majority of patients are privately insured. The study period was May 25 through June 24, 2005. Emergency department personnel were asked to respond to 24 statements including demographic information (i.e. age, sex, race, reli-
76
C. Macy et al.
gion, and occupation), past participation in resuscitation attempts with family presence, preferences and feasibility of family-witnessed resuscitation, and their overall perception of the psychological consequences. For the majority of the survey items, participants were asked to report if they ‘‘agreed’’, ‘‘disagreed’’, or were ‘‘not sure’’ with statements regarding family-witnessed resuscitation, while five of the statements were dichotomous in nature (yes/no).
Statistical analysis Comparisons between urban and suburban providers were conducted using independent samples t-tests and 2 tests, where appropriate. Proportions and 95% confidence intervals (95% CI) are also reported. No a priori sample size or power analysis was conducted. Both the Wayne State University and William Beaumont Hospital Human Investigation Committees approved this study.
Results There were 236 ED staff surveyed, of whom 218 (92.4%) responded (108 urban, 110 suburban). Among those who responded, 63.3% were female with a mean (S.D.) age of 36.9 (10.2). The majority classified themselves as white (66.8%) and Christian (78.4%). Most (60.1%) consisted of health care providers (i.e. physicians, nurses, and physician assistants) while the remainder was support staff
Table 1
(i.e. security, pastoral care, social workers, technicians, pharmacists, and other). Approximately half (53.7%) had participated previously in a CPR attempt in a resuscitation room of a hospital while a family member of an adult patient was present.
Overall Overall, half (50.9%; 95% CI: 44.3—57.6) of all ED personnel felt it was appropriate for an escorted family member of a patient who is undergoing CPR to be allowed to be present during the resuscitation attempt. However, this support was not consistent across urban and suburban providers. As shown in Table 1, urban providers were much less likely to support this practice than suburban providers. Their concerns differed mostly in relation to distractions from doing their job, the perception that the psychological impact to the family member is mostly harmful, and inadequate space availability in the resuscitation room. Few in each location had read scientific reports on FWR—–although suburban providers were more likely to believe that the existing literature supported the practice. Interestingly, most respondents in each location indicated that they would like training on how to incorporate a family member into the ED during a resuscitation attempt (69.5%; 95% CI: 63.3—75.7), and would support research on the topic if conducted in their department (76.5%; 95% CI: 70.9—82.1). However, this support for research was stronger in the suburban settings (68.5% urban versus 84.4% suburban; p < 0.01).
Comparison of responses from urban and suburban emergency department personnel
Performed pediatric resuscitation w/family Performed adult resuscitation w/family Would request to be present during a family member’s resuscitation Appropriate for family to be present Family distracts others from their job Family distracts me from doing my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Family presence will impair ability to teach Resuscitation room space is not adequate for FWR ED has good emotional support for the bereaved Asking family to leave may be a greater distraction It would be depressing to me w/family presence Have read any scientific reports on FWR Believes literature supports FWR Supports research on FWR Would like training on FWR All p-values were generated from the 2 test statistic.
Urban, n = 108 (%)
Suburban, n = 110 (%)
p-Value
27.8 34.3 44.4 38.9 43.5 29.6 55.4 28.7 50.0 59.3 73.8 21.5 47.7 28.0 25.0 68.5 68.9
57.3 72.7 58.2 62.7 26.4 21.8 29.0 21.8 40.9 38.2 81.8 24.8 38.2 21.1 40.9 84.4 70.1
<0.01 <0.01 0.04 <0.01 <0.01 0.19 <0.01 0.24 0.18 <0.01 0.16 0.57 0.16 0.24 0.01 <0.01 0.85
Hospital setting and perceptions of family-witnessed resuscitation Table 2
77
Comparison of responses by patient-respondent racial concordance Respondents race matches that of majority of ED patients at their hospital
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation It would be depressing to me w/family presence
Yes, n = 113 (%)
No, n = 105 (%)
54.9 33.6 27.4 38.2 26.5 42.0
46.7 36.2 23.8 45.9 23.8 43.8
p-value
0.23 0.69 0.54 0.26 0.64 0.78
All p-values were generated from the 2 test statistic.
