Effect of family presence during resuscitation in adult cardiac arrest on patient, family, and health care provider outcomes; EIT TFSR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. No Task Force members and other authors were recused from the discussion as they declared a conflict of interest. No Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees.

CoSTR Citation

Eastwood KJ, Considine J, Zelop C, Webster H, Smyth M, Nation K, Greif R, Dainty KN, Finn J, Bray J; on behalf of the International Committee on Resuscitation Education, Implementation and Teams, Basic Life Support, and Advanced Life Support Task Forces.

Family presence during adult resuscitation: A Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Resuscitation Education, Implementation and Teams, Basic Life Support, and Advanced Life Support Task Force, 2022 September. Available from: http://ilcor.org.

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of family presence during adult resuscitation conducted by the research team comprising of a range of clinical content experts. The systematic review search strategy was devised in conjunction with Lorena Romero, a Senior Librarian at the Alfred Health Ian Potter Library, Melbourne, Australia. Evidence for literature was sought and considered by the Education, Implementation and Teams, Basic Life Support and Advanced Life Support Task Forces. These data were taken into account when formulating the Treatment Recommendations.

Family presence during adult resuscitation was defined as a relative or significant other who is within sight of resuscitation of an adult (including in public areas, homes and hospital settings).

Systematic Review

Considine J, Eastwood KJ, Webster H, Smyth M, Nation K, Greif R, Dainty KN, Finn J, Bray J. for the International Committee on Resuscitation’s (ILCOR) Education, Implementation and Teams, Basic Life Support, and Advances Life Support Task Forces. Family presence during adult resuscitation from cardiac arrest: A systematic review. Resuscitation. 2022;180:11-23.

PICOST

Population: Adults requiring resuscitation for cardiac arrest in any setting.

Intervention: Family presence during resuscitation

Comparators: Family not present during resuscitation

Outcomes:

• Patient outcomes (short and long term): return of spontaneous circulation, survival (to hospital admission, hospital discharge/30-days, 3 months, 6 months, 1 year), survival with good neurological outcomes (at same time points), depression and anxiety.
• Family (or significant other) outcomes (short and long term): PTSD, coping, perception of the resuscitation, depression and anxiety amongst family members, complicated grief syndrome.
• Health care provider outcomes: perception of the resuscitation, performance, perceived futility in some circumstances, psychological stress including projection to provider’s own family.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were included, and unpublished studies (e.g., conference abstracts, trial protocols) were excluded.

Timeframe: All years and all languages were included as long as there was an English abstract. Literature search updated to May 10, 2022.

PROSPERO Registration CRD42021242384

Consensus on Science

In brief, the limited available evidence across 31 studies (Celik 2021 338, Jabre 2013 1008, Krochmal 2017 221, Wang 2019 e0213168, Metzger 2019 57, Soleimanpour 2017 113, Compton 2011 715, Belanger 1997 238, Post 1986 152, Magowan 2019 13, Sak-Dankosky 2015 2595, Ganz 2012 220, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Boyd 2000 51, Compton 2009 226, Waldemar 2021 23, De Stefano 2016 e0156100, Masa’Deh 2014 72, Weslien 2006 68, van der Woning 1999 186, Giles 2018 e1214, Hassankhani 2017A 127, Hassankhani 2017B 95, Bremer 2012 42, Monks 2014 353, Walker 2014 453, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32) examining family presence during adult resuscitation was of very low certainty. The included studies were highly heterogenous, comprising a range of study designs with just over a half of all the studies having a qualitative study design and only two being RCTs. (Celik 2021 338, Jabre 2013 1008) Downgrading also occurred due to potential confounding, heterogeneity or a lack of information across the studies regarding patient, family and provider characteristics, cardiac arrest settings. There was inconsistency in the reporting of results, indirectness in terms of population, study design, and outcomes of interest, and imprecision due to small sample sizes and large confidence intervals (when reported).

Patient outcomes were reported in 12 studies (Jabre 2013 1008, Krochmal 2017 221, Wang 2019 e0213168, Metzger 2019 57, Soleimanpour 2017 113, Oman 2010 524, Waldemar 2021 23, Masa’Deh 2014 72, Weslien 2006 68, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32) and of four studies that compared family presence to no family presence, (Jabre 2013 1008, Wang 2019 e0213168, Waldemar 2021 23, Krochmal 2017 221) only one identified a significant outcome that favored no family presence during resuscitation for patient survival at ROSC and discharge. (Krochmal 2017 221)

