Good Grief Bad Grief

Family presence during cardiopulmonary resuscitation

· Clinical Education

Words By Mitchell Trethowan



Cardiopulmonary resuscitation (CPR) can generate considerable stress on physicians and others nearby, whilst requiring immediate attention on a series of sequential interventions designed to address reversible, life-threatening conditions, and prevent some deaths (1). The decision to allow or deny the presence of family members during resuscitation is one of longstanding controversy (2). Since this concept was introduced in the 1980’s, family presence during resuscitation (FPDR) has gradually become more readily accepted within some societal groups, along with more recent integration into many international protocols such as those published by The American Heart Association (1,3). Despite this growing acceptance, however, cynicism remains in some emergency services providers. 

The decision to implement FPDR is complex, and often pressured by norms relating to particular settings, personal preferences, ethical beliefs and tension between patient families and clinicians (4). Making the wrong decision during such a critical moment may mean the difference between healthy processing of a traumatic experience and long-term symptoms of post traumatic stress, traumatic grief, depression and bereavement (2). The evidence cited throughout this paper, concerning FPDR, has predominantly derived from qualitative studies, using questionnaires to obtain opinions from the families and close friends of patients, as well as healthcare professionals, the majority of which are based within emergency departments (1,3). 


From a physician’s perspective, feedback gained from proponents highlights benefits such as FPDR helping families to become involved in care, assist in history taking, and making the healthcare team feel appreciated (5).  FPDR was not considered to interfere with medical efforts or increase stress within the health care team (6). Additionally, medicolegal consequences may be reduced, and family member perspectives, post-resuscitation, are noted as prodigiously positive overall. A similar study by Twibell et al (7), found that between 50-96% of family members believed that it was their right to be in attendance. Presence was cited to have improved satisfaction and advocation of care, allowed the family to bring comfort to the patient, helped comprehend the severity of illness and provided an opportunity for a final goodbye whilst facilitating the acceptance and reality of death (5,3). In addition, research addressing physiological impacts of FPDR highlighted improved variables at 90 days and 1-year post study, including less frequent depression, traumatic grief and bereavement related PTSD (2,6).

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In contrast, physicians opposing FPDR cite the potential for harm as a reality in that FPDR may be detrimental to team performance, with negative impact on optimal care and potential harmful to the patient (8,9). Across a total of 42,000 in-hospital cardiac arrests, FPDR implementation was associated with delayed vascular and airway access, increased medication errors and more frequent delays in defibrillation (1). Some health care workers also state that FPDR increases clinician stress, and limits open communication and teaching opportunities during resuscitation (1). From another perspective, many physician arguments are based upon concern for excessive emotional distress that family members may suffer, and the potential legal implications arising (5,8). Further trepidation arises around the FPDR movement focusing on benefit to family members overall, largely ignoring wishes of the patient. Presumption of consent by allowing FPDR may result in the violation of any patient’s right to autonomy and dismantle patient confidentiality. 


From an ethical standpoint, despite the potential for violating a patient’s autonomy, it may be duplicitous to disallow the presence of family members, unless each patient has made a determination about whom they wish to remain present. In summary, FPDR is increasingly becoming an important component of patient and family-centered care.  Through this focus, family members can be offered, encouraged and supported to be together with their loved ones. Paramount to overall positive outcome is physician education, with the implementation of family presence programs to assist in appropriate  identification of individual opportunities aligned to individual clinical situations. This may include designated support staff such as a nurse, paramedic or social worker, a professional in sensitive situations to explain interventions, respond truthfully and realistically to questions, interpret medical jargon, continually assess emotional and physical states, liaise with clinicians on each family member’s behalf and provide opportunity for them to reflect post-resuscitation. Due to the complexity of this decision, many families may currently be missing the chance to remain with their loved ones during end of life moments. Future investigation and advocacy are required to create such benefit through a large scale approach.  A positive “first step” may originate from a shift in evidence-based research from that of “Should” family presence be implemented to “How to” implement family presence through quality programs and robust training. 



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