Table 3
Comparison of responses from healthcare providers and support staff Respondent is directly involved in resuscitation (nurse, physician, and physician’s assistant)
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Resuscitation room space is not adequate for FWR It would be depressing to me w/family presence
Yes, n = 137 (%)
No, n = 81 (%)
61.1 26.7 17.6 32.3 19.1 43.5 38.2
35.6 47.1 37.9 56.0 34.5 56.3 50.0
p-value
<0.01 <0.01 <0.01 <0.01 0.01 0.06 0.09
All p-values were generated from the 2 test statistic.
Cross-racial perspectives
Healthcare providers
Although the patient population of these urban and suburban hospitals is predominately black or white, respectively, there was no evidence that personnel/patient cross-racial discordance affected support of FWR (Table 2). For example, white personnel whose patients were primarily white, and white personnel whose patients were primarily non-white had similar levels of support and concern for the practice.
Respondents were classified by position within the emergency department. Nurses, physicians, and physician assistants were compared to all others. This classification system was developed to assess the concerns of those most responsible for the practice of FWR. As shown in Table 3, healthcare providers in this population were more likely than support staff to believe that it was appropriate for an escorted family member of a patient who is
Table 4
Comparison of responses from those with and without experience in family-witnessed resuscitations Have participated in either a pediatric or adult family-witnessed resuscitation
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Resuscitation room space is not adequate for FWR It would be depressing to me w/family presence All p-values were generated from the 2 test statistic.
Yes (%)
No (%)
63.3 28.9 19.5 30.6 19.5 38.3 35.9
33.3 43.3 34.4 57.5 33.3 63.3 52.8
p-value
<0.01 0.03 0.01 <0.01 0.02 <0.01 0.01
78 undergoing CPR to be allowed to be present during the resuscitation attempt. Additionally, healthcare providers were less often concerned about distractions and negative psychological outcomes associated with the practice. Paradoxically, healthcare providers were also less likely to view FWR as increasing the potential for malpractice litigation.
Experience Previous experience with FWR was strongly associated with favorable perceptions of the practice. As shown in Table 4, ED personnel who had experience with FWR more often reported it as appropriate (63.3% versus 33.3%; p < 0.01), and were less likely to perceive that the practice would distract themselves or others, increase malpractice litigation, or find the practice depressing. Additionally, those with previous experience with FWR were less likely to state that psychological impact of FWR is mostly harmful (30.6% versus 57.5%; p < 0.01).
Discussion The results of this survey indicate hospital setting bears an important role in ED staff’s perceptions and attitudes toward family-witnessed resuscitations. Health care providers from urban settings are more uncomfortable with family presence during a resuscitation attempt and the majority do not perceive there to be a benefit for family members. This finding may be related to a variety of factors. The perception of inadequate resuscitation room size in urban settings may have influenced staff’s opinion of the benefit of FWR. Personnel in urban settings were more likely to convey concern that family presence may distract other medical personnel from doing their job. Urban hospitals have a smaller staff/patient ratio than suburban hospitals and this factor may be the cause of greater urban concern for distraction. Although both settings report a good process for providing emotional support to bereaved family members, urban personnel believed there to be greater psychological harm from witnessing a failed resuscitation. Another factor may be attributed to recent literature which reports that urban emergency department personnel have described higher rates of exposure to patient violence than their suburban counterparts.10 These justifications reflect the reality of the differences that exist in the two settings, and are the most likely explanations of the differences between the urban and suburban provider, since the difference in sup-
C. Macy et al. port was not related to the patient/provider race discordance. Nonetheless, the overall picture confirms there is no clear consensus from ED personnel on this topic, and that the literature has not penetrated very deeply in this population. In fact, only about 25% of the personnel surveyed were familiar with the literature or had read an article on FWR. Moreover, concerns of FWR in past literature (i.e. malpractice suits, fear of personal distraction or performance anxiety, etc.) were shown not to be an issue in this population. In addition, a circular problem exists were there can be no causal association inferred from ‘‘experience’’ questions—–one can not imply participation in FWR will lead to a greater support for the practice because those with experience probably supported the practice in the first place. Although this study presented many important findings, it is imperative to address its limitations. First, asking medical personnel to estimate their prior experience presents an inherent bias. Moreover, the data was reported from a convenience sample that may not be reflective of the views of all medical personnel. While the hospitals were classified dichotomously as urban or suburban, each hospital has its individual differences that may have affected the comparisons. For instance, all of the hospitals surveyed are considered medical teaching hospitals through the Wayne State University School of Medicine except for Troy William Beaumont Hospital. Also, the Detroit Receiving Hospital does not usually perform pediatric resuscitations. Lastly, the term ‘‘participation’’ in FWR was not clearly defined and its meaning could have been interpreted differently among individuals.
