Between life and death: should family witness resuscitation?
The unresponsive elderly woman lay on a stretcher as a team of physicians, nurses, and others worked busily trying to save her. Amidst the organized chaos, I soon realized I was not the only observer in the room. The woman’s husband and son had been invited in by the charge nurse. I wondered whether they should witness such intense and disturbing medical procedures, some even unsettling for me. I mean, shouldn’t we try to spare families from witnessing such dramatic events? And couldn’t they jump in at any moment and disrupt the care team?
What healthcare providers call “resuscitation” is usually the care provided to someone dying; it’s a last-ditch effort which is often unsuccessful. There is now good evidence that witnessing the care provided to a dying relative can ease grief and facilitate positive long-term psychological outcomes. Observing this process may ultimately help families come to terms with the finality and reality of death.
Traditionally, families were escorted away from their loved ones during resuscitation. This exclusion of family members was first questioned in 1982 by emergency room staff at the Foote Hospital in Michigan. An evaluation of chaplain services revealed that 73 percent of family members whose loved ones had died following unsuccessful resuscitation had wanted to be present during the final hours of resuscitative care. A program was then introduced that permitted select family members to be present in the treatment room. This was the first formally documented program of family-witnessed resuscitation (FWR) during critical medical care.
In the three decades since, FWR has been the subject of several more studies. They have shown benefits to those offered the option to be present during a loved one’s resuscitation.
Generally, a family left in the waiting room is more likely to misunderstand the care provided and FWR is linked to decreased medico-legal risk. Similarly, allowing families to be present helps them understand the severity of the patient’s condition and appreciate the extent of care provided. Several families have stated feeling reassured that their loved ones did not die alone.
This has led to more official endorsements from professional societies in both Canada and the United States. In 2000, the internationally respected American Heart Association (AHA) included FWR in its official recommendations for Advanced Cardiac Life Support.
The little we know from the patient’s perspective boils down to three anecdotal cases from people who survived resuscitation efforts. All three indicated feeling supported by having family present and did not feel their dignity or confidentiality were compromised.
Though data show the benefits of FWR, many health care practitioners have been slow to adopt the practice of inviting families to witness resuscitation efforts.
In a 2014 review, medical providers said their reluctance stemmed from a fear of potential litigation, heightened stress and anxiety, psychological trauma to the family, and concerns regarding the quality of care or potential for protective family to disrupt care.
While the evidence is now fairly strong for FWR, logistical obstacles remain, including determining who and how many family members should be present and how to accommodate them in addition to a large healthcare team and unwieldy medical equipment.
Though many initially feared having relatives present would result in unnecessary suffering to family or increased litigation when a loved one dies, it’s encouraging that data have revealed quite the opposite.
It’s also important to understand how to support family members through the experience of seeing emergency resuscitative care.
Some possible next steps to wider implementation of FWR may include:
- Thoughtfully designed spaces to accommodate family during resuscitative care.
- Formal guidelines on what constitutes “family” and how many people can be present without interfering with the care team.
- Early planning for the role of a designated “chaperone” to support family members during tough moments and provide a way out should it be necessary.
- Improved awareness from care professionals to consider the possibility of having lay witnesses present during resuscitative care.
Family witnessed resuscitation represents a critical opportunity to build trust, transparency, and inclusiveness. The question has shifted from whether we should allow family members during resuscitative care to how do we best ensure FWR is practiced in a way that is beneficial for patients, their loved ones and medical providers.
Matthew Piaseczny is a medical student at the University of Toronto with interest in emergency and critical care medicine. Samuel Vaillancourt is a specialist emergency physician and trauma team leader practicing at St. Michael’s Hospital and an associate scientist at the Li Ka Shing Knowledge Institute.