Long-term quality of life of caregivers of cardiac arrest survivors and the impact of witnessing a cardiac event of a close relative

Observer-reported cognitive decline in out-of-hospital cardiac arrest survivors and its association with long-term survivor and relative outcomes

AIM

Long-term cognitive decline after out-of-hospital cardiac arrest (OHCA) is still poorly understood. This study describes long-term observer-reported cognitive decline among Danish OHCA survivors, including differences in years since the event, and investigates characteristics and self-reported outcomes associated with observer-reported cognitive decline.

METHODS

Adults who survived an OHCA from 2016 to 2019, and their relatives, completed the national DANish Cardiac Arrest Survivorship survey. Relatives completed the Informant Questionnaire on Cognitive Decline in the Elderly, Cardiac Arrest version (IQCODE-CA), the Hospital Anxiety and Depression Scale (HADS) and the World Health Organisation-Five Well-being index; and survivors completed the Two Simple Questions (everyday activities and mental recovery), the Modified Fatigue Impact Scale, HADS, and the Short World Health Organisation Disability Assessment Schedule 2.0. Potential associations between survivor characteristics and the IQCODE-CA were investigated using a multivariable logistic regression model. Self-reported outcomes among survivors and relatives, and the association with IQCODE-CA scores were investigated using separate logistic regression models.

RESULTS

Total median IQCODE-CA score was 3.04 (IQR: 3.00-3.27), with 47% having possible cognitive decline (score ≥ 3.04), consistent across time groups. Increasing age (OR 0.98, 95% CI: 0.97-0.99) and worse self-reported mental and physical outcomes for survivors and relatives, except 'everyday activities' were significantly associated with possible cognitive decline among survivors.

CONCLUSIONS

Nearly half of OHCA survivors may suffer long-term cognitive decline. Worse self-reported mental and physical outcomes among survivors and their relatives are associated with potential cognitive decline emphasising the need for post-OHCA care to include systematic neurocognitive assessment, tailored support and effective rehabilitation.

Prioritizing intervention preferences to potentially reduce caregiver burden in racially and ethnically diverse close family members of cardiac arrest survivors

AIM

Close family members of cardiac arrest patients who survive to hospital discharge have elevated levels of psychological distress and caregiver burden. We assessed their preferences toward needs during hospitalization and beyond to inform intervention development.

METHODS

Through an online survey developed by a multidisciplinary team of researchers, clinicians, cardiac arrest survivors, and families, adult close family members recruited through advocacy organizations ranked top choice among 8 unique interventions addressing either information-based needs (n = 4) or well-being needs (n = 4). Logistic Regression analysis was conducted to assess the associations of family members' attributes, caregiving characteristics, and survivors' hospitalization factors with two intervention groups.

RESULTS

Of 657 responses received, ranking data of 550 close family members (59% between 18-40 years of age, 65% female, 51% of minority race/ethnicity, 53% partners, provided a median of 8 hours of caregiving, for a median of 4.5 months) were analyzed. Information needs were the more commonly preferred intervention group (63%; n = 347), with education on the potential recovery of survivors ranking first (28%; n = 149). In a multivariate model, family members age >40 years, families witnessing the cardiac arrest, assuming the caregiver role either during hospitalization or within one month of hospital discharge, and discharging directly to home were significantly associated with prioritizing information needs over well-being needs, after adjusting for sex, race, intensity, and duration of caregiving.

CONCLUSIONS

Interventions focusing on information needs are among the top priorities for families of cardiac arrest survivors. Prospective studies testing these hypotheses-generating findings are needed to inform further intervention development.

Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later

Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.

Factors Associated With Symptoms of Prolonged Grief and Psychological Distress Among Bereaved Family Members of Persons Who Died From Sudden Cardiac Arrest

BACKGROUND

Death from sudden cardiac arrest implies a stressful and challenging situation for bereaved family members with an increased risk of prolonged grief disorder and psychological distress.

OBJECTIVES

The aims of this study were (1) to explore the associations between symptoms of prolonged grief and psychological distress and (2) to identify factors associated with symptoms of prolonged grief and psychological distress among bereaved family members of persons who died from sudden cardiac arrest.