Conclusion Hospital setting and prior experience with FWR appears to influence the support strongly as well as a perceived benefit of FWR. Although FWR may not be as feasible in an urban setting, most participants in both settings were open to training and research regarding this topic. Overall, there is divided support among ED personnel for FWR and thus a further call for evidence is needed.
Acknowledgements Support provided by a grant from the Blue Cross Blue Shield of Michigan Foundation, and the Skarejelund Family Fund for Medical Education Research.
Hospital setting and perceptions of family-witnessed resuscitation
References 1. Tsai E. Should family members be present during cardiopulmonary resuscitation? N Engl J Med 2002;346(13):1019—21. 2. Timmermans S. High Touch in high tech: the presence of relatives and friends during resuscitative efforts. Sch Inq Nurs Pract 1997;(11):153—68. 3. Robinson SM, Campbell M-R, Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation. Lancet 1998;(352):614—7. 4. Meyers TA, Eichhorn DJ, Guzzetta CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs 1998;24(5):400—5. 5. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: foote hospital emergency department’s nine-year perspective. J Emerg Nurs 1992;18(2): 104—6.
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6. Doyle CJ, et al. Family participation during resuscitation: an option. Ann Emerg Med 1987;16(6):673—5. 7. Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accid Emerg Nurs 1996;4(3): 145—51. 8. McClenathan BM, Torrington KG, Uyehara CF. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest 2002;122(6):2204—11. 9. Swor R, Madgy A, Goldstein M, Dunne R, Sandhu J, Compton S. Emergency medical services providers’ experiences with family presence at resuscitation. Acad Emerg Med 2005;12(5 Suppl. 1):80—1. 10. Kowalenko TWB, Khare RK, Compton S. Workplace violence in the emergency department: a survey of the membership of the Michigan College of Emergency Physicians. Ann Emerg Med 2005;46(2):142—7.
CLINICAL PAPER
The relationship between the hospital setting and perceptions of family-witnessed resuscitation in the emergency department夽 Cheryl Macy a, Emily Lampe a, Brian O’Neil a,b, Robert Swor a,b, Robert Zalenski a, Scott Compton a,∗ a b
Wayne State University, Department of Emergency Medicine, Detroit, Michigan, United States William Beaumont Hospital, Department of Emergency Medicine, Detroit, Michigan, United States
Received 12 September 2005 ; received in revised form 4 November 2005; accepted 4 November 2005 KEYWORDS Cardiopulmonary resuscitation; Witnessed resuscitation
Summary Objective: To compare the support for, and perceptions of, family-witnessed resuscitation (FWR) in urban and suburban emergency departments (ED). Methods: A convenience sample of ED personnel from two urban and two suburban midwestern hospitals in the United States were surveyed. Survey questions assessed respondents’ opinions and experiences regarding the presence of family members during a resuscitation attempt. Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and 2 tests. Results: There were 218 respondents to the survey (108 urban, 110 suburban) of which the majority (63.3%) were female, and a mean (S.D.) age of 36.9 (10.2). The majority [131 (60.1%)] were health care providers (i.e. physicians, nurses, and physician assistants) while the remainder included support staff (i.e. security, pastoral care, and social workers). Half (50.9%; 95% CI: 44.3—57.6) of all ED personnel felt it was appropriate for an escorted family member to be allowed to be present during a resuscitation attempt. However, ED personnel of urban settings were less likely to support FWR (38.9% urban versus 62.7% suburban; p < 0.001). Likewise, fewer urban than suburban personnel thought that the psychological impact of witnessing a failed resuscitation attempt would be beneficial for a family member (37.6% versus 61.7%; respectively, p = 0.001). Of note, a minority, yet substantial percentage of all ED personnel believed that the practice would increase the potential for malpractice litigation (28.7% urban versus 21.8% suburban; p = 0.242).