Family outcomes were reported in 15 studies (Celik 2021 338, Jabre 2013 1008, Metzger 2019 57, Soleimanpour 2017 113, Compton 2011 715, Belanger 1997 238, Post 1986 152, Compton 2009 226, De Stefano 2016 e0156100, Masa’Deh 2014 72, Weslien 2006 68, van der Woning 1999 186, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32) investigating depression, anxiety, post-traumatic stress disorder (PTSD) and experience of witnessing the resuscitation of a family member. While three studies reported elevated depression (Metzger 2019 57) or PTSD, (Compton 2009 226, Compton 2011 715) there was little compelling evidence supporting the notion that witnessing the resuscitation of a family member caused one of these mental health conditions as no other potentially precipitating factors were considered. In terms of the experience of witnessing a family member’s resuscitation, both positive and negative outcomes were reported. Many family members stated they would witness resuscitation again,(Belanger 1997 238, Post 1986 152) and enabled them to better manage their grief. (Belanger 1997 238) Negative outcomes included concerns about managing their emotional responses,(Weslien 2006 68) interferring with the resuscitation(Weslien 2006 68) and the dehumanising nature of the resuscitation process(De Stefano 2016 e0156100).

where as some found the process long,( Post 1986 152) brutal and dehumanising (De Stefano 2016 e0156100) and excessive.(De Stefano 2016 e0156100)

Finally, healthcare provider outcomes were measured in 20 studies. Varying experience with family witness resuscitation was evident and overall, few positive or negative outcomes were reported. Providers were generally supportive of family presence during resuscitation(Post 1986 152, Meyers 2000 32) and felt their function was not impaired by family presence.(Belanger 1997 238, Post 1986 152) However, across the studies, some apprehension towards family presence was noted in providers and the need for family support personnel, training and unit based policies or protocols was identified.(Magowan 2019 13, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Hassankhani 2017B 95, Bremer 2012 42)

Overall, there was no evidence of harm as a direct result of family presence across the studies for patients or families. There was variability in practices and outcomes of family presence during resuscitation, but given the high desire for this choice and the potential for positive outcomes for family members, international resuscitation guidelines are likely to advocate for families to have a choice regarding their presence during resuscitation.

Study Characteristics

• Overall, there were 31 papers included. Eighteen were quantitative studies, including two RCTs(Celik 2021 338, Jabre 2013 1008) and 16 observational studies (Celik 2021 338, Jabre 2013 1008, Krochmal 2017 221, Wang 2019 e0213168, Metzger 2019 57, Soleimanpour 2017 113, Compton 2011 715, Belanger 1997 238, Post 1986 152, Magowan 2019 13, Sak-Dankosky 2015 2595, Ganz 2012 220, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Boyd 2000 51, Compton 2009 226, Waldemar 2021 23). Twelve were qualitative studies (De Stefano 2016 e0156100, Masa’Deh 2014 72, Weslien 2006 68, van der Woning 1999 186, Giles 2018 e1214, Hassankhani 2017A 127, Hassankhani 2017B 95, Bremer 2012 42, Monks 2014 353, Walker 2014 453, Giles 2016 2706, Wagner 2004 416) and one was a mixed methods study.(Meyers 2000 32)
• The majority of studies (24 studies) examined in-hospital resuscitation.(Wang 2019 e0213168, Masa’Deh 2014 72, Axelsson 2010 15-23, Badir 2007 83-92, Belanger 1997 238-9, Boyd 2000 51-3, Celik 2021 338-45, Compton 2011 715-21, Ganz 2012 220-7, Giles 2016 2706-17, Giles 2018 e1214-e24, Hassankhani 2017B 95-100, Hassankhani 2017A 127-34, Krochmal 2017 221-8, Magowan 2019 13-9, Meyers 2000 32-43, Monks 2014 353-9, Oman 2010 524-33, Post 1986 152-6, Sak-Dankosky 2015 2595-608, Soleimanpour 2017 113-7, Wagner 2004 416-20, Weslien 2006 68-74, Waldemar 2021 23-30) Resuscitation locations included the emergency department (ED) (n=11),(Belanger 1997 238-9, Boyd 2000 51-3, Celik 2021 338-45, Compton 2011 715-21, Giles 2016 2706-17, Giles 2018 e1214-e24, Hassankhani 2017B 95-100, Hassankhani 2017A 127-34, Magowan 2019 13-9, Post 1986 152-6, Walker 2014 453-8) intensive care unit (ICU) (n=5),(Ganz 2012 220-7, Giles 2016 2706-17, Giles 2018 e1214-e24, Krochmal 2017 221-8, Wagner 2004 416-20) critical care areas (n=5),(Masa’Deh 2014 72, Hassankhani 2017B 95-100, Hassankhani 2017A 127-34, Monks 2014 353-9, Sak-Dankosky 2015 2595-608) and all hospital areas (n=6).(Wang 2019 e0213168, Waldemar 2021 23, Giles 2016 2706-17, Giles 2018 e1214-e24, Meyers 2000 32-43, Oman 2010 524-33) In three studies the specific in-hospital context was not reported,(Axelsson 2010 15-23, Badir 2007 83-92, Soleimanpour 2017 113-7) and in eight studies more than one in-hospital location was reported.(Giles 2016 2706-17, Giles 2018 e1214-e24, Hassankhani 2017B 95-100, Hassankhani 2017A 127-34, Meyers 2000 32-43, Sak-Dankosky 2015 2595-608, Waldemar 2021 23-30, Walker 2014 453-8)
• Out-of-hospital resuscitation was examined in five studies,(Jabre 2013 1008, De Stefano 2016 e0156100, Metzger 2019 57-63, Compton 2009 226-9, Bremer 2012 42-52) one study reported on both in- and out-of-hospital resuscitation,(Walker 2014 453-8) and in another study the resuscitation context was not clear.(van der Woning 1999 186-92)

