Correspondence
Should Family Members Be Present during Cardiopulmonary Resuscitation?
N Engl J Med 2002; 347:450-452August 8, 2002
- Article
To the Editor:
Dr. Tsai (March 28 issue)1 rightly questions the policy of excluding family members when resuscitation efforts are under way in an emergency room. However, she does not address several important issues. First, there are risks to the family members. During the first resuscitation I ever conducted, the patient, a child, did well, but the sight of his child's blood made the father faint and led to his admission to the hospital for injuries related to his fall. Second, emergency rooms in small community hospitals usually cannot muster teams of personnel like those seen on television shows. When a resuscitation team consists of only two people, the questions and other needs of distraught family members can become a very serious distraction — even when they do not faint. Third, the presence of family members when multiple simultaneous resuscitation efforts are under way would create enough complications to keep television scriptwriters busy for years. Finally, medically trained family members present special difficulties. Is it realistic to expect someone who has been trained in resuscitation to stand a few feet away and not interfere when things are not going well?
Emergency departments should serve and protect the patient. Dr. Tsai has not argued that patients are harmed by a policy that excludes family members, only that the family members may benefit. The most prudent position, therefore, is to retain a general policy of exclusion but permit exceptions on a case-by-case basis.
1 ReferencesPaul H. Axelsen, M.D.
University of Pennsylvania, Philadelphia, PA 191041
Tsai E . Should family members be present during cardiopulmonary resuscitation? N Engl J Med 2002;346:1019-1021
Full Text | Web of Science | Medline
To the Editor:
In 1999, my 35-year-old wife had a sudden cardiac arrest. Despite my efforts and those of paramedics and the emergency department staff of a large teaching hospital, she could not be resuscitated. My inadvertent observation of a technician carrying a bloody rib spreader from the trauma room after a failed attempt at open-heart massage was traumatic enough; I remain grateful that I was not offered the opportunity to watch the actual procedure.
Jonathan E. Skillings, B.S., P.A.-C.
Midatlantic Cardiovascular Associates, Baltimore, MD 21237
jonsk@erols.com To the Editor:
During my fourth year in medical school, I witnessed the performance of cardiopulmonary resuscitation on my mother. She had been sent for a ventilation–perfusion scan because of suspected pulmonary emboli. My father accompanied her. At one point, she leaned toward him and told him in gasping breaths that she loved him. After he responded similarly, she had cardiac arrest. My father was asked to leave as the members of the resuscitation team squeezed into the small room. I arrived with the anesthesiologist and witnessed the team crawling on top of my mother, stripping her, and pushing her chest in; I heard the sounds of her ribs breaking, and I saw the bagging and intubation. I left the room and sat beside my father in an adjacent hallway. My mother survived an additional 48 hours.
Feeling close to my mother just before her death was of great comfort to my father. But witnessing my mother's resuscitation remains one of the most painful and traumatic experiences of my life. My father's final goodbye was accomplished without his having to visualize the resuscitation efforts. It is my opinion that families should not be present during resuscitations. I do not believe that the family benefits by witnessing medicine's final assault on their loved ones.
Andrew P. Manista
Case Western Reserve University School of Medicine, Cleveland Heights, OH 44118-4410
apm3@cwru.edu To the Editor:
For the past 25 years, I have allowed virtually every family member who wishes to observe a patient's treatment into my resuscitation room. During that time I have been a paramedic, and the resuscitation room is usually the home or workplace of the patient or even a supermarket or restaurant. I have enlisted family members to hold intravenous fluids or lights or even to take part in the resuscitation itself, sometimes teaching them cardiopulmonary resuscitation on the spot.
It has been rare that someone has interfered with our treatment or resuscitation. I have never, in my memory, had a patient's relative become ill during the resuscitation, although some do leave the room. I find it ironic that the health care providers with the least training and the most limited equipment are able to deal with family members during resuscitations, whereas hospitals, with their cadres of support personnel, such as clergypersons, social workers, and security officers, are not.
