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Knowledge, skills and counselling behaviour of Belgian general practitioners on CPR-related issues
Resuscitation, 24 (1992) 49-54 Elsevier Scientific Publishers Ireland Ltd.
49
Knowledge, skills and counselling behaviour of Belgian general practitioners on CPR-related issues Leo L. Bossaerta, Theo Putzeysb, Koenraad G. Monsieursa and Raf J. Van Hoeyweghena @Departmentof Intensive Care, University Hospital Antwerp, UIA and bHuisartsen Regio Mortsel and Wetenschappelijke Vereniging voor Vlaamse Huisartsen (Belgium) (Received April 3rd, 1992; revision received May 12th, 1992; accepted May 19th, 1992)
General practitioners (GP) can identify potential cardiac arrest victims. They have the opportunity to inform cardiac patients and their families about the risk of sudden cardiac death and can motivate family members to attend a CPR-course. To study actual counselhng practices concerning basic CPR-training a questionnaire was mailed to a representative sample of Belgian GPs (n = 1119). The level of CPRtraining of the GPs was fairly good: 67% had received BLS training on a manikin and 63% had already attended a cardiac arrest event. A discrepancy was observed between the positive attitude towards CPR and the counselling of family members to attend a CPR-course (9%). GPs feared to inflict additional stress to the patient (32%) or the family (43%) or did not know where CPR courses were organised (37%). GPs are a primary target group for CPR-training and should learn how to counsel potential bystanders of a cardiac arrest to attend a CPR-course without inflicting additional anxiety on the patient or his family. Key words: cardio-pulmonary
resuscitation; CPR-training; general practitioner; cardiac arrest
INTRODUCTION
Cardio-Pulmonary Resuscitation (CPR), initiated by a bystander and subsequently followed by early defibrillation and Advanced Life Support, can improve survival of out-of-hospital cardiac arrest’. Many efforts have been done to teach knowledge and skills of resuscitation to the public and specific target groups of the society, such as tire fighters, policemen and general practitioners*. Based on epidemiological data of cardiac arrest victims, family members of patients suffering a cardiac disease and elderly people living at home can be identified as primary lay target groups for CPR-teaching3. These target groups have a higher risk than the average citizen to be confronted with a victim of sudden death, but are at present poorly represented in large scale citizen-CPR courses4. General practitioners (GPs) can identify the potential cardiac arrest victim. They have the opportunity to inform the patient and his family about sudden death and to motivate family members to attend a citizen-CPR course. Limited literature data Correspondence to: Leo L. Bossaert, Universiteitsplein
1, B-2610 Antwerpen, Belgium.
0300-9572/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
50
are available on the role of GPs in the primary and secondary prevention of cardiac arrest5-lo. In this study, knowledge of CPR and attitude and behavior concerning CPR education of the Belgian GPs have been studied in order to find out whether and how their health promotion practice can be improved. METHODS
As the method of data collection a mailed questionnaire was used. The participating GPs were asked to answer anonymously a number of questions related to their knowledge of CPR and their attitude in emergency care issues. The content of the questionnaire was inspired by previous literature data6-9. Questions were either dichotomous or semi-quantitative. In the semi-quantitative questions a graded answer using a score ranging between 0 and 5 was used (0, never = 0%; 1, seldom = l-24%; 2, sometimes = 25-49%; 3, frequently = 50-74%; 4, usually = 75-99%; 5, always = 100%). The questionnaire was tested in a well-organised group of 98 GPs working in a well-defined area: ‘Huisartsen Regio Mortsel (HRM)‘. GPs with a practice time of less than 2 years were excluded. This group was selected because of their involvement in several research projects on emergency care issues”. In this test group, the response rate was 84%. The questionnaire was then mailed to a randomly selected group of 27% (n = 3950) of all Belgian GPs. All GPs with a practice time of less than 2 years were excluded because of the possibility of bias originating from different highlights during their graduate training period. GPs from the test group HRM were also excluded from the mailing list. Response rate after a single mailing was 26% (1021/3950). In this study, both samples, the test population HRM and the respondents of the random mailing, were analysed together since there was no difference between the two samples and between each sample and the total population of Belgian GPs in regional distribution, age and sex of respondents, nor in the answers. RESULTS
The respondents answered positively in 85% of cases on the question whether they knew basic CPR (Table I). The majority (67%) had learned CPR on a manikin and
Table I.
