ABSTRACT
This systematic review aimed to examine the preferences and experiences of family members who had witnessed cardiopulmonary resuscitation.
Electronic searches were performed on Cochrane, JBI, Ovid, PubMed, Scopus, and Web of Science. We included studies conducted among adult patients and family members that were published in peer-reviewed journals in English between 2013-2018. The studies were summarized by the researchers independently. Then, the summaries were compared, and a consensus was established among the researchers. A total of nine studies were included. Family members expressed that they wanted to witness the cardiopulmonary resuscitation and expected to have that decision respected by healthcare professionals. Although the number of studies were limited, family members who had witnessed cardiopulmonary resuscitation experienced less anxiety, depression, post-traumatic stress, and grief. Further comparison studies are needed to identify the positive and negative experiences of family members who witnesss cardiopulmonary resuscitation.
Keywords: Family witnessed resuscitation, family presence, family members’ preferences, family members’ experiences
Introduction
Although the presence of the families is not desired during the cardiopulmonary resuscitation (CPR), family presence during resuscitation (FPDR) has been recommended as an interdisciplinary intervention due to its importance within the recovery process (1). FPDR refers to the intervention of CPR to the patient with the presence of his or her family (2,3) or by ensuring that the family is in visual or physical contact with their loved one during CPR (3).
FPDR is consistent with family-centered care model (4) and considered a very important component (5). Creating patient and family-centered care policies would ensure the day-to-day interaction of healthcare professionals as well as the structuring of facilitating designs (4,6). Furthermore, this model has been reported to have positive effects, such as the improvement of healthcare outcomes, effective utilization of resources, patient satisfaction, and patient family satisfaction. It is important to include families in the healthcare process when the patients are intubated in intensive care and emergency units where they cannot be involved in decision-making regarding themselves as they are not able to speak. FPDR in these units contributes to the partnership of healthcare professionals, patients, and families within the care process (6). Therefore, many professional organizations, such as the American Association of Critical-Care Nurses and Emergency Nurses Association, support the idea of family-witnessed CPR due to its benefits for patients and families and have published guidelines on their implementation (1,3). In addition, the European Resuscitation Council guidelines emphasize that patients’ relatives should be offered the option of being present during CPR, and cultural and social differences regarding these decisions should be respected (7).
Studies have shown that family-witnessed CPR has positive effects on patients, family members and healthcare professionals (8). However, research results still suggest that this issue is a very controversial, underutilized, and unusual practice (9,10).
When examining the literature, there is a lack of sufficient studies on the subject. Listed among existing studies are a systematic review examining the impact of training provided to support FPDR implementation by healthcare professionals (11), a meta-synthesis in which qualitative studies of patients, families, and nurses are combined (6), a review of the literature on barriers related to using FPDR in the emergency department (12,13), and an integrative review on the behaviors and experience of nurses and physicians (14). However, there are no systematic reviews in the literature regarding the preferences and experiences of the families of adult patients regarding FPDR itself. Therefore, this review aimed to bring these studies together and share their results.
Materials and Methods
This systematic review aimed to examine the preferences and experiences of family members witnessing CPR. A literature review was done by using a systematic approach. Sackett (1997) framework, known as Population, Intervention, Comparison, and Outcome, was used to elicit insight into the current body of evidence (15). The following framework was used; Population: patients and relatives who were 18 years or older; Intervention: family members who had witnessed CPR practices; Comparison: family members who had witnessed CPR and those who had not; Outcome: preferences and experiences of family members.
Cochrane, JBI, Ovid, PubMed, Scopus and Web of Science databases were searched using the keywords “CPR,” “support”, “witnessed resuscitation”, “family-witnessed resuscitation”, “family presence”, “family members’ preferences”, “family members’ experiences”, and “impacts on family members”. Studies concerning adult patients and families published in English in peer-reviewed journals between 2013 and 2018 were included in the study, while studies in languages other than English and those concerning child patients and families were excluded. A total of 1,317 articles (Web of Science: 503, Scopus: 328, Cochrane Library: 259, PubMed: 105, Ovid: 107, JBI: 15, other sources: 3) were transferred to the EndNote program. After 119 duplicate articles were removed, 671 articles published within the given dates were transferred to the program, and a separate file was created. Then, the headlines and abstracts of the 671 articles were evaluated. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was used to guide article inclusion, and a total of nine studies meeting the PRISMA research criteria were included in the sample. A total of 662 studies not meeting the PRISMA research criteria were excluded because these studies were about different healthcare professionals’ or students’ experiences, or scale development studies or the sample of the research comprised children and their families regarding FPDR (Figure 1).
Data Analysis
To summarize the data, researchers developed a Data Summarization Form, evaluated the data according to it and summarized each article independently. Then, the summaries were compared, and consensus was established among the researchers. Because the type of research and measurement methods of the studies included in this systematic review were different from each other, it was aimed to present any relevant data without performing a meta-analysis.
Results
The final data set consisted of nine articles: two randomized experimental studies, four qualitative studies, one cross-sectional study, one descriptive study, and one multivariate, comparison prospective study. While seven of these studies were conducted with family members, one concerned patient family and nurses and another concerned patient, family members, and healthcare professionals (physicians, nurses, and paramedics). In these two studies, only the results obtained from the family members were taken into consideration. The study included papers from France (3 papers), United States (2 papers), Australia (2 papers), Finland (1 paper), and Iran (1 paper). The titles, designs, sample characteristics, findings and suggestions of the papers are given in Table 1.