夽
A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2005.11.013. ∗ Corresponding author at: Wayne State University, 4201 St. Antoine, UHC-6G, Detroit, MI 48201, United States. Tel.: +1 313 745 4238; fax: +1 313 993 7703. E-mail address: [email protected] (S. Compton). 0300-9572/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.11.013
Hospital setting and perceptions of family-witnessed resuscitation
75
Conclusion: Overall, there is divided support among ED personnel for FWR. The hospital setting appears to influence this support strongly, as well as the perceived benefit of FWR. © 2005 Elsevier Ireland Ltd. All rights reserved.
Introduction The International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care advocated family member presence during cardiopulmonary resuscitation. The support for this practice is based on previous studies that suggested there were benefits to the family member as a result of witnessing a loved one’s failed resuscitation attempt. These benefits are thought to include the removal of doubt that everything possible was done, a reduction of overall fear and anxiety, a higher sense of connection and bonding with the patient, and a greater feeling of closure.1—6 Additionally, one study showed that greater than three quarters of families felt their grieving process was improved by witnessing the resuscitation attempt.5 However, the same evidence that has led the AHA to recommend family-witnessed resuscitations has been insufficient for many emergency department personnel to remove their doubts about its logistical limitations, and the potential negative affect it may have on the family member. In a large study of emergency personnel from a single institution, many nurses and physicians were described as not supportive of family-witnessed resuscitations (FWR).7 Hesitations stem from concerns related to the psychological trauma to family members, the fear of distraction or performance anxiety affecting the CPR team, and an increased potential for malpractice litigation.7 In addition, staff have reported concerns that the resuscitation may continue beyond the recommended length of time when family members are present.8 These findings suggest that despite the recommendation for implementing family-witnessed resuscitations, the evidence is not enough to convince many emergency personnel of its value. These perceptions may be influenced by several factors. For example, it is possible that many emergency department personnel are not familiar with the literature regarding family-witnessed resuscitations. Additionally, it is also possible that clinical and environmental factors play a significant role in the personal perception of the logistical feasibility and value of instituting the practice—–a fact that would not be identifiable by surveys conducted at a single institution. Urban centers participate in traumatic resuscitations with younger patients more
frequently, who have no prior illness or expectation of a life-threatening event. Environmental factors may include the hospital setting (urban versus suburban) and the cross-racial identity of patient and ED personnel. This assertion would seem to be supported by a recent study of emergency medical service (EMS) personnel from urban and suburban settings.9 This study showed urban providers reported more often that they felt threatened by family members and that family interfered more often with their ability to attempt resuscitation in a pre-hospital based environment. These environmental factors may have important implications in an emergency department setting, but as of yet there has been little research in this area. Therefore, this study was conducted to compare the perceptions, experiences, and attitudes toward family-witnessed resuscitations between urban and suburban emergency department personnel.
Methods A survey of a convenience sample of urban and suburban emergency department personnel employed by four large midwestern hospitals (two urban and two suburban) was conducted to determine perceptions, experiences, and attitudes regarding familywitnessed resuscitation. The two urban hospitals were Sinai-Grace Hospital (approximate annual ED census: 55,000) and Detroit Receiving Hospital (approximate annual ED census: 80,000). Both are located in Wayne County, Michigan, and are core members of the Detroit Medical Center, which is affiliated with the Wayne State University School of Medicine. The patient populations of these urban hospitals are primarily African—American and underinsured. The two suburban hospitals were William Beaumont Hospital-Royal Oak (approximate annual ED census: 115,000) and William Beaumont Hospital-Troy (approximate annual ED census: 55,000). Both are located in Oakland County, Michigan, which is one of the wealthiest counties in the United States. The patient population is predominantly white, and the majority of patients are privately insured. The study period was May 25 through June 24, 2005. Emergency department personnel were asked to respond to 24 statements including demographic information (i.e. age, sex, race, reli-
76
C. Macy et al.
gion, and occupation), past participation in resuscitation attempts with family presence, preferences and feasibility of family-witnessed resuscitation, and their overall perception of the psychological consequences. For the majority of the survey items, participants were asked to report if they ‘‘agreed’’, ‘‘disagreed’’, or were ‘‘not sure’’ with statements regarding family-witnessed resuscitation, while five of the statements were dichotomous in nature (yes/no).
Statistical analysis Comparisons between urban and suburban providers were conducted using independent samples t-tests and 2 tests, where appropriate. Proportions and 95% confidence intervals (95% CI) are also reported. No a priori sample size or power analysis was conducted. Both the Wayne State University and William Beaumont Hospital Human Investigation Committees approved this study.