Previous CPR training of general practitioners.
Knowledge of BLS Manikin BLS training Graduate BLS training Postgraduate BLS training Endotracheal intubation Defibrillation
Yes
No
VW
(“/I
No answer (“/s)
Total (n)
85 61 56 45 22 16
15 25 39 46 18 81
0 8 5 9 0.1 3
1095 933 933 933 1011 1011
51
Table II.
Previous CPR field experience of general practitioners and estimated usefulness of basic CPR.
Attended a cardiac arrest Performed CPR Usefulness of basic CPR by a doctor Usefulness of CPR by a lay person
Yes
No
(“N
(%)
No Answer (%)
Total (n)
63 54 94 80
37 45 5 18
0.2 0.9 1 2
1101 1101 1101 1101
56% had taken the CPR-course at medical school, 45% during a postgraduate training. Endotracheal intubation and defibrillation was learned by, 22% and 16%, respectively, of the responding GPs. The participating GPs were asked to report on their personal attending of a cardiac arrest event during the past five years (period 1985-1989) (Table II). The majority (63%) had attended at least one cardiac arrest and more than half of the respondents (54%) had performed CPR during the same period. The usefulness of CPR, as well if performed by a doctor as if performed by a lay person, was well recognized by the respondents (94% and 80%, respectively). The respondents were asked to describe their practice of counselling cardiac patients and their families using a graded scale between 0 and 5 (Table III). Counselling on ‘prudent heart behaviour’ issues (risk factors for atherosclerosis) was done in most cases, more in patients (always and usually by 84% of responding GPs) than in family members (always and usually by 53%). Respondents counselled on warning signals preceding an acute myocardial infarction always or usually in 57% when it concerned patients and in 46% in case of family members. How to get access into the Emergency Medical Service (EMS) system was counselled rather infrequently
Table III. Counselling cardiac patients and their family members on primary and secondary prevention of cardiac arrest. Questions were semi-quantitative with graded answers using a score ranging between 0 and 5 (0, never = 0%; 1, seldom = l-24%; 2, sometimes = 25-49%; 3, frequently = 50-740/o; 4, usually = 75-99%; 5, always = 100%). Percent in each category shown. 5 100 %
4 75-99 %
3 50-74 %
2 25-49 %
1 1-24 %
0 0 %
Total (n)
52 31 14
32 26 15
12 20 16
3 13 18
1 6 24
0.3 5 13
1087 1077 1070
29 28 18 3
22 22 17 6
15 20 19 13
7 9 22 37
3 4 12 41
1086 1081 1067 1070
Cowwelling cardiac patients
Risk factors of atherosclerosis Warning symptoms of heart attack How to get access in the EMS system
Cowlselling family members of cardiac patients
Risk factors of atherosclerosis Warning symptoms of heart attack How to get access in the EMS system To attend a CPR course
24 18 13 1
52 Table IV. Motives of the general practitioner (test group HRM and total study population) for not counselling the family members of patients with coronary heart disease to attend a CPR course, in percent. More than one motive is possible.
Never thought abouta Don’t know how to organize Increases stress to family Increases stress to patient They would not understand Had no time to discuss this
HRM (n = 73) %
Total (HRM excluded) (?I= 908) %
44 49 31 18 1
38 37 43 32 23 10
aThis choice was not included in the questionnaire used in the test group HRM.