In the two randomized controlled studies, conducted by the same authors using the same sample group, a total of 570 family members present or not present during CPR were compared. A trained psychologist collected the data using a scale during telephone interviews 90 days after the resuscitation in the first study and one year following the resuscitation in the second study. In both studies, post-traumatic stress syndrome-related symptoms, the Hospital Anxiety and Depression scale, or the Major Depressive Episode scores were found to be significantly higher in the control group (16,17). In addition, Jabre et al. (16) (2014) also studied complicated grief status, finding it to be higher also in the control group. Furthermore, another study (experimental: 70, control: 70) identified that FPDR had reduced the anxiety and stress in the families as well as fostered reports of well-being in the family (18).
Four of the studies included in the systematic review had been planned as qualitative research, of which three were conducted with family members (1,19,20) and one with family members, patients, and healthcare professionals (21), with sample sizes ranging from 12 to 30. Giles et al. (21) (2016) examined in detail the factors affecting family members’ decisions to accept or reject FPDR. Family members regarded caring for their loved ones and being present with them as their fundamental rights.
De Stefano et al. (19) evaluated the experiences of family members during CPR, also. The findings indicated that active participation during resuscitation was very important in terms of supporting the loved one emotionally and observing the efforts of the healthcare professionals to save the patient, ensuring effective communication between the family and healthcare professionals, increasing satisfaction from the efforts of the resuscitators, and making death and loss easier to accept. Furthermore, this study indicated the central role that family presence played in accepting death and relieving the pain of death based on the experiences and reactions of the families who witnessed CPR, the feeling of participation at this important moment, and the communication between the family and the healthcare team.
Leske et al. (1) emphasized the importance of collaboration among the family and healthcare team in his study. In Sak-Dankosky et al.’s (20) study, aiming to determine the preferences of the family members regarding FPDR, concluded that there were gaps in the presentation of family-centered care in intensive care units, that the families desired more involvement in patient care during CPR, and that healthcare professionals should be more attentive and respectful during CPR.
In the descriptive study of Zali et al. (22) (2017), randomly selected nurses and family members were asked to evaluate the positive and negative aspects of witnessing CPR. Family members shared the opinion that it was helpful to be with their loved one to see that everything was being done for them and to provide spiritual support.
In the population-based study using a cross-sectional design (23), 1,208 individuals were contacted by phone in order to evaluate the level of the social support given to families present during CPR and to determine whether or not opinions had changed in the case that the patient was a child, adult, or themselves as well as to identify effective factors. The study concluded that younger adults (18-25 years) had strong desires to be present during CPR and wanted their family members to be present during CPR. Their opinions were affected by gender, prior experience of witnessing CPR, experiences of relatives, and cases when CPR was conducted on a child, adult, or themselves. The study determined that younger adults had wanted to be present during CPR of a child at the rate of 75%.
Discussion
FPDR is the fundamental component of family-centered care. According to family care nursing theory, health affects all family members, health and illness are family events, and families determine healthcare processes and outcomes (24). For this reason, it is very important for healthcare professionals to provide families with the FPDR option. This review aimed to examine the preferences and experiences of family members regarding FPDR.
Family members wanted to show support by being present with their loved one during CPR and thought this was helpful (22). Family members desired more inclusion during CPR and expected their presence to be understood and respected by healthcare professionals (20). Furthermore, anxiety, depression, post-traumatic stress, and grief experienced by families decreased (16,17). Moreover, witnessing CPR resulted in reports of well-being by the families (25) and played an important role in relieving the pain of family members as well as accepting death (19).
FPDR remains a controversial issue due to medical, social, cultural, ethical, and legal aspects as well as to the psychological and emotional effects it has on the patient’s family (26,27). Despite the positive results, studies have reported also that health professionals had differing opinions (14). Some healthcare professionals who look positively upon FPDR think of it as a “patient’s right,” helping to facilitate the family’s acceptance of their loved-one’s death and make the grieving process easier (26,27). Negative attitudes included patient safety, emotional responses of family members, performance anxiety, concerns about creating stress in the healthcare environment, and distraction (28,29). In addition, some healthcare professionals look negatively at FPDR from cultural and religious aspects, thinking that it creates stress burden, affects the CPR procedure negatively, and creates trauma on the patient’s family. Moreover, healthcare professionals are doubtful toward FPDR due to the lack of formal policy and sufficient studies on the subject (26,27). In a study conducted with 63 healthcare professionals in Turkey, 65.07% of them strongly opposed FPDR, 71.41% stated that the presence of family members negatively affected their performance, and they were concerned about making mistakes during the CPR because CPR requires focus (27). In another study conducted using a randomized experimental design, the anxiety levels of patients’ families and healthcare professionals were evaluated. Despite there being no differences in the anxiety levels of the families who witnessed CPR, there were differences in anxiety levels of the healthcare professionals, and it was found that especially physicians who performed CPR with FPDR experienced more stress (30).
Although the history of FPDR dates back many years, it is still not included in routine family-centered nursing practice in healthcare settings (31). That is why, to benefit from FPDR, it is important to raise awareness in healthcare professionals regarding its positive effects.
Strengths and Limitations
The strengths of this systematic review are that many nursing and medical databases were searched extensively. In addition, quality assessment and data extraction in duplicate were done by two separate authors using piloted forms. The limitation of this systematic review was the inclusion of studies published between 2013-2018 in English only.
Conclusion
Although there are few studies investigating the preferences and experiences of family members related to family-witnessed CPR, it has positive effects on families. Family members desire to be with their loved one and support him or her spiritually and want healthcare professionals to respect these wishes. However, further research is needed to explore the positive and negative experiences of family members witnessing CPR.
