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Shane from Australia wrote 03-16-2013 03:41:54 pm
I am really interested by this - its not something I personally feel comfortable with, but am aware of the literature in paeds resuscitation. I've always been worried that it is far too graphic for families, and in some circumstances (eg reopening a chest) I think its just not possible.

Harbo wrote 03-17-2013 05:25:19 pm
Following on from the paediatric experience, I have encouraged this for some time (>10 years)
I find a supernumerary doctor or nurse to stand with the family and translate the scene in real time. They are also able to escort them should they wish to leave (there is always someone available)
It is confronting, to us, when we first start, families are not often confronted and usually are thankful, no matter what the outcome.
If you have ever been a family member in an ICU or ED waiting room, you know that the clock does not work (minutes take hours) and what you are imagining is far worse than what is happening.
Within the limits of asepsis, my feeling is that family should be allowed to stay for many procedures, one of the most "rewarding" is brain death clinical examinations.

Todd Fraser from Australia wrote 03-17-2013 09:38:13 pm
I posted this on a number of other fora too - not everyone agrees. For those who can access it, here's what was said on LinkedIn - http://linkd.in/114GsgN

Myrenek from Australia wrote 03-17-2013 10:16:39 pm
This is a prehospital study. The families in both groups witnessed the "death" of their loved one in their own home and had to initiate a call for help themselves - no doubt they were very grateful for whatever came next. 40% of the "did not get invited" group got to witness anyway, and 30% of the invited group declined?? Note that the only suicides all occured in the "witnessed" group suggesting a subset of at risk people - how do we choose?? ( see medscape review of artlicle).

I too feel uncomfortable.

I have 2 very difficult paed resusc anecdotes which have influenced my views on family presence since : -

a colleague placed a Left ICC in a struggling pre - arrest neonate with a large HTX post cardiac surgery, who promptly exanguinated as ICC in heart -Family witnessed, and no doubt in their mind, of cause of death. Highly destructive for all concerned.

Second was a RRT for a baby with a trachy for resp arrest. Paeds retrieval team had just paralysed baby for transport when trachy completely blocked. The blocked trachy was left in situ and peads retrieval hand bagging via facemask.(This baby had a trachy in due to airway obstruction from a massive hygroma.). This was a peadiatric background retrieval team and were very much out of their depth wrt trachys. The family were present. On arrival, there was complete silence in the room and I struggled to elicit sequence of events from team. Child blue and bardycardic and about to receive adrenaline. I replaced trachy, problem solved. But trying to establish crisis history was clearly hampered by family presence and child may well have died.


My biggest concern is the dramatic change in communication style, accuracy, honesty and completeness, that occurs in the presence of family, and the potential harm this may cause to the patient.

Is there a difference between resuscitation in ED (most of the paeds literature) vs unexpected deterioration of inpatients? And is there a difference between CPR when nothing to lose, vs appropriate procedures and their small but real catastrophic risk??

I occassionaly allow family member presence at procedures, but I choose carefully. I also teach a junior at nearly every procedure I do( ie: junior doing procedure) - they are already nervous enough - I don't think adding a family member is appropriate to that scenario. I supervised a quite senior registrar put in their first vascath yesterday, having done many central lines and very competent - patient was anxious and nervy and jumped at everything - not sure that family members need to see that, and would they be upset in that it would appear that the operator was learning??

Finally, resusc providers are human. These are stressful situations albeit, different from the families stress. We have many coping and communication skills. Is it fair to have our coping, communication and teamwork skills compromised by family presence and does that harm the patient?? Lead in to the next anecdote!!

At an adult inpatient resusc, unbeknown to the team, the patients daughter was outside, and lighthearted banter was occuring during the resusc.The daughter who heard and took all out of context, burst in and started hitting one member of the team and yelling at the rest of us. No harm done to patient that I can recall, but major embarrassment to all and seriously upset relative.

Take home message is - relatives either in room and evreyone knows this, or nowhere near!!

Todd Fraser from Australia wrote 03-19-2013 12:36:47 pm
Comment from Dr George Kyriazopoulos, an intensivist from Greece :

"CPR is a critical medical procedure in which decisions and actions are to be taken in seconds, a human life is determined within minutes and well trained medical staf (doctors & nurses) is under immense stress. The family presence exacerbates it and by no means improves outcome. In addition, the emotional bond of the family, combined with ignorance of emergency and the critical techniques undertaken onto the patient, can trigger misunderstantings and loss of confidence about the manner of the CPR, in the case that the former is not a 100% successful.
If you allow family presence during CPR you should allow it also during a brain tumor excision or an appendicectomy, with soft music echoing, light snack and beverages (and a "quickie" in the resident's room in between emergencies). I am not joking, relevant TV series show us how people (families) see and what they expect from us i.e. to perform constantly miracles and to cure our stress with an increased libido.
From the mystic and secretive practice of medicine in ancient times we have reached the other end, everything in broad light. I am certain that neither of them is of patient or family, or doctor benefit.
When I have my precious car's engine tunned every year I am not allowed by the mechanic to be present because I am distracting him. I trust and respect his qualifications and skills and have no idea whether he uses fine and sofisticated procedures or a sledgehammer. I hope the former and I tolerate the latter as far as I am happy with the result.
In conclusion, everytime I lead in a CPR, I move away immediately firstly the family followed by everybody else (doctors and nurses even the manager of the hospital who may be passing through) who is not actively involved with it.
Sorry about all this chatter, but after 25 years of active medical practice, I still believe strongly that any medical procedure should be carried out with friends and family of the patient in the waiting room (outside the hospital if I could make the rules !!!!)
Regards, George"

Todd Fraser from Australia wrote 03-19-2013 12:39:27 pm
Comment from Lorette Gijsbers from Netherlands :


"In the netherlands it is almost a common thing in the neonatology intensive care setting. In the adult ic there are still a lot differences. I know that UMC Groningen was for a few years ago the first intensive care where relatives are there in the CPR setting and they get help from social workers . In my hospital it depends on who is working if family get involved. When the setting is at the emergency room, then the family is present and they get support from the nurse. I can remember myself a setting when a mother was asking : why do you stop to the intensivist, he told here over and over , and we stood there as a team, it was very emotional. But it feld bether that the parents did see that we did everything for their son. afther this situation we talked about what we feld in this situation together as a team. And the parents where seen after this situation by the dokter, even months after this situation they could talk with the intensivist. In our country there are a lot of students ho wrote there final research document about family presence during CPR , it is well known that this is bether for relatives to cope with this experience. For professionals it is nessesery that there is the time to evaluate together and to show feelings."

Mike from United States Of America wrote 03-19-2013 01:12:18 pm
I have not personally encountered this in the peds realm (just not my specialty), and I can't speak to the psychological ramifications in family members post-event. What I can say, is that having a family watch has, on several occasions, allowed us to end obviously futile resuscitations that probably wouldn't have occured in the first place if people had a more realistic idea of what goes on during CPR. With respect to Dr. Kyriazopoulos, resuscitation is far different than a sterile operation, I think the way to eliminate ignorance and misunderstanding at end-of-life and potential end-of-life is to pull the curtain away whenever possible, not hide behind it.