METHODS

This cross-sectional survey included bereaved adult family members. Demographic data and measures of prolonged grief (Prolonged Grief Disorder-13), anxiety and depression (Hospital Anxiety and Depression Scale), posttraumatic stress (Posttraumatic Stress Disorder Checklist for DSM-5), and perceived social support (Multidimensional Scale of Perceived Social Support) were analyzed using Spearman's correlations ( r s ) as well as univariate and multiple linear regression analyses.

RESULTS

In total, 108 family members participated. Significant associations between symptoms of prolonged grief, anxiety, depression, and posttraumatic stress were identified ( r s = 0.69-0.79, P < .001). Offered, sought, and/or received professional support from healthcare, lower levels of perceived social support, being a spouse of the deceased, female sex, younger age, and family presence during resuscitation were significantly associated with higher symptom levels of prolonged grief, anxiety, depression, and/or posttraumatic stress.

CONCLUSIONS

The results indicate that family members with higher levels of symptoms were offered, sought, and/or received professional support. However, because a minority are offered professional support after deaths from cardiac arrest, future interventions need to proactively identify family members in need of support. Furthermore, perceived social support seems to be an important factor for family members of persons who died from cardiac arrest.

Family experiences and health outcomes following a loved ones' hospital discharge or death after cardiac arrest: A scoping review

Aim

Synthesise the existing literature on experiences and health outcomes of family members of adult cardiac arrest patients either after hospital discharge or death and identify gaps and targets for future research.

Methods

Following recommended scoping review guidelines and reporting framework, we developed an a priori protocol and searched five large biomedical databases for all relevant studies published in peer-reviewed journals in the English language through 8/8/2022. Studies reporting either on the experiences or health outcomes of family members of adult cardiac arrest patients who survived to hospital discharge (i.e., co-survivors) or bereaved family members were included. Study characteristics were extracted and findings were reviewed for co-survivors and bereaved family members. We summarised practice recommendations and evidence gaps as reported by the studies.

Results

Of 44 articles representing 3,598 family members across 15 countries and 5 continents, 89% (n = 39) were observational. Co-survivors described caregiving challenges and difficulty transitioning to life at home after hospital discharge. Co-survivors as well as bereaved family members reported significant and persistent psychological burden. Enhanced communication, information on what to expect after hospital discharge or the death of their loved ones, and emotional support were among the top recommendations to improve family members' experiences and health outcomes.

Conclusion

Family members develop significant emotional burdens and physical symptoms as they deal with their loved ones' critical illnesses and uncertain, unpredictable recovery. Interventions designed to reduce family members' psychological distress and uncertainty prevalent throughout the illness trajectory of their loved ones admitted with cardiac arrest are needed.

Symptoms of post-traumatic stress disorder among first aid providers

Background

Every year, large numbers of individuals are present or provide first aid in situations involving out-of-hospital cardiac arrest, injuries, or suicides. Little is known about the impact of providing first aid or witnessing a first aid situation, but research indicates that many first aid providers (FAP) experience persistent psychological difficulties. Here we aimed to assess the level of psychological impact of being a FAP.

Methods

In this retrospective study, FAP attending follow-up were asked to complete the International Trauma Questionnaire (ITQ), which is a self-report diagnostic measure of post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). We recorded endorsement of a symptom or functional impairment (score ≥ 2/4 on at least one of 18 items).

Results

Of the 102 FAP in this study, 86 (84%) showed endorsement of a symptom or functional impairment. Common symptoms/functional impairments included being super-alert, watchful, or on guard; having powerful mental images; avoiding internal reminders or memories; and being affected in important parts of one's life. One-third had affected ability to work. Of the FAPs who attended follow-up more than one month after the incident (n = 32), 19% met the criteria for PTSD or CPTSD.

Conclusions

The majority of FAPs have endorsement of a symptom or functional impairment. Some FAPs fulfil the criteria of PTSD. We suggest that follow-up should be offered by the EMS to all FAPs involved in incidents with an unconscious patient.