(sometimes, seldom or never: patients 55% and family members 53%). It was striking to find that family members were only very occasionally encouraged to attend a CPR-course (sometimes, seldom or never in 91% of participating GPs). General practitioners who usually failed (n = 73 of the test group HRM and n = 908 of the random study population) to advise the family members of cardiac patients to attend a CPR-course were asked about their motives for this behavior (Table IV). In 38% of these GPs the idea to advise a CPR-course did not occur (38%) or they would not know how to organise a CPR-course (37%). The concern to inflict additional stress to the family member (43%) or to the patient (32%) seemed to be an important motive not to advise a CPR-course. A minority of these physicians claimed that his patient and/or the family would not understand the relevance of the CPR-course and 10% answered not to have time to discuss the subject. DISCUSSION
Several studies indicate that the majority of unexpected cardiac arrests that are treated by the EMS-system occurs at home and is witnessed3. In addition, patients with known coronary artery disease are at high risk for sudden cardiac death, particularly patients with a recent myocardial infarction. Therefore, family members of these patients have been identified as a high priority target group for CPR training ‘. In Belgium, as in the UK, many patients call their GP first in case of a medical emergency’1-‘3. Therefore, family physicians will frequently be confronted with patients presenting with respiratory and/or circulatory arrest. In many cases the attending GP is also the first to provide emergency medical care. GPs are recognized as an important target group for teaching and refreshing CPR skills5y6. Specific programs for teaching CPR to non-critical care physicians have been designed by the American Heart Association and by others2. The GP has also a crucial role in promoting CPR, since he is in the best position to stimulate the family members of the patients with a cardiac disease to attend a CPR course5’10. In a survey by St. Louis
53
et al. in Seattle, only 40% of physicians recommended CPR training to the spouses of their patients with known coronary disease7. Mandel et al. performed a survey in all cardiologists and a 25% sample of the internists, GPs and family physicians of the area. The majority of respondents (91% of cardiologists and 75% of the other physicians) discussed warning symptoms with their cardiac patients and families and how to get access to the Emergency Medical System. In this study area of Seattle, 37% of GPs and 52% of cardiologists recommended CPR training to more than 50% of the families of their high-risk patients. In a study by Goldberg et al., respondents had a positive attitude regarding CPR practice and CPR training. Most participating physicians counselled their patients on risk factor modification (950/o),warning symptoms preceding myocardial infarction (85%) and access to the EMS system. Despite this, only 6% of the physicians regularly recommended CPR training for family members of their patients with coronary heart disease’. In this survey, attitude and behavior of Belgian GPs was described in a representative sample. It could be argued that the response rate of 25% is too low to allow conclusions. The major problem of mailed questionnaires being the usually low proportion of respondents, we improved the power of the survey by studying not only a random sample of Belgian GPs, but also the complete cohort of the GPs of a well defined region, where an almost complete response rate was obtained after exclusion of GPs with short practice time. No statistically significant differences were observed regarding to the socio-demographic profile and the answers between both study populations. The results revealed the same discrepancy, which was noticed before by Goldberg et al. between the positive attitude towards CPR and the observed action in counselling family members to attend a CPR course 9. The main reason for not doing this was the fear of inflicting excessive stress to the family in about l/3 of respondents, or to the patient himself in another l/3. In l/3 the reason was that the GP did not know the practical modalities how to have a CPR course organised. Family members of patients with known ischaemic heart disease are considered as a primary target group for CPR-education, but they are usually under-represented in CPR-courses4. Therefore, it is important to find out whether the reasons why GPs do not counsel family members of cardiac patients to learn CPR are justifiable or not. In a study on the psychological impact of learning CPR on family members of cardiac patients Dracup et al. concluded that this might have an adverse psychological effect on the patients and his family I4. Additional anxiety could be caused by the abrupt confrontation with the reality of being at risk for a cardiac arrest, by the new idea of being dependent on somebody else, or by the sense of responsibility for the life of another. This interpretation could be used by those family physicians who do not encourage family members to learn CPR. Dracup et al. observed also in a specifically designed CPR training course that family members who were anxious and/or depressed before the course were more likely to fail initially and needed some additional support and training to increase their self-contidence’5,‘6. It was concluded that virtually all family members of cardiac patients (anxious or not) can learn CPR successfully if a specifically designed training strategy is available.