Patient Outcomes

• For the critical outcomes of patient survival (short and long term), twelve studies reported on between six and 1525 patients.(Jabre 2013 1008, Krochmal 2017 221, Wang 2019 e0213168, Metzger 2019 57, Soleimanpour 2017 113, Oman 2010 524, Waldemar 2021 23, Masa’Deh 2014 72, Weslien 2006 68, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32)
• Survival at a range of timepoints was most commonly reported, including ROSC,(Jabre 2013 1008, Wang 2019 e0213168, Oman 2010 524, Weslien 2006 68, Masa’Deh 2014 72) 12 hours,(Weslien 2006 68) hospital discharge,(Krochmal 2017 221) hospital admission,(Jabre 2013 1008) 11 months,(Weslien 2006 68) 28-days,(Jabre 2013 1008, Soleimanpour 2017 113) 30-days,(Waldemar 2021 23) 90-days(Metzger 2019 57) and unreported.(Wagner 2004 416, Meyers 2000 32, Giles 2016 2706)
• Only four of twelve studies reporting patient outcomes examined the impact of family presence versus no family presence during resuscitation and three identified no significant difference to survival based on family presence.(Jabre 2013 1008, Wang 2019 e0213168, Waldemar 2021 23). One study favored family absence during cardiac arrest for ROSC and survival to discharge.(Krochmal 2017 221) The remaining eight studies only reported overall survival without consideration of whether family were present or absent. (Metzger 2019 57, Soleimanpour 2017 113, Oman 2010 524, Masa’Deh 2014 72, Weslien 2006 68, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32) One study found significantly lower unadjusted (p=0.04) and adjusted (p=0.03) rates of survival to discharge when families were present (Krochmal 2017 221). However, two other studies investigating out-of-hospital (Jabre 2013 1008) and in-hospital (Waldemar 2021 23) resuscitation reported on survival to admission, 28-days and 30-days and found no significant difference between groups for survival.(Jabre 2013 1008)

Family Outcomes

For the important outcomes of family (short and long term) outcomes, there were fifteen studies identified comprising between five and 570 family members.(Celik 2021 338, Jabre 2013 1008, Metzger 2019 57, Soleimanpour 2017 113, Compton 2011 715, Belanger 1997 238, Post 1986 152, Compton 2009 226, De Stefano 2016 e0156100, Masa’Deh 2014 72, Weslien 2006 68, van der Woning 1999 186, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32)

