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Draft:Family Presence During Resuscitation

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Family presence during resuscitation (FPDR), also referred to as family-witnessed resuscitation (FWR), is defined as the practice of allowing relatives to be present during a family member’s in-hospital cardiopulmonary resuscitation (CPR) attempt in an emergency or critical care setting. This may involve the relative witnessing medical procedures being performed on the family member, such as chest compressions, endotracheal intubation, cardiac defibrillation, or other advanced life support measures. The approach, once considered controversial, has been the focus of increasing research and professional debate and is now incorporated into some hospital protocols.

History and origins

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Foote Hospital, Michigan (1982)

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One of the earliest published reports on family presence during resuscitation came from Foote Hospital (now Henry Ford Health – Jackson Hospital) in Jackson, Michigan, United States. In 1982, Emergency Department personnel began to reconsider the routine exclusion of families after several relatives insisted on remaining at the bedside during cardiac arrest care, prompting staff to explore family presence as a formal option.[1]

Rationale and concerns

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Reported benefits

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Supporters of FPDR highlight potential benefits, including:

  • Facilitating bereavement – “Some families reported that being present during resuscitation helped them cope with loss and better understand that everything possible was done.”[2]
  • Perceived transparency in care – Some have claimed that witnessing resuscitation can reassure family members that appropriate medical action was taken. This perception may contribute to trust in the healthcare team.[3]
  • Recognition of family roles in care – FPDR has been described as consistent with family-centered care principles.[4]

Common concerns

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Concerns raised in the literature include:

  • Disruption of medical care – Clinicians have expressed concern that family presence may interfere with procedures, especially in high-pressure environments.[5]
  • Psychological impact on witnesses – Although many relatives report benefits, some may experience distress or symptoms of post-traumatic stress, especially after unsuccessful resuscitation.[6]
  • Legal and liability concerns – Institutions have noted potential medicolegal risks, though research has not demonstrated an increase in litigation where structured FPDR protocols exist.[4]
  • Clinician discomfort – Some providers report increased anxiety or altered performance when a family member is present, particularly in the absence of trained support staff.[7]

Research

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Randomized trials

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A pilot randomized trial in the United Kingdom (Robinson et al., 1998) assigned 25 family members to FPDR or control groups. Those offered presence had lower rates of intrusive imagery and grief symptoms, with no evidence of psychological harm. The study was terminated early when clinicians declined to withhold FPDR from subsequent families.[8]

A 2013 cluster-randomized trial in France (Jabre et al.) involving 570 relatives of out-of-hospital cardiac arrest patients found that those who witnessed resuscitation had lower rates of post-traumatic stress, anxiety, and complicated grief at follow-up. No negative effects on CPR performance or clinician stress were reported.[9]

U.S.-based studies

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Several studies from Wayne State University (Detroit, Michigan) have examined FPDR in urban emergency and prehospital settings:

  • A comparison of two hospitals found more favorable perceptions of FPDR among staff at the institution with an established policy.[10]
  • Emergency medical service (EMS) providers surveyed reported general comfort with family presence during field resuscitations.[11]
  • An observational study conducted in the United States found that family members who witnessed unsuccessful out-of-hospital resuscitation efforts experienced significantly more symptoms of post-traumatic stress disorder (PTSD) during early bereavement, particularly in the domains of avoidance and arousal.[12]
  • A prospective study in an urban emergency department found no significant differences in symptoms of post-traumatic stress or depression between relatives who witnessed resuscitation and those who did not.[3]
  • Simulation-based research has shown that the presence and behavior of a family witness during cardiopulmonary resuscitation (CPR) can alter physician performance. In a randomized study using simulated resuscitations, physicians exposed to a family member exhibiting overt grief delivered fewer defibrillation shocks and took longer to administer the first shock compared to control groups without a family witness or with a quiet observer.[13]

Guidelines

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Several professional organizations support FPDR under specific conditions:

  • The American Heart Association (AHA) includes FPDR as a consideration in its 2020 resuscitation guidelines.[14]
  • The European Resuscitation Council (ERC) recommends FPDR when supported by appropriate staffing and protocols.[15]
  • The Emergency Nurses Association (ENA) supports FPDR in settings with trained personnel and institutional policies.[4]

