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Witnessed resuscitation: can relatives be present? Elaine Cole Abstract:This article, whilst not aiming to provide a solution for the complex issue of witnessed resuscitation, presents some of the arguments for and against the practice, in order to provoke thought and discussion. 10 references, 11 items in bibliography. Contents. Back to Nursing Progress contents. A man was knocked off his bicycle by an HGV, sustaining a traumatic amputation of his leg and a severely fractured pelvis. His wife arrived in the A&E department shortly after the resuscitation of her husband had commenced. She asked to go in and see her husband. The team resuscitating her husband did not think that this was appropriate and she was told to wait until he was "more stable". He never was - he died in theatre. She finally got to see her husband an hour and a half later in the mortuary viewing room. Another man suffered an impalement injury after being ejected from his car (not wearing a seat belt). He arrived in A&E, was resuscitated and taken to theatre and then ITU (after which he made a full recovery!). His father arrived in A&E with the patient and insisted that he stay with his son in the department. He stayed near his son during the resuscitation until the patient was taken to theatre. These are just two of many examples of relatives' requests to be with their loved ones during trauma resuscitation. In A&E we also receive requests from relatives (of adult and paediatric patients) to be present for part of or all of a cardiac or respiratory arrest resuscitation. The emotive subject of witnessed resuscitation by relatives provokes many arguments for and against the practice of allowing relatives to be present during resuscitation attempts. There are other areas within the Trust that do allow this practice - ITU and paediatric departments, for example. However, it may not be an applicable practice in all wards and departments due to lack of staff and supportive resources. The Trust is currently trying to agree practice guidelines that enable witnessed resuscitation rather than go against relatives' wishes. These guidelines have provoked much discussion and disagreement within the Trust from members of the multidisciplinary teams involved in resuscitation. This article, whilst not aiming to provide a solution for the complex issue of witnessed resuscitation, presents some of the arguments for and against the practice, in order to provoke thought and discussion for staff in individual clinical areas. Sensory disturbance Resuscitations can be visually disturbing, even to the most experienced of clinical staff. At an olfactory level there may be odours from patient secretions, blood, even defibrillation. Patients who are under-sedated or in pain may cry out or make noise which would cause auditory disturbance for the relatives and the team. Confidentiality If the patient is unconscious, it is not possible to gain their consent to their relatives being present during resuscitation attempts. Consequently, patient confidentiality may be broken if the patient's wishes are not known. When considering relatives' presence, Fullbrook suggests that, "Not only would relatives see everything happening to the patient, they may hear information of an intensely personal nature". (1) At a professional level, the UKCC states,"No-one, not even a loved one or relative is entitled to information which the patient does not want them to have".(2) Complaints An American study stated that staff feared that by allowing relatives to observe resuscitations, an observed action or remark may offend relatives leading to a complaint.(3) There was also a fear that allowing observation of procedures (for example intubation, cannulation) would increase the risk of litigation against the doctor or hospital. Staff response Nursing, medical and allied staff use a variety of methods to deal with the stress of resuscitation. In my experience, some bleak situations may be peppered with a small degree of humour, which can help to keep the team functioning under stress. The presence of relative may inhibit this coping mechanism, thereby affecting team performance. Schilling, a cardiologist, notes that (during a resuscitation) he, "appears to be detached about what is going on around me, even making occasional light hearted comments".(4) Conversely, by having relatives present, staff may become upset by identifying with the family. "I was afraid that I might cry or do something dumb if I found myself relating too closely to the family".(3) Relatives' emotional response This has been cited as a main argument against witnessed resuscitation. Two groups of staff were interviewed about the practice and this was their main concern. "Panic by relatives disrupts medical efforts". (5) "Fear of uncontrollable relative grief would disrupt the team".(3) Clinical performance When a relative is witnessing resuscitation there is a pressure on the team td perform well. This may be affected by the relative's presence inhibiting discussion. "We felt unable to voice our opinion about the deterioration of the patient's condition" (5) Decision making may be delayed, "The resuscitation was kept going for longer than usual". (5) "It would be difficult to stop the resuscitation if relatives were present, and disagreed with the decision". (6) Respecting the relative's wishes Probably the most powerful argument for the practice of witnessed resuscitation is that of respecting what the relative (and probably the patient) wants. We do not resuscitate patients for altruistic reasons, we want to save their lives and return them to their family and friends. The quote below is from a woman (whilst being supported by a doctor) who witnessed her brother's resuscitation. "It seems that most professionals would prefer relatives not to be present but I would not have been anywhere else at that time". Sadly, she goes on to add, "I would've liked to have held his hand, but didn't dare ask". (7) Allowing a relative to be present during resuscitation may help to dispel their anxieties. It also allows them to touch and talk to the patient. "Relatives can see that everything possible is being done for their loved one". (8) Media influences The media seem to be obsessed by nursing, medicine and hospitals. There are many documentaries, soaps and docu-dramas featuring medical emergencies. The general public have access to the "workings" of a hospital like never before. It would be naive to think that a relative who has watched defibrillation on "ER" would be fully prepared and understand the reality of the procedure in practice. However, they may not be as unprepared as one would imagine. Interestingly, a study looking at outcomes from resuscitations on both American and British medical dramas showed that British television showed more realistic outcomes, grounding the public in reality.