Results There were 236 ED staff surveyed, of whom 218 (92.4%) responded (108 urban, 110 suburban). Among those who responded, 63.3% were female with a mean (S.D.) age of 36.9 (10.2). The majority classified themselves as white (66.8%) and Christian (78.4%). Most (60.1%) consisted of health care providers (i.e. physicians, nurses, and physician assistants) while the remainder was support staff
Table 1
(i.e. security, pastoral care, social workers, technicians, pharmacists, and other). Approximately half (53.7%) had participated previously in a CPR attempt in a resuscitation room of a hospital while a family member of an adult patient was present.
Overall Overall, half (50.9%; 95% CI: 44.3—57.6) of all ED personnel felt it was appropriate for an escorted family member of a patient who is undergoing CPR to be allowed to be present during the resuscitation attempt. However, this support was not consistent across urban and suburban providers. As shown in Table 1, urban providers were much less likely to support this practice than suburban providers. Their concerns differed mostly in relation to distractions from doing their job, the perception that the psychological impact to the family member is mostly harmful, and inadequate space availability in the resuscitation room. Few in each location had read scientific reports on FWR—–although suburban providers were more likely to believe that the existing literature supported the practice. Interestingly, most respondents in each location indicated that they would like training on how to incorporate a family member into the ED during a resuscitation attempt (69.5%; 95% CI: 63.3—75.7), and would support research on the topic if conducted in their department (76.5%; 95% CI: 70.9—82.1). However, this support for research was stronger in the suburban settings (68.5% urban versus 84.4% suburban; p < 0.01).
Comparison of responses from urban and suburban emergency department personnel
Performed pediatric resuscitation w/family Performed adult resuscitation w/family Would request to be present during a family member’s resuscitation Appropriate for family to be present Family distracts others from their job Family distracts me from doing my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Family presence will impair ability to teach Resuscitation room space is not adequate for FWR ED has good emotional support for the bereaved Asking family to leave may be a greater distraction It would be depressing to me w/family presence Have read any scientific reports on FWR Believes literature supports FWR Supports research on FWR Would like training on FWR All p-values were generated from the 2 test statistic.
Urban, n = 108 (%)
Suburban, n = 110 (%)
p-Value
27.8 34.3 44.4 38.9 43.5 29.6 55.4 28.7 50.0 59.3 73.8 21.5 47.7 28.0 25.0 68.5 68.9
57.3 72.7 58.2 62.7 26.4 21.8 29.0 21.8 40.9 38.2 81.8 24.8 38.2 21.1 40.9 84.4 70.1
<0.01 <0.01 0.04 <0.01 <0.01 0.19 <0.01 0.24 0.18 <0.01 0.16 0.57 0.16 0.24 0.01 <0.01 0.85
Hospital setting and perceptions of family-witnessed resuscitation Table 2
77
Comparison of responses by patient-respondent racial concordance Respondents race matches that of majority of ED patients at their hospital
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation It would be depressing to me w/family presence
Yes, n = 113 (%)
No, n = 105 (%)
54.9 33.6 27.4 38.2 26.5 42.0
46.7 36.2 23.8 45.9 23.8 43.8
p-value
0.23 0.69 0.54 0.26 0.64 0.78
All p-values were generated from the 2 test statistic.
Table 3
Comparison of responses from healthcare providers and support staff Respondent is directly involved in resuscitation (nurse, physician, and physician’s assistant)
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Resuscitation room space is not adequate for FWR It would be depressing to me w/family presence
Yes, n = 137 (%)
No, n = 81 (%)
61.1 26.7 17.6 32.3 19.1 43.5 38.2
35.6 47.1 37.9 56.0 34.5 56.3 50.0
p-value
<0.01 <0.01 <0.01 <0.01 0.01 0.06 0.09
All p-values were generated from the 2 test statistic.
Cross-racial perspectives
Healthcare providers
Although the patient population of these urban and suburban hospitals is predominately black or white, respectively, there was no evidence that personnel/patient cross-racial discordance affected support of FWR (Table 2). For example, white personnel whose patients were primarily white, and white personnel whose patients were primarily non-white had similar levels of support and concern for the practice.
