It seems counterintuitive: allowing family members of deathly ill patients to watch while doctors try to restart the patients' hearts. Wouldn't it be traumatic for the family to see? Couldn't it be distracting for the doctors?
But a new study, the largest rigorous trial on this issue to date, has found that family members who observed resuscitation efforts were significantly less likely to experience symptoms of post-traumatic stress, anxiety and depression than family members who did not.
The results, published online on Wednesday in The New England Journal of Medicine, applied regardless of whether the patient survived; most did not, since frequently patients in such dire condition cannot be saved. The study, which involved 570 people in France whose family members were treated by emergency medical teams at home, also found that the presence of relatives did not affect the results of cardiopulmonary resuscitation, did not increase stress on physicians or other members of the medical teams, and did not result in legal claims. (One family member who had observed CPR even sent a thank-you note.)
Allowing family members to witness CPR is increasingly being discussed in emergency medicine. Historically, although parents of children have been allowed to be present for various reasons, relatives of adult patients have not because medical personnel, especially physicians, believed it would interfere with their work or would be upsetting for the family. Some still do.
But as medical practices change to increasingly involve family in the care of patients, growing numbers of emergency medical practitioners say that giving relatives the option of watching CPR can be a good idea. Several national organizations, including the American Heart Association, the Emergency Nurses Association and the American Association of Critical-Care Nurses have revised their policies in recent years to call for giving family members the option of being present during CPR.
Witnessing CPR, say some emergency medicine experts and family members, can demystify a seemingly frightening process, provide reassurance that everything has been done to try to save the patient, and offer closure for relatives wanting to be with loved ones until the very last moment. It also shows relatives why reviving someone in cardiac arrest is much less likely than people assume from watching television.
"It's not like on 'Baywatch,' where somebody gets pulled out of the water and you do a few compressions and they walk away," said Dr. Rosemarie Fernandez, an associate professor of emergency medicine at the University of Washington. "Taking the mystery away is huge."
Scott Compton, an clinical researcher in emergency medicine who has conducted several studies, said many in the medical community were reconsidering their reluctance to welcome family witnesses.
"To get them to recognize the family member as the patient is a new thing for them," said Dr. Compton, now at Duke-NUS Graduate Medical School in Singapore.
"But for every one patient you save, there are countless family members that have just lost a relative," he continued. "Bang for the buck — there's more to be done for family members than there is for the small percentage that will survive a cardiac arrest."
Still, while experts said the French study bolsters arguments for allowing relatives to observe, questions remain. Some studies have been less convincing, particularly about whether medical personnel can get distracted. A key factor may be whether CPR is done at home, as in the French study, or under hospital conditions.
Dr. Fernandez, Dr. Compton and colleagues conducted a study in Detroit, in which medical residents performed CPR in a hospital setting on a kind of mannequin. In some cases, actors playing family members watched, with some remaining quiet and others asking questions or touching the patient. Actors playing social workers helped comfort the family members. The study found that while some medical steps were unaffected, residents with more gregarious family observers took longer to deliver the first shock to the heart and gave fewer total shocks.
Dr. Michael Copass, who for years headed emergency services at Harborview Medical Center in Seattle and still practices, said that he supported allowing family to witness CPR at home, and always where children were involved, but that he could be uncomfortable with it in the hospital emergency department with adult patients.
"In the E.R., sometimes those can get pretty bloody, messy," he said, adding that occasionally, overwrought family members were asked to leave. "I've been in E.R. resuscitations where I wish the family had not been there. It's not helpful to the doctor. You might have a grieving wife asking questions when you're trying to save the person."
But he knows family members can appreciate it. Kathleen Gage Damm and her mother and sister asked to watch CPR on her father in 2002 at Harborview, which did not regularly allow it then, she said.
They did not want to sit in a waiting room, where "you've got doors closed, and it's not that nurses and doctors don't come out, but they of course don't tell you too much because they don't want to upset you," she said. "To be able to see him even in those last moments, to know that they were working — we were so thankful."
Harborview allows family observation frequently now, said Becky Pierce, an associate administrator, and, like other hospitals that do so, designates staff members to accompany the family.
The lead author of the French study, Dr. Frederic Adnet, an emergency medicine professor, said he was surprised that relatives witnessing CPR experienced less psychological anguish and rarely became aggressive. He and Dr. Tomislaz Petrovic, who participated in some of the resuscitations, said they previously prohibited most relatives from watching. But, said Dr. Petrovic, "Now, I always ask."
A family member in that study, who asked that only her first name, Jayne, be used, watched two ambulance crews try reviving her 55-year-old husband after he collapsed on their veranda.
"Because I witnessed it I know that they tried everything," she said. "There isn't this whole 'Did they try that, did they do this?' "
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