(9) Empirical evidence (USA) In 1992 the Foote Hospital in Michigan, USA started a programme to allow relatives to witness resuscitations in their emergency department.(3) This was in response to the demands of two sets of relatives who had insisted on being present. Many staff were opposed to the practice but agreed to participate with the programme, as there was a recognised local need for some guidelines. The nine-year study allowed relatives to witness cardiac resuscitations, supported by a trained nurse or a pastoral care person. The results from the study after nine years show:
Since the results were published:
The staff regard patients as part of a community - not merely a clinical challenge. Empirical evidence (UK) From a British perspective, Robinson et al examined whether relatives wished to be present during resuscitation and if they did whether they experienced any adverse psychological effects.(10) This was a small study of 25 patients from Addenbrooks Hospital. Half of the relatives were given a choice of being present (all did), and the other half (the control group) were taken to a quiet room. In the Resuscitation room one relative per patient was supported by one of three members of staff. These relatives witnessed many invasive procedures including CVP line insertion, cannulation, chest thoracentesis, pericardiocentesis and intubation (including failed intubation). The study was completed earlier than expected as the staff could see the benefits of having relatives present. Those relatives that were present were followed up after one month to see whether they regretted their decision and after one, six and nine months to examine the psychological effects. The findings were:
When concluding, Robinson et al noted that there was little evidence to support the exclusion of relatives who wish to be present during resuscitation.(10) Relatives' presence during resuscitation is a complex and controversial issue involving many differences of professional opinion. It is an area that needs much more research -especially on this side of the Atlantic.(6) In an era of patient centred, family centred care it is surprising that there are vociferous arguments from nurses against witnessed resuscitation.(11) Obviously there are many factors to consider - there are cost implications for staff availability, staff training and relative evaluation follow up. In a ward setting it may not be as appropriate as for a unit such as A&E, ITU or SCBU. Finally, in the multi cultural area of London that this Trust provides for there are many cultural and language considerations to be taken into account. In summary, I believe that a recommendation for our practice must be one of patient and relative choice, treating each case individually. "The action (of excluding relatives) is based on genuine compassion for the feelings of the relatives". Baskett (1994) However... "The paternalistic desire to protect relatives (from resuscitation) misunderstands the human response to possible death" Higgs (1994) Nursing Progress: Issue 7: November 1999. Copyright: Nursing Progress, Royal Hospitals NHS Trust. Back to Nursing Progress contents. Back to issue 7 contents list. 1. Fullbrook S. Medico-legal insights, legal implications of relatives witnessing resuscitation. British Journal of Theatre Nursing 1998: 7.10; 33-5. 2. UKCC. Guidelines for Professional Practice. London UKCC 1996. 3. Hanson C, Strawser D. Family presence during cardio-pulmonary resuscitation: Foote Hospital ED nine year perspective. Journal of Emergency Nursing 1992: 18.2; 104-6. 4. Schilling R. No room for spectators (letter). British Medical Journal 1994: 309; 406. 5. Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accident & Emergency Nursing 1996: 4; 145-51. 6. Small G, Pryse B. Witnessed resuscitation and bereavement services. 3M A&F Focus, 3M Health Care 1999: 10; 19-21. 7. Adams S, Whitlock M, Bloomfield P, Baskett P, Higgs A. Should relatives be allowed to watch resuscitation? British Medical Journal 1994: 308; 1687-9. 8. Martin J. Rethinking traditional thoughts. Journal of Emergency Nursing 1991:17.2; 67-8. 9. Gordon PN, Williamson S, Lawler PG. As seen on TV: observational study of CPR British television medical drama. British Medical Journal 1998: 317.7161; 780-3. 10. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. The Lancet 1998: 352; 614-17. 11. Dight A. Should relatives be allowed into the resuscitation room? Nursing Times 1999: 95 17; 30-1. Barrett F, Wallis D. (1997) Relatives in the resuscitation room: their point of view. Journal of Accident & Emergency Medicine 1997: 15; 109-11. Back D, Rooke V. The presence of relatives in the resuscitation room. Nursing Times 1994: 90; 34-5. Chalk A. Should relatives be present in the resuscitation room? Accident & Emergency Nursing 1995: 3; 56-61. Dolan B. A drama within a crisis-relatives in the resuscitation room. Journal of Clinical Nursing 1995: 4; 275. Egleston CV et al. Relatives in the resuscitation room-Here to stay? Resuscitation 1997: 32; 2; 193. Gregory C. I should have been with Lisa when she died Accident & Emergency Nursing 1995: 3; 136-8. Judkins KC. Relatives can be helpful. (letter) British Medical Journal 1994: 309; 406. Kendrick K. Sudden death: walking a moral minefield. Emergency Nurse 1997: 5.11; 7-19. Mitchell M, Lynch M. Should relatives be allowed in the resuscitation room? Journal of Accident & Emergency Medicine 1997: 14; 366-9. Osuagwn C. ED codes: Keep the family out. Journal of Emergency Nursing 1991: 17. 6; 363-4. Zoltie N, Sloan IR, Wright B. (1994) Should relatives watch resuscitation? May affect doctors performance (letter). British Medical Journal 1994: 309; 406-7. Back to Nursing Progress contents. Back to issue 7 contents list. Page last updated by DEB on 1/7/02 |
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