With Fearful Eyes: Exploring Relatives' Experiences With Out-of-Hospital Cardiac Arrest: A Qualitative Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) imposes significant consequences for a family, but little is known about relatives' experiences.

OBJECTIVE

Our aim was to explore relatives' experiences with the OHCA and the following months after.

METHOD

A qualitative approach using phenomenological-hermeneutic methodology was applied. Data consisted of semistructured interviews with 12 relatives of OHCA survivors. We analyzed data based on Paul Ricoeur's theory of interpretation.

RESULTS

Relatives experienced OHCA as an abrupt and stressful event filled with imposing concerns for the cardiac arrest survivor. Relatives were fellow sufferers confronted with the possibility of bereavement, watching from the sideline with fearful eyes. After the OHCA, relatives experienced a troubled time with anxiety and edginess, monitoring the survivor for signs of a new cardiac arrest and trying to adapt to a new normality. Relatives' previous identities and positions within their families were disrupted.

CONCLUSION

Relatives were challenged with the OHCA and the trajectory after it, experiencing a high level of distress and anxiety. Relatives took on an immense responsibility, always watching the survivor for potential symptoms of a new cardiac arrest. The cardiac arrest and the survivor's possible cognitive impairments gave rise to assuming a new authority as a relative. We advocate for a new family approach to relatives, acknowledging relatives' stress and central role in supporting cardiac arrest survivors.

British Cardiovascular Intervention Society Consensus Position Statement on Out-of-hospital Cardiac Arrest 2: Post-discharge Rehabilitation

Out-of-hospital cardiac arrest (OHCA) is a major public health issue that poses significant challenges both in immediate management and long-term follow-up. Survivors of OHCA often experience a combination of complex medical, physical and psychological needs that have a significant impact on quality of life. Guidelines suggest a multi-dimensional follow-up to address both physical and non-physical domains for survivors. However, it is likely that there is substantial unwarranted variation in provision of services throughout the UK. Currently, there is no nationally agreed model for the follow-up of OHCA survivors and there is an urgent need for a set of standards and guidelines in order to ensure equal access for all. Accordingly, the British Cardiovascular Interventional Society established a multi-disciplinary working group to develop a position statement that summarises the most up-to-date evidence and provides guidance on essential and desirable services for a dedicated follow-up pathway for survivors of OHCA.

A change of perspective? An explorative study on why patients may not subjectively report cognitive impairments after a cardiac arrest

AIM

Cardiac arrest survivors are at risk of long-term cognitive impairment. Patients with cognitive impairments do not always have cognitive complaints and vice versa. Not reporting cognitive complaints could be caused by a lack of awareness. We hypothesized that caregivers report more cognitive failures than patients, indicating patients' lack of insight into cognitive functioning.

METHODS

This is a secondary analysis of the Activity and Life After Survival of Cardiac Arrest study on survivors of cardiac arrest and their caregivers. They were assessed at two weeks, three months, and one year after cardiac arrest. At each time point, the patient and the caregiver filled out the cognitive failure questionnaire (CFQ) regarding the patient. We analysed the correlation, intraclass correlation, and self-proxy discrepancy between patients and caregivers on the CFQ over time.

RESULTS

One-hundred-and-nineteen cardiac arrest survivors (mean age = 60, 85 % male) and their caregivers were included. The CFQ scores of the patients and caregivers were equally low. The correlation (T1 r = 0.31; T2 r = 0.40; T3 r = 0.55) and intraclass correlation (T1 r = 0.48; T2 r = 0.56; T3 r = 0.71) between patient and caregiver increased over time.

CONCLUSION

This study does not support a lack of awareness of cognitive impairments by long-term cardiac arrest survivors. Future research may focus on alternative explanations for why patients have less cognitive complaints than expected based on the frequency of cognitive impairments. Possible explanations include a response shift.

Grief reactions in relation to professional and social support among family members of persons who died from sudden cardiac arrest: A longitudinal survey study

BACKGROUND

The loss of a close person from sudden cardiac arrest (CA) leaves family members at risk of developing grief reactions such as symptoms of prolonged grief, anxiety, depression, and posttraumatic stress. The aim was to describe longitudinal variations in grief reactions and its association with professional and social support among bereaved family members after a close person's death from sudden CA.