See also

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References

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  1. ^ Doyle, Constance J; Post, Hank; Burney, Richard E; Maino, John; Keefe, Marcie; Rhee, Kenneth J (1987). "Family participation during resuscitation: An option". Ann Emerg Med. 16 (6): 673–675. doi:10.1016/S0196-0644(87)80069-0. ISSN 0196-0644. PMID 3578974.
  2. ^ Hanson, C; Strawser, D (1992). "Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department's nine-year perspective". J Emerg Nurs. 18 (2): 104–106. PMID 1573794.
  3. ^ a b Compton, S (2011). "Family-witnessed resuscitation: Bereavement outcomes in an urban environment". J Palliat Med. 14 (6): 715–721. doi:10.1089/jpm.2010.0463. PMID 21504307.
  4. ^ a b c "ENA Clinical Practice Guideline: Family Presence During Invasive Procedures and Resuscitation" (PDF). Emergency Nurses Association. 2012.
  5. ^ McClement, SE; Fallis, WM; Pereira, A (2009). "Family presence during resuscitation: Canadian critical care nurses' perspectives". J Nurs Scholarsh. 41 (3): 233–240. doi:10.1111/j.1468-3083.2009.03449.x. PMID 19793150.
  6. ^ Compton, S (2009). "Post-traumatic stress disorder associated with witnessing unsuccessful prehospital CPR". Acad Emerg Med. 16 (3): 226–229. doi:10.1111/j.1553-2712.2008.00336.x. PMID 19133848.
  7. ^ Fernandez, R; Compton, S; Jones, K; Velilla, M (2009). "The presence of a family witness impacts physician performance during simulated medical codes". Crit Care Med. 37 (6): 1956–1960. doi:10.1097/CCM.0b013e3181a00818. PMID 19384215.
  8. ^ Robinson, S (1998). "Randomised trial of family presence during resuscitation". Lancet. 352 (9128): 1058–1062. doi:10.1016/S0140-6736(05)79762-7 (inactive 6 July 2025).{{cite journal}}: CS1 maint: DOI inactive as of July 2025 (link)
  9. ^ Jabre, P (2013). "Family presence during out-of-hospital cardiopulmonary resuscitation". N Engl J Med. 368 (11): 1008–1018. doi:10.1056/NEJMoa1203366. PMC 4123210. PMID 23484829.
  10. ^ Macy, C; Compton, S (2006). "The relationship between hospital setting and perceptions of family-witnessed resuscitation in the emergency department". Resuscitation. 70 (1): 74–79. doi:10.1016/j.resuscitation.2005.11.012. PMID 16757086.
  11. ^ Compton, S (2006). "EMS providers' experience with family presence at resuscitation". Resuscitation. 70 (2): 223–228. doi:10.1016/j.resuscitation.2005.11.013. PMID 16806642.
  12. ^ Compton, S; Grace, H; Madgy, A; Swor, R (2009). "Post-traumatic stress disorder symptomology associated with witnessing unsuccessful out-of-hospital cardiopulmonary resuscitation". Acad Emerg Med. 16 (3): 226–229. doi:10.1111/j.1553-2712.2008.00339.x. PMID 19032506.
  13. ^ Fernandez, R; Compton, S; Jones, K; Velilla, M (2009). "The presence of a family witness impacts physician performance during simulated medical codes". Crit Care Med. 37 (6): 1956–1960. doi:10.1097/CCM.0b013e3181a00818. PMID 19384215.
  14. ^ Meaney, PA; Bobrow, BJ (2020). "2020 American Heart Association Guidelines for CPR and ECC: Systems of Care, Education, and Resuscitation". Circulation. 142 (16_suppl_2): S222 – S283. doi:10.1161/CIR.0000000000000898. PMID 33081525.
  15. ^ Olasveengen, TM (2021). "European Resuscitation Council Guidelines 2021: Systems Saving Lives". Resuscitation. 161: 80–97. doi:10.1016/j.resuscitation.2021.02.008. PMID 33773834.
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