Respondents were classified by position within the emergency department. Nurses, physicians, and physician assistants were compared to all others. This classification system was developed to assess the concerns of those most responsible for the practice of FWR. As shown in Table 3, healthcare providers in this population were more likely than support staff to believe that it was appropriate for an escorted family member of a patient who is
Table 4
Comparison of responses from those with and without experience in family-witnessed resuscitations Have participated in either a pediatric or adult family-witnessed resuscitation
Appropriate for family to be present Family distracts others from their job Family distracts me from my job Psychological impact to family is mostly harmful Family presence will increase malpractice litigation Resuscitation room space is not adequate for FWR It would be depressing to me w/family presence All p-values were generated from the 2 test statistic.
Yes (%)
No (%)
63.3 28.9 19.5 30.6 19.5 38.3 35.9
33.3 43.3 34.4 57.5 33.3 63.3 52.8
p-value
<0.01 0.03 0.01 <0.01 0.02 <0.01 0.01
78 undergoing CPR to be allowed to be present during the resuscitation attempt. Additionally, healthcare providers were less often concerned about distractions and negative psychological outcomes associated with the practice. Paradoxically, healthcare providers were also less likely to view FWR as increasing the potential for malpractice litigation.
Experience Previous experience with FWR was strongly associated with favorable perceptions of the practice. As shown in Table 4, ED personnel who had experience with FWR more often reported it as appropriate (63.3% versus 33.3%; p < 0.01), and were less likely to perceive that the practice would distract themselves or others, increase malpractice litigation, or find the practice depressing. Additionally, those with previous experience with FWR were less likely to state that psychological impact of FWR is mostly harmful (30.6% versus 57.5%; p < 0.01).
Discussion The results of this survey indicate hospital setting bears an important role in ED staff’s perceptions and attitudes toward family-witnessed resuscitations. Health care providers from urban settings are more uncomfortable with family presence during a resuscitation attempt and the majority do not perceive there to be a benefit for family members. This finding may be related to a variety of factors. The perception of inadequate resuscitation room size in urban settings may have influenced staff’s opinion of the benefit of FWR. Personnel in urban settings were more likely to convey concern that family presence may distract other medical personnel from doing their job. Urban hospitals have a smaller staff/patient ratio than suburban hospitals and this factor may be the cause of greater urban concern for distraction. Although both settings report a good process for providing emotional support to bereaved family members, urban personnel believed there to be greater psychological harm from witnessing a failed resuscitation. Another factor may be attributed to recent literature which reports that urban emergency department personnel have described higher rates of exposure to patient violence than their suburban counterparts.10 These justifications reflect the reality of the differences that exist in the two settings, and are the most likely explanations of the differences between the urban and suburban provider, since the difference in sup-
C. Macy et al. port was not related to the patient/provider race discordance. Nonetheless, the overall picture confirms there is no clear consensus from ED personnel on this topic, and that the literature has not penetrated very deeply in this population. In fact, only about 25% of the personnel surveyed were familiar with the literature or had read an article on FWR. Moreover, concerns of FWR in past literature (i.e. malpractice suits, fear of personal distraction or performance anxiety, etc.) were shown not to be an issue in this population. In addition, a circular problem exists were there can be no causal association inferred from ‘‘experience’’ questions—–one can not imply participation in FWR will lead to a greater support for the practice because those with experience probably supported the practice in the first place. Although this study presented many important findings, it is imperative to address its limitations. First, asking medical personnel to estimate their prior experience presents an inherent bias. Moreover, the data was reported from a convenience sample that may not be reflective of the views of all medical personnel. While the hospitals were classified dichotomously as urban or suburban, each hospital has its individual differences that may have affected the comparisons. For instance, all of the hospitals surveyed are considered medical teaching hospitals through the Wayne State University School of Medicine except for Troy William Beaumont Hospital. Also, the Detroit Receiving Hospital does not usually perform pediatric resuscitations. Lastly, the term ‘‘participation’’ in FWR was not clearly defined and its meaning could have been interpreted differently among individuals.
Conclusion Hospital setting and prior experience with FWR appears to influence the support strongly as well as a perceived benefit of FWR. Although FWR may not be as feasible in an urban setting, most participants in both settings were open to training and research regarding this topic. Overall, there is divided support among ED personnel for FWR and thus a further call for evidence is needed.
Acknowledgements Support provided by a grant from the Blue Cross Blue Shield of Michigan Foundation, and the Skarejelund Family Fund for Medical Education Research.
Hospital setting and perceptions of family-witnessed resuscitation
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