Watching CPR Helps Ease Family's Grief

Family members who witnessed a cardiopulmonary resuscitation, or CPR attempt were less likely to experience symptoms of post-traumatic stress disorder later on, a new study found.

The proportion of family members with PTSD three months after the CPR attempt was lower among those offered the opportunity to be present than for those who were not directly invited (27 percent versus 37 percent), Dr. Frederic Adnet of Hôpital Avicenne in Bobigny in France and colleagues reported in the March 14 issue of the New England Journal of Medicine.

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Whether or not witnessing CPR on a family member who experienced cardiac arrest at home is beneficial or harmful has been controversial ever since the topic was first addressed 25 years ago.

Some have argued that being present would be associated with an increased emotional burden and other difficulties, not only for the family but also for the emergency medical services team, yet the sole randomized trial looking at this was stopped prematurely because of apparent benefits for families.

Despite the lack of evidence, international guidelines today favor family presence during CPR.

To address the ongoing controversy, Adnet and colleagues conducted a prospective study in which eight EMS units routinely asked family members if they wanted to witness their attempts to resuscitate the patient, explaining the process in a structured fashion.

In seven control units, the medical team did not systematically invite family members to witness the resuscitation attempt.

Three months later, the researchers contacted the 570 family members, interviewing them about PTSD symptoms on the Impact of Event Scale, and about other symptoms on the Hospital Anxiety and Depression Scale.

A single family member was used for each patient in the analysis, with 266 in the intervention group and 304 in the control group.

A total of 79 percent of family members in the intervention group chose to be present, compared with 43 percent of controls.

At the three-month interview, a total of 17 percent of family members declined to participate further because of emotional distress. This included five in the intervention group and 20 controls.

Only 4 percent of patients survived for a month or longer following CPR. In an analysis that excluded these patients, whose family members might be experiencing less grief, the greater likelihood of PTSD at three months was still higher in the control group.

Symptoms of anxiety were more common in the control group than in the intervention group overall (23 percent versus 15 percent), and also as reported by individual family members (24 percent versus 16 percent).

There was no significant difference between the intervention and control groups in the proportion of family members who reported symptoms of depression, although more individual members who did not witness the CPR reported symptoms of depression (26 percent versus 15 percent).

Another concern the researchers addressed was whether family members would become disruptive while witnessing the resuscitation, but this occurred in fewer than 1 percent of cases.

A total of 12 percent of those who were not present said they wished they had been, while only 3 percent of those who were present regretted it.

The median level of stress reported by the medical team during CPR was 5 on a visual analog scale of 100 points.

No family members claimed damages or pursued lawsuits during a mean follow-up period of almost 2 years.

"Many medical team members are reluctant to permit the presence of family members during resuscitation because of fear of medicolegal conflicts," Adnet and colleagues noted.

"Although our sample size is small and the medicolegal culture may be different in France than elsewhere, our findings should help allay physicians' medicolegal concerns," they wrote.

A possible limitation of the study was its exclusion of resuscitative attempts taking place in the hospital, and further work will be needed to establish the generalizability of these findings to other settings.

"This study provides useful data that will advance debate surrounding family-witnessed resuscitation," Dr. Daniel B. Kramer and Dr. Susan L. Mitchell of Harvard University wrote in an accompanying editorial.

"Most notably, when offered the choice to witness resuscitative efforts, most relatives opted to do so, and having that choice improved mental health outcomes, with no evidence of harm to any stakeholders," Kramer and Mitchell wrote.

"Future studies should aim to improve our understanding of why this choice may reduce the suffering of family members and whether such an approach could be implemented in practice in a safe and cost-effective manner," they advised.