Decisions on Family Observing Resuscitation Efforts Center on Autonomy, Beneficence
Family presence during resuscitation efforts remains controversial, leaving clinicians to wonder whether it is helpful or harmful. A group of researchers decided to study this situation in the ED.1
“We started with the question of whether witnessing resuscitations is beneficial or deleterious for family members,” says Mert Erogul, MD, the study’s lead author. “Even while you’re doing your best to resuscitate a critically ill patient, your mind travels to the person who will be left behind. What words will you use? And would they derive any benefit from seeing what takes place?”
Physicians have wondered whether family presence during resuscitation permits some sort of psychological closure. There have been numerous studies on family presence over the years, with inconsistent findings. “It turns out this is a relatively difficult question to approach,” says Erogul, an emergency physician at Maimonides Medical Center in Brooklyn.
One consideration is whom to study. Most previous studies included cardiac arrest victims. The authors focused on family members of patients whose circulation had failed and were receiving CPR.2-5
Erogul and colleagues thought it would be more valuable to study all critically ill patients, regardless of the resuscitation outcome. The researchers wanted to help physicians decide how to proceed at the moment when a seriously ill patient arrives with his or her family at the ED.
Erogul and colleagues contacted 423 family members of critically ill patients, identified by the ED’s EHR, and administered a validated scale that measures post-traumatic distress symptoms. Family members were divided into two groups: those who had witnessed resuscitation efforts, and those who had not.
Those who witnessed the resuscitations exhibited more PTSD symptoms one month after the event. That does not necessarily mean family presence is harmful. It is possible transient PTSD symptoms could lead to long-term psychological benefits. “There is some evidence to that end in the post-traumatic growth literature,” Erogul notes.6,7
Another ethical question: Who makes the decision? “Does autonomy trump all in this case, as it does for many other matters of gravity in bioethics?” Erogul asks.
Typically, autonomy concerns the patient who has a direct relationship with the physician. If the patient is too sick to participate in decision-making, clinicians are left with a secondary relationship (between the physician and the family member).
“It seems reasonable that family members be permitted autonomy to make a decision in this case. The outcome of the decision has bearing on real consequences in their lives,” Erogul says.
At the Maimonides Medical Center ED, clinicians typically give family members the choice to be present. “We still do not know for certain if this will harm or help the person who is left behind,” Erogul says.
While it is not realistic for an ethicist to be at the bedside when that decision is made, ethicists can discuss underlying ethical issues with clinicians proactively. “Given the considerable burden of keeping up with the medical literature, most doctors never have an opportunity to reflect on these kinds of things,” Erogul observes.
Ethicists also can help develop clear, consistent policies on family-witnessed resuscitation. Based on all the evidence to date, says Erogul, “it’s reasonable to give family members the choice to be present — and to support them should they choose not to watch.”
REFERENCES
- Erogul M, Likourezos A, Meddy J, et al. Post-traumatic stress disorder in family-witnessed resuscitation of emergency department patients. West J Emerg Med 2020;21:1182-1187.
- Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998;352:614-617.
- Compton S, Grace H, Madgy A, Swor RA. Post-traumatic stress disorder symptomology associated with witnessing unsuccessful out-of-hospital cardiopulmonary resuscitation. Acad Emerg Med 2009;16:226-229.
- Compton S, Levy P, Griffin M, et al. Family-witnessed resuscitation: Bereavement outcomes in an urban environment. J Palliat Med 2011;14:715-721.
- Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med 2013;368:1008-1018.
- Kleim B, Ehlers A. Evidence for a curvilinear relationship between posttraumatic growth and posttrauma depression and PTSD in assault survivors. J Traum Stress 2009;22:45-52.
- Dekel S, Ein-Dor T, Zahava S. Posttraumatic growth and posttraumatic distress: A longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy 2012;4:94-101.
Ethicists can discuss underlying issues with clinicians proactively. They also can help develop clear, consistent policies on family-witnessed resuscitation.
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