54
We agree with the statement of Wechsler et al. that the GP has a major role in the CPR teaching process, since he is not only frequently the first responder who can perform a life-saving intervention but he is also the best contact person for the family members of patients with coronary heart disease, which is the group of people that has the highest risk of attending a sudden cardiac arrest”. Unfortunately, we were able to demonstrate before that this primary target group of housewives is largely under-represented in the CPR course attendants4. Therefore, GPs should not only learn how to perform CPR correctly, but they should also learn how to counsel the family members of cardiac patients to attend a CPR course without inflicting additional anxiety to the patient nor his family. In this study we also observed the need for practical information to the GPs on how to have a CPR course organized. REFERENCES 1 Cummins R, Ornato J, Thies W, Pepe P. Improving survival from sudden cardiac arrest: the “chain of survival” concept. Circulation 1991; 83: 1882-1847. 2 American Heart Association. Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. J Am Med Assoc 1986; 255: 2841-3044. 3 Mullie A, Lewi P, Van Hoeyweghen R, Cerebral Resuscitation Study Group. Pre-CPR conditions and the final outcome of CPR. Resuscitation 1989; 17 Suppl: Sll-S21. 4 Bossaert LL, Teaching CPR for citizens: lessons from a Belgian Experience. In: Vincent J, editor. Update 1990. Heidelberg: Springer 1990. 5 Pai G, Haites N, Rawles J, One thousand heart attacks in Grampain. The place of CPR in general practice. B Med J 1987; 294: 352-354. 6 Berden H, Willems F, Ten Have F, Van Egmond J, Driessen J, Pijls N, De primaire reanimatievaardigheden van de huisarts. Ned Tijdschr Geneesk 1988; 132: 1797-1801. 7 St. Louis P, Carter W, Eisenberg M. Prescribing CPR: a survey of physicians. Am J Pub1 Health 1982; 72: 1158-1160. 8 Mandel L, Cobb L, Weaver D. CPR training for patients’ families: do physicians recommend it? Am J Pub1 Health 1987; 77: 727-728. 9 Goldberg R, Decosimo D, St. Louis P, Gore J, Ockene J, Dalin J. Physicians’ attitudes and practices towards CPR training in family members of patients with coronary heart disease. Am J Pub1 Health 1987; 75: 281-283. 10 Wechsler H, Levine S, Idelson R, Rohman M, Taylor J. The physicians role in health promotion. N Engl J Med 1983; 308: 97-100. 11 Bossaert L, Demey H, Colemont L, Fierens HRM. Prehospital thrombolytic treatment of acute myocardial infarction. Crit Care Med 1988; 16: 823-830. 12 Rawlins D. Study of the management of suspected cardiac infarction by British immediate care.doctors. Br Med J 1981; 282: 1677-1679. 13 Colquhoun M. Use of defibrillators by general practitioners. Br Med J 1988; 297: 336. 14 Dracup K, Guzy P, Taylor S. Barry J. CPR-training: consequences of family members of high risk cardiac patients. Arch Intern Med 1986; 146: 1757-1761. 15 Dracup K, Breu C. Teaching and retention of CPR skills for families of high risk patients with cardiac disease. Focus Crit Care 1987 14: 67-72. 16 Dracup K, Heaney D, Taylor S, Guzy P, Breu C, Can family members of high risk cardiac patients learn CPR? Arch Intern Med 1989; 149: 61-64.
49
Knowledge, skills and counselling behaviour of Belgian general practitioners on CPR-related issues Leo L. Bossaerta, Theo Putzeysb, Koenraad G. Monsieursa and Raf J. Van Hoeyweghena @Departmentof Intensive Care, University Hospital Antwerp, UIA and bHuisartsen Regio Mortsel and Wetenschappelijke Vereniging voor Vlaamse Huisartsen (Belgium) (Received April 3rd, 1992; revision received May 12th, 1992; accepted May 19th, 1992)
General practitioners (GP) can identify potential cardiac arrest victims. They have the opportunity to inform cardiac patients and their families about the risk of sudden cardiac death and can motivate family members to attend a CPR-course. To study actual counselhng practices concerning basic CPR-training a questionnaire was mailed to a representative sample of Belgian GPs (n = 1119). The level of CPRtraining of the GPs was fairly good: 67% had received BLS training on a manikin and 63% had already attended a cardiac arrest event. A discrepancy was observed between the positive attitude towards CPR and the counselling of family members to attend a CPR-course (9%). GPs feared to inflict additional stress to the patient (32%) or the family (43%) or did not know where CPR courses were organised (37%). GPs are a primary target group for CPR-training and should learn how to counsel potential bystanders of a cardiac arrest to attend a CPR-course without inflicting additional anxiety on the patient or his family. Key words: cardio-pulmonary
resuscitation; CPR-training; general practitioner; cardiac arrest
INTRODUCTION
Cardio-Pulmonary Resuscitation (CPR), initiated by a bystander and subsequently followed by early defibrillation and Advanced Life Support, can improve survival of out-of-hospital cardiac arrest’. Many efforts have been done to teach knowledge and skills of resuscitation to the public and specific target groups of the society, such as tire fighters, policemen and general practitioners*. Based on epidemiological data of cardiac arrest victims, family members of patients suffering a cardiac disease and elderly people living at home can be identified as primary lay target groups for CPR-teaching3. These target groups have a higher risk than the average citizen to be confronted with a victim of sudden death, but are at present poorly represented in large scale citizen-CPR courses4. General practitioners (GPs) can identify the potential cardiac arrest victim. They have the opportunity to inform the patient and his family about sudden death and to motivate family members to attend a citizen-CPR course. Limited literature data Correspondence to: Leo L. Bossaert, Universiteitsplein
1, B-2610 Antwerpen, Belgium.