• Depression: There were conflicting results for depression in family members present during resuscitation: one study reporting witnessing resuscitation of a family member as an independent predictor of depression at 90-days,(Metzger 2019 57) whereas two others reported fewer symptoms of depression at 30- and 90-days.(Jabre 2013 1008, Soleimanpour 2017 113) A study examining 30-day outcomes, found no significant difference in depression symptoms.(Compton 2011 715)
• Anxiety: In three studies witnessing a resuscitation was associated with less anxiety (Metzger 2019 57, Soleimanpour 2017 113) or anxiety-related symptoms.(Jabre 2013 1008)
• Post-traumatic stress disorder (PTSD) symptoms: Two of the four studies measuring PTSD symptoms reported fewer PTSD symptoms at 90-days in family members who witnessed resuscitation.(Jabre 2013 1008, Soleimanpour 2017 113) Conversely, two other studies identified significantly higher PTSD symptom scores at 79-84 days (Compton 2009 226) and increased arousal at 60-days in those who witnessed resuscitation of a family member.(Compton 2011 715) In the latter study, no significant difference was seen in other PTSD symptoms such as re-experiencing or avoidance or depression symptoms.(Compton 2011 715)
• Family member experience of witnessing resuscitation: The experience of family members present during resuscitation was investigated in nine studies. (Belanger 1997 238, Post 1986 152, De Stefano 2016 e0156100, Weslien 2006 68, van der Woning 1999 186, Giles 2016 2706, Wagner 2004 416, Meyers 2000 32, Masa’Deh 2014 72)
• Two quantitative studies reported that almost all respondents stated they would witness the resuscitation again,(Belanger 1997 238, Post 1986 152) and that they believed it enabled them to better manage their grief,(Belanger 1997 238) and adjust to their family member’s death .(Post 1986 152) These findings were reflected in a mixed-methods interview study that found all witnesses of resuscitation of a family member thought it was important and helpful to be present.(Meyers 2000 32) Two of three studies that questioned respondents about regret and found that very few (Giles 2016 2706)(Jabre 2013 1008) family members regretted being present, whereas one small study reported 3 of 5 family members interviewed regretted witnessing the resuscitation of a family member.(van der Woning 1999 186) An RCT study reported that few of those who were not present during the resuscitation regretted being absent.(Jabre 2013 1008)

Some studies reported negative outcomes and found that family members who witness resuscitation found it brutal and dehumanizing,(De Stefano 2016 e0156100) distressing (De Stefano 2016 e0156100, Weslien 2006 68) and were concerned about removing thoughts of the resuscitation.(Weslien 2006 68) Two studies reported family members felt the resuscitation was too long(Post 1986 152) with an excessive or unnecessarily heroic approach to resuscitation.(De Stefano 2016 e0156100) Family members who witnessed resuscitation also reported being afraid of disrupting or interfering with the resuscitation process (Weslien 2006 68) or losing emotional control.(Weslien 2006 68)

Healthcare provider outcomes

Twenty studies reported on provider outcomes and included between six and 1710 providers.(Celik 2021 338, Jabre 2013 1008, Belanger 1997 238, Post 1986 152, Magowan 2019 13, Sak-Dankosky 2015 2595, Ganz 2012 220, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Boyd 2000 51, Waldemar 2021 23, Giles 2018 e1214, Hassankhani 2017A 127, Hassankhani 2017B 95, Bremer 2012 42, Monks 2014 353, Walker 2014 453, Giles 2016 2706, Meyers 2000 32)

• Provider experience with family presence during resuscitation: Seven quantitative studies(Magowan 2019 13, Ganz 2012 220, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Wagner 2004 416) and six qualitative studies (Giles 2018 e1214, Hassankhani 2017A 127, Hassankhani 2017B 95, Bremer 2012 42, Monks 2014 353, Walker 2014 453) reported on provider experience of family presence during resuscitation.
• Prevalence of provider experience with family presence during resuscitation ranged from 35% to 63%.(Magowan 2019 13, Sak-Dankosky 2015 2595, Ganz 2012 220) Providers reported having little experience with inviting family members to be present(Sak-Dankosky 2015 2595, Axelsson 2010 15, Badir 2007 83) and this was more likely in critical areas than in general wards.(Waldemar 2021 23)
• Providers reported few positive or negative experiences with family presence during CPR in four quantitative studies.(Sak-Dankosky 2015 2595, Ganz 2012 220, Axelsson 2010 15, Badir 2007 83) The qualitative studies reported positive experiences grounded in caring for the family. (Hassankhani 2017A 127, Bremer 2012 42, Monks 2014 353, Walker 2014 453) Whereas, negative experiences stemmed from aggressive or disruptive family members and provider concerns about psychological trauma for family members due to negative, visually distressing images of the resuscitation.(Hassankhani 2017A 127, Monks 2014 353)
• Factors influencing provider experience of family presence during resuscitation: Providers internal conflicts and emotional factors influencing provider experience of family presence during resuscitation included the need to balance compassionate care and technical competence,(Monks 2014 353, Walker 2014 453) professional practice and responsibilities,(Monks 2014 353) the shift from patient to family care and guilt associated with resuscitation termination.(Bremer 2012 42)
• Some studies identified that experience alone was not sufficient for effective family support,(Bremer 2012 42) and that there is a need for provider training for managing family presence, a support person for families and unit based policies or protocols for family presence during resuscitation.(Magowan 2019 13, Oman 2010 524, Axelsson 2010 15, Badir 2007 83, Hassankhani 2017B 95, Bremer 2012 42)
• Provider perceptions of family presence during resuscitation: Around three-quarters of providers supported family presence during resuscitation,)(Post 1986 152, Meyers 2000 32) and up to 68% believe their function during resuscitation was not impaired by family presence.(Belanger 1997 238, Post 1986 152)
• Two qualitative studies identified negative provider perceptions of family presence during resuscitation reporting that a minority felt family may hinder clinical performance,(Magowan 2019 13) interrupt care,(Magowan 2019 13) interfere with care(Oman 2010 524) and negatively impact team communication (Oman 2010 524)

