Should relatives be invited to witness a resuscitation attempt? A review of the literature

BACKGROUND

Should relatives be invited to witness a resuscitation attempt? A review of the literature M. van der Woning

This review of the literature focuses upon the somewhat controversial question of whether relatives should be invited to witness the resuscitation of a family member. The pioneering study undertaken at the Foote Hospital, Michigan is explored, as is much of the anecdotal case study material available. The review focuses around three main areas: 0 Allowing the relatives into the resuscitation room. 0 Success of the encounter. 0 The effects upon the relatives who witness the event.

Melanie

van der Waning

RGN, BSc (Hons), ENB 124, PGD Research Methods, Senior Lecturer; School of Nursing & Mldwlfery, Wolverhampton University New Cross Hospital Site, Wolverhampton, West Midlands WV IO OQF: UK Manuscript I996

accepted

8 August

It is clear from this review that opinion about the presence of relatives in the resuscitation room remains inconclusive, with an apparently equal balance of both positive and negative family responses during the resuscitation attempt. However, whilst there is some evidence regarding short term effects on relatives who actually choose to witness a resuscitation attempt, there is little evidence to suggest what the long-term effects are likely to be. This is an aspect of resuscitation that certainly merits further exploration.

Accident and EmergencyNursing (I 997) 5.2 15-2 I8 0 Harcourt Brace and Company Lrd I997

This study comes at a time when, as adults, we are able to choose to watch real life rescue and resuscitation dramas on TV, along with the varied fictitious TV series, which include Accident and Emergency dramas, hospital ward-based dramas, police surgeon dramas, general practice dramas and even dramas revolving around post mortems! From the TV ratings it is clear that we have a fascination with this kind of entertainment; we are able to live for the moment that these dramas are in, and continue in our lives with little evidence to suggest prolonged emotional trauma. As most of the general public wilI have witnessed a cardiac arrest and resuscitation event on TV, if not in real life, it seems a natural progression that the majority will soon no longer accept the traditional exclusion of themselves from the resuscitation of a family member. The veil of mystery and heroism has been lifted through TV, and for the general public resuscitation is a frequent and procedural event for the medical team. It is an event from which some of this general public need not be ‘shielded’ anymore. From experience of working in an Accident & Emergency (A & E) department and a Coronary Care Unit (CCU), it becomes apparent that for many relatives their first request, upon arrival, is to be with their loved one. Whether it be a child, adult or elderly person, it becomes increasingly difficult to divert the persistent relative’s attention to a nearby ‘quiet’ sitting room. Whilst some medical teams are prepared to let the persistent relative into the resuscitation room, many are not. An informal poll of 8 doctors and 12 nurses in Texas conducted by Osuagwu (1991), revealed that the general attitude of this group was negative, emphasizing that many things could go wrong when the family is allowed to view the resuscitation event, and that the family members may hinder the process because the experience is too traumatic for them. One respondent explains that ‘family members do not understand the resuscitation procedure and it is cruel to let them in’. Osuagwu further states that ‘witnessing a resuscitation attempt is an experience that is non therapeutic, regretful, and traumatic enough to haunt the surviving family member as long as he or she lives’. These are sentiments that are used to present a very strong argument for not allowing relatives into the resuscitation area. However, Sommers (1985) has identified that in addition to the demands placed on critical care nurses to maintain the life of the arresting patient, nurses are also responsible for providing information

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and emotional support to the patient’s family, and for maintaining a supportive and emotional atmosphere during resuscitation. Perhaps one of the key ways of facilitating this is by careful planning to allow the relatives into the resuscitation room (Redheffer 1989).