0300-9572/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
50
are available on the role of GPs in the primary and secondary prevention of cardiac arrest5-lo. In this study, knowledge of CPR and attitude and behavior concerning CPR education of the Belgian GPs have been studied in order to find out whether and how their health promotion practice can be improved. METHODS
As the method of data collection a mailed questionnaire was used. The participating GPs were asked to answer anonymously a number of questions related to their knowledge of CPR and their attitude in emergency care issues. The content of the questionnaire was inspired by previous literature data6-9. Questions were either dichotomous or semi-quantitative. In the semi-quantitative questions a graded answer using a score ranging between 0 and 5 was used (0, never = 0%; 1, seldom = l-24%; 2, sometimes = 25-49%; 3, frequently = 50-74%; 4, usually = 75-99%; 5, always = 100%). The questionnaire was tested in a well-organised group of 98 GPs working in a well-defined area: ‘Huisartsen Regio Mortsel (HRM)‘. GPs with a practice time of less than 2 years were excluded. This group was selected because of their involvement in several research projects on emergency care issues”. In this test group, the response rate was 84%. The questionnaire was then mailed to a randomly selected group of 27% (n = 3950) of all Belgian GPs. All GPs with a practice time of less than 2 years were excluded because of the possibility of bias originating from different highlights during their graduate training period. GPs from the test group HRM were also excluded from the mailing list. Response rate after a single mailing was 26% (1021/3950). In this study, both samples, the test population HRM and the respondents of the random mailing, were analysed together since there was no difference between the two samples and between each sample and the total population of Belgian GPs in regional distribution, age and sex of respondents, nor in the answers. RESULTS
The respondents answered positively in 85% of cases on the question whether they knew basic CPR (Table I). The majority (67%) had learned CPR on a manikin and
Table I.
Previous CPR training of general practitioners.
Knowledge of BLS Manikin BLS training Graduate BLS training Postgraduate BLS training Endotracheal intubation Defibrillation
Yes
No
VW
(“/I
No answer (“/s)
Total (n)
85 61 56 45 22 16
15 25 39 46 18 81
0 8 5 9 0.1 3
1095 933 933 933 1011 1011
51
Table II.
Previous CPR field experience of general practitioners and estimated usefulness of basic CPR.
Attended a cardiac arrest Performed CPR Usefulness of basic CPR by a doctor Usefulness of CPR by a lay person
Yes
No
(“N
(%)
No Answer (%)
Total (n)
63 54 94 80
37 45 5 18
0.2 0.9 1 2
1101 1101 1101 1101
56% had taken the CPR-course at medical school, 45% during a postgraduate training. Endotracheal intubation and defibrillation was learned by, 22% and 16%, respectively, of the responding GPs. The participating GPs were asked to report on their personal attending of a cardiac arrest event during the past five years (period 1985-1989) (Table II). The majority (63%) had attended at least one cardiac arrest and more than half of the respondents (54%) had performed CPR during the same period. The usefulness of CPR, as well if performed by a doctor as if performed by a lay person, was well recognized by the respondents (94% and 80%, respectively). The respondents were asked to describe their practice of counselling cardiac patients and their families using a graded scale between 0 and 5 (Table III). Counselling on ‘prudent heart behaviour’ issues (risk factors for atherosclerosis) was done in most cases, more in patients (always and usually by 84% of responding GPs) than in family members (always and usually by 53%). Respondents counselled on warning signals preceding an acute myocardial infarction always or usually in 57% when it concerned patients and in 46% in case of family members. How to get access into the Emergency Medical Service (EMS) system was counselled rather infrequently
Table III. Counselling cardiac patients and their family members on primary and secondary prevention of cardiac arrest. Questions were semi-quantitative with graded answers using a score ranging between 0 and 5 (0, never = 0%; 1, seldom = l-24%; 2, sometimes = 25-49%; 3, frequently = 50-740/o; 4, usually = 75-99%; 5, always = 100%). Percent in each category shown. 5 100 %
4 75-99 %
3 50-74 %
2 25-49 %
1 1-24 %
0 0 %
Total (n)
52 31 14
32 26 15
12 20 16
3 13 18
1 6 24
0.3 5 13
1087 1077 1070
29 28 18 3
22 22 17 6
15 20 19 13
7 9 22 37
3 4 12 41
1086 1081 1067 1070
Cowwelling cardiac patients
Risk factors of atherosclerosis Warning symptoms of heart attack How to get access in the EMS system
Cowlselling family members of cardiac patients
Risk factors of atherosclerosis Warning symptoms of heart attack How to get access in the EMS system To attend a CPR course
24 18 13 1
52 Table IV. Motives of the general practitioner (test group HRM and total study population) for not counselling the family members of patients with coronary heart disease to attend a CPR course, in percent. More than one motive is possible.