Three studies investigated provider anxiety(Celik 2021 338) or stress.(Jabre 2013 1008, Boyd 2000 51) Mean anxiety was higher in providers who had family witnessing resuscitation compared to providers who carried out resuscitation without family witnessing the process.(Celik 2021 338) No difference was found in stress levels for either study reporting provider stress.(Jabre 2013 1008, Boyd 2000 51)

Treatment Recommendations

• We suggest that family members be provided with the option to be present during in-hospital adult resuscitation from cardiac arrest. (weak recommendation; very low certainty of evidence)
• We suggest that family members be provided with the option to be present during out-of-hospital adult resuscitation from cardiac arrest acknowledging that providers are often not able to control this. (weak recommendation; very low certainty of evidence)
• Policies or protocols about family presence during resuscitation should be developed to guide and support healthcare professional decision-making. (Good Practice Statement)
• When implementing family presence procedures, healthcare providers should receive education about family presence during adult cardiac arrest resuscitation, including how to manage these stressful situations, family distress and their own responses to these situations. (good practice statement)

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the Education, Implementation and Teams (EIT), the Basic Life Support (BLS), and the Advanced Life Support (ALS) Task Forces considered the following:

• Some of the participants in these studies may have cultural, religious or other sociological factors that can influence their attitudes and behaviors regarding family presence during adult resuscitation. The Task Forces considered the overall findings on patient, family and provider outcomes excluding these factors because none of the included studies investigated them.
• There will be a need for resuscitation councils to adapt the treatment recommendations to their local environments to meet the cultural, religious and sociological expectations of family presence during adult cardiac arrest resuscitation.
• The practice context (out-of-hospital versus in-hospital) can vary significantly in terms of attitudes and experiences of family presence during resuscitation, however establishing the overall impact on patient, family and provider outcomes was considered more important than isolating the findings to one setting.
• The nature of the cardiac arrest requiring resuscitation, or the characteristics of the patient (i.e. younger versus older adult, precipitating illness/ condition) were not reported in the included studies. Therefore, the Task Forces considered the overall findings on patient, family and provider outcomes in the absence of this information. The age of family members viewing resuscitation may require further consideration especially when they are less than 18 years of age.
• There were only two RCTs (Celik 2021 338, Jabre 2013 1008) comprising between 100-630 participants but these trials contained some methodological limitations. Nonetheless, we acknowledge the difficulty in conducting an RCT in this setting where it would be unethical to stop a family member from being present or absent in these circumstances.
• In making the recommendations we considered the reported negative experiences of providers from a psychological and family management standpoint. However, the expert opinion of the Task Forces is that the implementation of provider education, and unit-based policies and protocols will address many of these issues.
• Provider education and unit-based policies or protocols were not directly examined in any of the studies, however two Good Practice Statements have been made based on the recommendations of the included studies and the absence of any evidence of harm.
• While none of the studies considered any other factors that may contribute to detrimental mental health outcomes following family witnessed resuscitation for family members or healthcare providers, there may be a need for education and/or structured follow-up regarding the possible long-term effects of witnessed resuscitation on these cohorts.

Knowledge Gaps

None of the included studies considered the impact of the nature of resuscitation on patient, family or providers. This included factors such as specific patient characteristics, precipitating events/ illness resulting in cardiac arrest, whether or not family members provided bystander CPR or the resuscitation setting. Research is required to provide higher quality of evidence of the impact of these factors on patient, family and provider outcomes.

• The cultural, religious or other sociological or health equity factors that may have influenced attitudes and behaviors regarding family presence during adult resuscitation were not considered in the included studies. Future research using qualitative and quantitative study designs should investigate the impact of these factors on family presence during resuscitation.
• While some studies mentioned established unit-based policies and protocols or family support personnel, there were no studies that investigated the impact of the presence or absence of these resources on patient, family and provider outcomes in family presence during resuscitation. Future research should be conducted to inform organizational guidelines and policies to reduce the decision burden on individuals and to facilitate and operationalize care of families during adult resuscitation. These studies should include an evaluation of the cost-effectiveness of resourcing the resuscitation setting to accommodate family presence. Studies should then focus on the impact of these resources on healthcare providers.

Attachments: ETD Family presence in Adults Final

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