ALLOWING

THE

RELATIVES

IN

It appears from the literature that the pioneering study in this area was undertaken at the Foote Hospital, Jackson, Michigan. This was a 9-year study that recorded the effects of allowing family members into the resuscitation room (Hanson & Strawser 1992). In 1982, staff in this emergency department questioned their policy of not allowing relatives into the resuscitation room, when two separate incidents occurred in which family members demanded to be present. One person, after riding in the ambulance during resuscitation, refused to leave the patient. Another begged to enter, even if only for a few minutes, to be with her husband - a police officer who had been shot. When these two situations were evaluated, positive feedback came from both families and staff. The staff then surveyed family members of recently deceased patients to determine whether they had felt a need or desire to be present. Of the 18 surveyed, 13 (72%) responded that they wished they had been present during the resuscitation. At Foote Hospital 47 family members were used in a survey to determine the effects of allowing family members into the resuscitation room. The main fears expressed by the nursing staff were that families would be disruptive or interfere with the care of the patient, and that grieving families would make it difficult or impossible for staff to control their own emotions during a death. An unspoken fear seemed to be that nurses would be observed doing or saying something that would offend grieving family members. This is a fear not exclusive to nursing staff, indeed it is this aspect of the resuscitation attempt that many doctors fear (Zoltie et al 1994). In a survey undertaken by Chalk (1995) it was apparent that more nurses than doctors were keen to allow relatives to be present. Could this be related to the fact that it is predominantly the doctors’ clinical skills that are being observed, whereas the nurse is more concerned with compassion towards relatives? At Foote Hospital, family members were rarely disruptive. They seemed awed by the activity in the room, and frequently had to be led to the bedside and encouraged to touch and speak to their loved one. Nurses described that the patient was viewed more as a part of a

loving family unit and less as a clinical chalnot one lenge. In their 9-year experience, instance of actual interference with resuscitation activities occurred. In a few reported instances family members were overcome with grief and felt faint or hysterical. Twenty-one staff members completed surveys in 1985 after participation in the initial programme. They all reported some increased stress during resuscitation, but 71% endorsed the practice. This is supported by Keating Yanks (1993) who, in her reported case study, describes the process of allowing a relative in the resuscitation room with a child, and summarizes with the poignant statement ‘no child should die among strangers, and without a parent or family member’. Hampe (1975) identifies that it is natural for the family to wonder whether everything is being done to provide the best possible care for their loved ones, but should this be facilitated through the allowing of every relative into the resuscitation room? Malone (1993) suggests that when staff refuse admission to family members who want to be near their loved one, they may believe that doctors and nurses are doing what is best for the patient and the family. We may also be living out the myth of the superhuman, the heroic and the ‘in control’. She further states that when we exclude families, as a matter of routine, Tom a dying patient’s bedside, we make death a mere clinical event and a therapeutic failure. We devalue the importance of any particular death as a profoundly unique human event that touches the lives of others, and we ignore the significance of death as a passage, as a mystery. In doing so, we protect and perpetuate our own myth of control. In a study into the needs of the grieving spouse in a hospital setting, Hampe (1975) interviewed family members and concludes that the spouse needs to be informed of their partner’s condition. She further identified their expressed need to be with the dying person, and to know that the dying person was not in pain. Indeed, the least supportive behaviour by the medical team was said to be the removal of the family members from the bedside of the dying person. Whilst this research was conducted within the specialist field of palliative care, where the subjects’ relatives had long-standing terminal illnesses and death was expected, it does suggest that similar studies should be conducted with spouses of acutely ill patients.

A SUCCESSFUL

ENCOUNTER?

Success of these schemes tends to be discussed in terms of having a trained person, in addition

Should

to those in the resuscitation team, who can discuss the procedure with relatives or close friends and offer to stay with them during resuscitation. Also, the touching and holding of the patient’s hand seems important within this success (Adams et al 1994; Hatchett 1994). Is it possible that we are attempting to fulfil the wishes of ourselves, the living, and not those of the dying? As Osuagwu (1993) proposes, ‘would the dying prefer that their loved ones remember them when they are well, rather than when we are gagging their throat and stamping on their chest?‘. Should we then call this image a ‘successful’ encounter for the observing relative? Some arguments have centred upon the ethical question of excluding relatives from such a procedure (Malone 1993), believing that exclusion may devalue the death to a clinical procedure or a failure of treatment rather than seeing death as a unique human event that touches the lives of others. Post (1989) states that sequestering the family of a dying patient in a waiting room seems as unthinkable as barring fathers from delivery rooms. He states that the time has come to encourage familial bonding during the death of a loved one, just as we encourage it at birth. It is true that in some circumstances the family are actively encouraged to be present, and indeed, to participate with providing basic nursing care for the dying relative, particularly within terminal care settings. However, in an emergency resuscitation attempt, it is not always possible for relatives to know how they will react. In what could have been a potentially well planned observation, i.e. a trained nurse close by for support, inviting the observer to touch the relative, the observer may still experience overwhelming distress at such sights as cardiac massage, and invasive procedures such as central line insertion. Indeed, Schilling (1994) recounts a case study of a distressed mother who, during resuscitation of her daughter, tried to pull the doctor performing cardiac massage off her daughter, and subsequently required three nurses to remove and comfort her, inevitably delaying defibrillation. Crisci (1994) states that in his experience in Southern Italy, it is extremely rare to obtain a minimum of self control or co-operation from the relatives of a patient to be resuscitated. The emotional distress and despair are always expressed by an aggressive attitude towards the doctors and paramedics. He recounts that ‘whilst trying to resuscitate a patient, doctors are often physically assaulted by relatives who get the feeling that “something” is going wrong’.