Never thought abouta Don’t know how to organize Increases stress to family Increases stress to patient They would not understand Had no time to discuss this
HRM (n = 73) %
Total (HRM excluded) (?I= 908) %
44 49 31 18 1
38 37 43 32 23 10
aThis choice was not included in the questionnaire used in the test group HRM.
(sometimes, seldom or never: patients 55% and family members 53%). It was striking to find that family members were only very occasionally encouraged to attend a CPR-course (sometimes, seldom or never in 91% of participating GPs). General practitioners who usually failed (n = 73 of the test group HRM and n = 908 of the random study population) to advise the family members of cardiac patients to attend a CPR-course were asked about their motives for this behavior (Table IV). In 38% of these GPs the idea to advise a CPR-course did not occur (38%) or they would not know how to organise a CPR-course (37%). The concern to inflict additional stress to the family member (43%) or to the patient (32%) seemed to be an important motive not to advise a CPR-course. A minority of these physicians claimed that his patient and/or the family would not understand the relevance of the CPR-course and 10% answered not to have time to discuss the subject. DISCUSSION
Several studies indicate that the majority of unexpected cardiac arrests that are treated by the EMS-system occurs at home and is witnessed3. In addition, patients with known coronary artery disease are at high risk for sudden cardiac death, particularly patients with a recent myocardial infarction. Therefore, family members of these patients have been identified as a high priority target group for CPR training ‘. In Belgium, as in the UK, many patients call their GP first in case of a medical emergency’1-‘3. Therefore, family physicians will frequently be confronted with patients presenting with respiratory and/or circulatory arrest. In many cases the attending GP is also the first to provide emergency medical care. GPs are recognized as an important target group for teaching and refreshing CPR skills5y6. Specific programs for teaching CPR to non-critical care physicians have been designed by the American Heart Association and by others2. The GP has also a crucial role in promoting CPR, since he is in the best position to stimulate the family members of the patients with a cardiac disease to attend a CPR course5’10. In a survey by St. Louis
53
et al. in Seattle, only 40% of physicians recommended CPR training to the spouses of their patients with known coronary disease7. Mandel et al. performed a survey in all cardiologists and a 25% sample of the internists, GPs and family physicians of the area. The majority of respondents (91% of cardiologists and 75% of the other physicians) discussed warning symptoms with their cardiac patients and families and how to get access to the Emergency Medical System. In this study area of Seattle, 37% of GPs and 52% of cardiologists recommended CPR training to more than 50% of the families of their high-risk patients. In a study by Goldberg et al., respondents had a positive attitude regarding CPR practice and CPR training. Most participating physicians counselled their patients on risk factor modification (950/o),warning symptoms preceding myocardial infarction (85%) and access to the EMS system. Despite this, only 6% of the physicians regularly recommended CPR training for family members of their patients with coronary heart disease’. In this survey, attitude and behavior of Belgian GPs was described in a representative sample. It could be argued that the response rate of 25% is too low to allow conclusions. The major problem of mailed questionnaires being the usually low proportion of respondents, we improved the power of the survey by studying not only a random sample of Belgian GPs, but also the complete cohort of the GPs of a well defined region, where an almost complete response rate was obtained after exclusion of GPs with short practice time. No statistically significant differences were observed regarding to the socio-demographic profile and the answers between both study populations. The results revealed the same discrepancy, which was noticed before by Goldberg et al. between the positive attitude towards CPR and the observed action in counselling family members to attend a CPR course 9. The main reason for not doing this was the fear of inflicting excessive stress to the family in about l/3 of respondents, or to the patient himself in another l/3. In l/3 the reason was that the GP did not know the practical modalities how to have a CPR course organised. Family members of patients with known ischaemic heart disease are considered as a primary target group for CPR-education, but they are usually under-represented in CPR-courses4. Therefore, it is important to find out whether the reasons why GPs do not counsel family members of cardiac patients to learn CPR are justifiable or not. In a study on the psychological impact of learning CPR on family members of cardiac patients Dracup et al. concluded that this might have an adverse psychological effect on the patients and his family I4. Additional anxiety could be caused by the abrupt confrontation with the reality of being at risk for a cardiac arrest, by the new idea of being dependent on somebody else, or by the sense of responsibility for the life of another. This interpretation could be used by those family physicians who do not encourage family members to learn CPR. Dracup et al. observed also in a specifically designed CPR training course that family members who were anxious and/or depressed before the course were more likely to fail initially and needed some additional support and training to increase their self-contidence’5,‘6. It was concluded that virtually all family members of cardiac patients (anxious or not) can learn CPR successfully if a specifically designed training strategy is available.
