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Seeing failed CPR of loved one may help coping

By Gene Emery

NEW YORK (Reuters Health) - When family members were allowed to watch emergency personnel try but fail to resuscitate a loved one, the relatives were less likely to have post traumatic stress symptoms, anxiety or depression months later, in a new French study.

The researchers, who published their findings in the New England Journal of Medicine, also found that allowing the family to witness the rescue attempts did not increase stress on the health care workers, influence whether the victim survived or result in more lawsuits.

"Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts," wrote the team, led by Dr. Patricia Jabre of Avicenne Hospital in Bobigny.

CPR is unsuccessful in the vast majority of cases.

Supporters of the idea of allowing family members to observe say it can help them understand that medical workers did everything they could, come to grips with the reality of death and give the family the chance to say goodbye.

Although the question of whether it's a good idea has received little study, international guidelines encourage letting the family watch.

"Our results show that it is very important to systematically propose to the relative (it's not mandatory) that the relative attend CPR and offer the choice to be present or not," study author Dr. Frederic Adnet, also of Avicenne Hospital, told Reuters Health in an email.

"What this study says is, 'It's not a serious problem if a close relative wants to be around for the process,'" said Dr. Gordon Tomaselli, past president of the American Heart Association and a cardiologist at Johns Hopkins University School of Medicine.

The French group's conclusions were based on 570 cases treated by 15 emergency medical teams equipped with mobile intensive care units and staffed with at least one doctor and nurse. In each case when watching was permitted, family members were directly asked if they wanted to observe. If not, they were taken to another portion of the home.

When people chose to watch, a member of the team briefed the relatives throughout the process.

Ninety days later, relatives were interviewed using a 15-item questionnaire.

Among the 266 cases in which family were asked if they wanted to watch, someone did choose to do so 79 percent of the time. In the 304 cases where no special effort was made to ask and the usual practice was in place, 43 percent of the time someone chose to witness the resuscitation attempts.

Of the 570 people who underwent CPR, only 20 were still alive 28 days later, a survival rate of 4 percent. Whether family members were allowed to watch made no difference in that rate.

Among the participating families who did not witness the CPR, the rate of post-traumatic stress disorder (PTSD) symptoms was 60 percent higher than among the relatives who did watch the CPR.

And while 12 percent of the people who did not witness the CPR said they wished they had, only 3 percent of the relatives who were present for it said they wished they hadn't been.

Less than 1 percent fought with the medical team, and team members reported comparable stress levels whether or not family members were present.

No lawsuit threats were received. The culture may be different in France, the researchers said, but "our findings should help allay physicians' medicolegal concerns."

"Although our study involved only out-of-hospital cardiac arrest, we think that it is applicable for in-hospital cardiac arrest in the U.S.," said Adnet. "Two American studies involving pediatric patients... found results similar to ours."

"It's nice to finally see documentation for what many of us, as physicians, have known for a long time - that often family members will come to you afterwards and say 'Thank you so much. You did as much as you could possibly do,'" after a revival attempt, said Comilla Sasson, a CPR researcher at the University of Colorado School of Medicine, who was not involved in the new research.

There can be a reluctance to let family watch because "we know most people will not survive, and as members of the medical community we don't want them to think it was our fault," Sasson said in a telephone interview. "So there's a huge amount of fear associated with it."

In a Journal editorial, Drs. Daniel Kramer and Susan Mitchell of Beth Israel Deaconess Medical Center in Boston noted that "the intervention involved well-trained medical teams that followed a scripted protocol, a designated support assistant charged with carefully explaining the resuscitative efforts, and a comprehensive postresuscitation debriefing from a qualified physician.

"Thus, it would be imprudent to adopt this strategy into clinical practice without a similar commitment to training and staffing emergency response teams and without an understanding of the cost-effectiveness of such an approach," they wrote.

Tomaselli told Reuters Health that most U.S. rescue units don't have someone designated to explain the CPR process to the family as it's happening. "As care teams get smaller because of cost, fewer people are available to do this type of thing."

In addition, the emphasis is often on quickly stabilizing the patient enough to get to the hospital, which may hamper the ability for the type of interaction with the family seen in the French study, Tomaselli said.

The French researchers said their test should be replicated in a hospital setting to see if the results are different.

Survival after CPR tends to be higher in France than in the U.S., and an unrelated study published in the same issue of the journal found that for U.S. patients over 65, the odds of surviving a cardiac arrest that takes place in the hospital to be discharged are just 22 percent.

Among those survivors, 28 percent ended up with some sort of neurologic disability and in 10 percent of those cases that disability was severe.

Yet when someone age 65 and older does survive, the long-term outlook is good.

Younger patients fared better than older patients, women did better than men and whites did better than blacks, said the team, led by Dr. Paul Chan of the Mid America Heart Institute in Kansas City, Missouri.

But, overall, the one-year survival rate was 73 percent among the people who had survived their hospital stay with a mild neurologic disability or no disability at all, 61 percent for people with a moderate disability and 42 percent with a severe disability. Just 10 percent of those who left the hospital in a coma or were in a vegetative state survived for a year.

SOURCE: http://bit.ly/YrM4KW and http://bit.ly/YrMdxR New England Journal of Medicine, online March 13, 2013.

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