I understand the reluctance to change a long-standing tradition — in this case, the barring of family members from resuscitations — but my experience has, on the whole, been positive.
Dennis M. Marien
522 W. Second St., Davison, MI 48423
dmarien@tm.net Author/Editor Response
Dr. Tsai replies:
To the Editor: Axelsen mentions the unfortunate father who was injured on fainting at the sight of his child's blood. Skillings and Manista recount their own traumatic experiences with resuscitation — accounts not unlike previous anecdotal reports used to support objections to this practice. However, the evidence to date shows that the majority of family members who witness resuscitations have positive experiences1-3 — a fact that runs counter to Axelsen's call “to retain a general policy of exclusion.” Thirty years ago, who would have believed that a man could withstand viewing the delivery of a child without fainting? Today, we think there is something wrong with the father who chooses not to participate in the miracle of birth.
Marien's overwhelmingly positive experience during 25 years of practice as a paramedic is consistent with my own observations and those reported in letters that I have received since the publication of my article. In fact, members of the lay press have expressed surprise that the exclusion of family members from the resuscitation room is standard practice whereas we expect patients and family members to be full participants in all other aspects of medical care, including making decisions about cardiopulmonary resuscitation. Others — parents of my pediatric patients, friends, nonmedical colleagues at the hospital — tell me that there is nothing that could keep them away from the side of a dying loved one. For those who wish to say goodbye while there is still the possibility that the patient may be able to hear them, the opportunity to do so is of immeasurable value.
The special circumstances Axelsen describes — the two-person resuscitation team at a small community hospital, multiple simultaneous resuscitations, the medically trained family member — as well as other scenarios that I could easily dream up can pose challenges. These instances, however, highlight the need for formal policies and procedures to enable hospitals to deal with family members should they wish to be present, without compromising the care of the patient.
3 ReferencesEllen Tsai, M.D., M.H.Sc.
Queen's University, Kingston, ON K7L 2V7, Canada
tsaie@kgh.kari. net 1
Doyle CJ ,Post H ,Burney RE ,Maino J ,Keefe M ,Rhee KJ . Family participation during resuscitation: an option. Ann Emerg Med 1987;16:673-675
CrossRef | Web of Science | Medline2
Meyers TA ,Eichhorn DJ ,Guzzetta CE , et al. Family presence during invasive procedures and resuscitation. Am J Nurs 2000;100:32-43
CrossRef | Web of Science | Medline3
Robinson SM ,Mackenzie-Ross S ,Campbell Hewson GL ,Egleston GL ,Prevost AT . Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998;352:614-617
CrossRef | Web of Science | Medline
- Citing Articles (5)
Citing Articles
1
Robert Zalenski, Richard F. Gillum, Tammie E. Quest, James L. Griffith. (2006) Care for the Adult Family Members of Victims of Unexpected Cardiac Death. Academic Emergency Medicine 13:12, 1333-1338
CrossRef2
Katherine J. Gold, Daniel W. Gorenflo, Thomas L. Schwenk, Susan L. Bratton. (2006) Physician experience with family presence during cardiopulmonary resuscitation in children*. Pediatric Critical Care Medicine 7:5, 428-433
CrossRef3
Ryan M. Taylor, Paula Bockenstedt, Grace L. Su, Jorge A. Marrero, Shawn M. Pellitier, Robert J. Fontana. (2006) Immune thrombocytopenic purpura following liver transplantation: A case series and review of the literature. Liver Transplantation 12:5, 781-791
CrossRef4
Bernice Redley, Mari Botti, Maxine Duke. (2004) Family member presence during resuscitation in the emergency department: An Australian perspective. Emergency Medicine Australasia 16:4, 295-308
CrossRef5
Muhammad Waseem, Mary Ryan. (2003) Parental Presence During Invasive Procedures in Children: What Is the Physicianʼs Perspective?. Southern Medical Journal 96:9, 884-887
CrossRef