54
We agree with the statement of Wechsler et al. that the GP has a major role in the CPR teaching process, since he is not only frequently the first responder who can perform a life-saving intervention but he is also the best contact person for the family members of patients with coronary heart disease, which is the group of people that has the highest risk of attending a sudden cardiac arrest”. Unfortunately, we were able to demonstrate before that this primary target group of housewives is largely under-represented in the CPR course attendants4. Therefore, GPs should not only learn how to perform CPR correctly, but they should also learn how to counsel the family members of cardiac patients to attend a CPR course without inflicting additional anxiety to the patient nor his family. In this study we also observed the need for practical information to the GPs on how to have a CPR course organized. REFERENCES 1 Cummins R, Ornato J, Thies W, Pepe P. Improving survival from sudden cardiac arrest: the “chain of survival” concept. Circulation 1991; 83: 1882-1847. 2 American Heart Association. Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. J Am Med Assoc 1986; 255: 2841-3044. 3 Mullie A, Lewi P, Van Hoeyweghen R, Cerebral Resuscitation Study Group. Pre-CPR conditions and the final outcome of CPR. Resuscitation 1989; 17 Suppl: Sll-S21. 4 Bossaert LL, Teaching CPR for citizens: lessons from a Belgian Experience. In: Vincent J, editor. Update 1990. Heidelberg: Springer 1990. 5 Pai G, Haites N, Rawles J, One thousand heart attacks in Grampain. The place of CPR in general practice. B Med J 1987; 294: 352-354. 6 Berden H, Willems F, Ten Have F, Van Egmond J, Driessen J, Pijls N, De primaire reanimatievaardigheden van de huisarts. Ned Tijdschr Geneesk 1988; 132: 1797-1801. 7 St. Louis P, Carter W, Eisenberg M. Prescribing CPR: a survey of physicians. Am J Pub1 Health 1982; 72: 1158-1160. 8 Mandel L, Cobb L, Weaver D. CPR training for patients’ families: do physicians recommend it? Am J Pub1 Health 1987; 77: 727-728. 9 Goldberg R, Decosimo D, St. Louis P, Gore J, Ockene J, Dalin J. Physicians’ attitudes and practices towards CPR training in family members of patients with coronary heart disease. Am J Pub1 Health 1987; 75: 281-283. 10 Wechsler H, Levine S, Idelson R, Rohman M, Taylor J. The physicians role in health promotion. N Engl J Med 1983; 308: 97-100. 11 Bossaert L, Demey H, Colemont L, Fierens HRM. Prehospital thrombolytic treatment of acute myocardial infarction. Crit Care Med 1988; 16: 823-830. 12 Rawlins D. Study of the management of suspected cardiac infarction by British immediate care.doctors. Br Med J 1981; 282: 1677-1679. 13 Colquhoun M. Use of defibrillators by general practitioners. Br Med J 1988; 297: 336. 14 Dracup K, Guzy P, Taylor S. Barry J. CPR-training: consequences of family members of high risk cardiac patients. Arch Intern Med 1986; 146: 1757-1761. 15 Dracup K, Breu C. Teaching and retention of CPR skills for families of high risk patients with cardiac disease. Focus Crit Care 1987 14: 67-72. 16 Dracup K, Heaney D, Taylor S, Guzy P, Breu C, Can family members of high risk cardiac patients learn CPR? Arch Intern Med 1989; 149: 61-64.