relatives

EFFECTS

witness

a resuscitation

UPON

THE

attempt?

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Zoltie et al (1994) state that their A & E department facilitates the exposure of relatives to the resuscitation room, and estimate that one in 20 adult resuscitations is watched by a relative, and over half of children’s resuscitations are witnessed by the parents. They state that follow-up of relatives, particularly parents, who have witnessed resuscitation attempts, shows 100% to be appreciative of the experience and report benefits in terms of grieving and coming to terms with an unsuccessful resuscitation. What is not clear from this descriptive account is whether it was at the insistence of the relatives that they were present in the resuscitation room, or by invitation from clinical staff. If the first, this may indicate some previous experience, or awareness of resuscitation and related procedures, or an individual need, so much so that the relative gains personal satisfaction and confidencefrom witnessing the event (Martin 1991). Further, this particular department claims that records are not kept of the people who witness the resuscitation attempt. Therefore, it can only be assumed that the ‘follow-up’ is of the immediate and therefore, short-term effects, and not of the longer term effects. From the case studies reviewed, it appears that there is an equal balance of predominantly anecdotal evidence as to positive and negative family responses during the resuscitation attempt, in the short term. The Foote Hospital study appears to provide the only formal evidence of this practice’s ‘success’ in the long term. After two years of allowing families into the resuscitation room, they conducted a survey to find out how families felt about the experience. Of the 47 respondents, 97% said that they would choose to be in the room again. It is not clear how many questionnaires were actually distributed, and perhaps this large percentage of families who would return to the resuscitation room reflects their positive attitude to the experience. Forty-seven respondents seems a low number from a two-year study. All participants who responded said they were confident everything possible had been done to save their loved one. Only two respondents are reported to have felt that the experience did not help them. One of them is quoted as saying ‘the scene remains an unpleasant memory’. It is not clear from this study whether any follow-up counselling was offered to the participants, and indeed, whether this had any bearing on the outcome of experiences.

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Crisci

C. 1994 Local factors may influence decision. British Medical Journal 309(6951): 406 Hampe S 1975 Needs of the grieving spouse in the

CONCLUSION The literature regarding relatives’ presence in the resuscitation room remains inconclusive. With such apparent inconsistencies should we really be inviting relatives to watch this potentially traumatic event? It has been recognized that whilst there is some anecdotal evidence that focuses upon the short term effects on relatives who actually choose to witness a resuscitation attempt, there is little research evidence as to suggest what the longer term effects are likely to be (Mehanna 1994). This is an issue that certainly merits further exploration. Indeed, whether relatives should or could be present in the resuscitation room must be addressed only in the light of evidence relating to the possible long-term effects upon them. The multi-disciplinary team must come together to discuss the issues that are currently surrounding both them and the community within which they serve.

hospital setting. Nurse Researcher 24(2): 113-9 Hanson C, Strawser D 1992 Family presence during CPR: Foote Hospital emergency department’s nine-year perspective. Journal of Emergency Nursing 18(2): 104-106 Hatchett R 1994 Should relatives watch resuscitation? A successful

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programme.

Journal 309(6951): 407 Keating Yanks K 1993 More resuscitation.

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477-478 Malone R 1993 The

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