May 122013
Families Allowed to Witness CPR Felt Better, Had Fewer Regrets

Should family members be allowed, or even encouraged, to witness the health care team's attempts to revive their family member with CPR after a cardiac arrest? In the interests of openness and transparency, many have argued "yes," with the thought that witnessing the heroic efforts to forestall death will help surviving members accept and cope with the loss. But allowing family members to witness a "code blue" may make the job more difficult or stressful for those delivering care, create legal risk if a mistake is made, or cause psychological trauma like PTSD in family members who watch what can often seem a brutal process.

Although there's no strong evidence supporting either side of the argument, a few observational and qualitative studies support allowing family members to witness CPR, and this is the current trend in the U.S and elsewhere. A new study in the New England Journal of Medicine suggests the practice is sound, safe, and possibly beneficial.

What They Did

Patricia Jabre et al randomized 15 French pre-hospital emergency medical teams (first responders) to either systematically offer family members the chance to watch CPR being done on their family member, or not offer it, when arriving on scene of a cardiac arrest at the family's home. Ninety days later, a psychologist followed up with the family by phone using the IES and HADS instruments.

What They Found

A total of 342 family members (60%) witnessed CPR and 228 did not. According to their surveys at 90 days,

  • More people who were not offered the chance to watch CPR developed PTSD-like symptoms (adjusted odds ratio of 1.6) than those who were invited to witness the code.
  • 12% of those who did not witness CPR felt sorry that they did not, while only 3% of those who did witness it regretted having done so.
  • There was no statistical difference between groups in the effectiveness of resuscitation, duration of CPR, the survival rate, or selection of drugs.

Less than 1% of family members became aggressive or came in conflict with the first responders. There were no lawsuits filed by family members in either group during ~2 years of followup. This was in France, with a completely distinct medicolegal environment than the U.S. (e.g., France has a public fund to reimburse victims of health care harm on a no-fault basis).

French health care workers are either extremely cool characters, or menteurs: they reported only a median of 5 on a visual-analog scale of 0-100 for their stress level in the period immediately after each resuscitation. I'd put mine at about a 47 after a code, and that's when it goes well. Ah, c'est la vie ... et c'est la mort ... quelle est la difference?

What It Means

It's a stretch to extrapolate study findings across cultures, continents and health systems. That said, people are people, and CPR is hopefully quite similar across the developed world. This study adds convincing evidence of the absence of harm, and potential benefits, of offering family the chance to watch their loved one's resuscitation attempt after cardiac arrest.

The real question, though, is why the default condition has historically been exclusion. Why should we ever systematically prohibit family members from being present for their loved one's last moments on earth, assuming there is no flagrant interference with care? Fear of lawsuits is presumably the reason, but it's a craven one, with potentially cruel consequences. If a wife or husband wants to be present, and feels ready to bravely face the painful, stark loss if things don't go well, how can you lock them out? Medically, spiritually, professionally -- what is gained by this?

Death happens. Whatever downstream psychological consequences might result from watching a family member's "code blue" are a fact of emotional life, not something created by the professional people trying to help. Even if there were a high rate of PTSD in the CPR-witnessing group, the answer would be to warn of the risk before (with a 2-sentence script) and offer counseling after -- not to paternalistically deny families a final, deeply meaningful experience close to the loved one they are probably losing.

Patricia Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM 2013;368:1008-1018.

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Allowing families to witness CPR had positive effects (RCT)