METHODS

This longitudinal multimethod survey included 69 bereaved family members who completed a questionnaire 6 and 12-months after the CA, including the Prolonged Grief Disorder-13, Hospital Anxiety and Depression Scale, PTSD Checklist for DSM-5, and Multidimensional Scale of Perceived Social Support. Qualitative data were collected by open-ended questions. Quantitative data was analyzed using Wilcoxon signed-rank test and linear regression analysis while written comments were analyzed using qualitative content analysis.

RESULTS

The median age was 62 years, 67 % were women, and 38 % had been present during the resuscitation attempts. Using the cut-off scores at the 6- and 12-month assessments respectively, 14 % and 17 % reported symptoms of prolonged grief, 32 % and 26 % symptoms of anxiety, 14 % and 9 % depression, and 4 % and 1 % posttraumatic stress. Professional and social support at the 6-month assessment were significantly associated with symptoms of prolonged grief, anxiety, depression, and/or posttraumatic stress at the 12-month assessments but could not predict any changes in the grief reactions.

CONCLUSIONS

Family members' grief reactions point to the importance of proactive and available support over time to meet family members' needs.

Caught between competing emotions and tensions while adjusting to a new everyday life: a focus group study with family caregivers of out-of-hospital cardiac arrest survivors

AIMS

Caring for an out-of-hospital cardiac arrest (OHCA) survivor may impact family caregivers' lives due to the sudden onset of the illness and possible secondary cognitive, emotional, and physical challenges. However, experiences of caring for an OHCA survivor are sparsely described. Thus, this study aimed to explore how family caregivers of OHCA survivors experience the potential burden.

METHODS AND RESULTS

Using an explorative qualitative approach, six focus group interviews were conducted with a sample of 25 family caregivers of OHCA survivors and analysed using a phenomenological hermeneutic approach inspired by the philosophy of Ricoeur. The OHCA survivors attended a rehabilitation course, and the family caregivers were interviewed as part of the course.Based on the analysis, three themes emerged: (i) feeling unexpectedly alone and invisible; the family caregivers experienced an emotional burden that could not be shared-leading to caregiving being a lonely experience, (ii) fear of loss; the fear of losing a loved one was a constant companion contributing to the burden, and (iii) adjusting to a new everyday life; the family caregivers had difficulties adjusting to living their lives on the premise of the survivors' needs.

CONCLUSION

The findings of this study emphasize the burden experienced by family caregivers and how they can be trapped in competing emotions and tensions. The possible caregiver burden following OHCA should be acknowledged. Interventions to reduce the burden should be tested and implemented as part of the clinical care of OHCA survivors and their families.

Acute Traumatic Stress Screening Can Identify Patients and Their Partners at Risk for Posttraumatic Stress Disorder Symptoms After a Cardiac Arrest: A Multicenter Prospective Cohort Study

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent in patients who have had a cardiac arrest and their partners. Accordingly, acute traumatic stress screening is recommended, but its association with later PTSD symptoms has never been addressed in postresuscitation settings.

OBJECTIVE

The aim of this study was to examine whether acute traumatic stress is associated with PTSD symptoms in patients who have had a cardiac arrest and their partners.

METHODS

This multicenter longitudinal study of 141 patients and 97 partners measures acute traumatic stress at 3 weeks and PTSD symptoms at 3 months and 1 year after resuscitation, using the Impact of Event Scale. Linear regression models were used to evaluate the association between severity of acute traumatic stress and PTSD symptoms and post hoc to explore effects of group (patients/partners), age, and sex on acute traumatic stress severity. We categorized Impact of Event Scale scores higher than 26 at 3 months and 1 year as clinical severe PTSD symptoms .

RESULTS

Higher acute traumatic stress severity is significantly positively associated with higher PTSD symptom severity at 3 months (patients and partners: P < .001) and 1 year (patients and partners: P < .001) postresuscitation, with the strongest association for women compared with men ( P = .03). Acute traumatic stress was higher in women compared with men across groups ( P = .02). Clinical severe PTSD symptoms were present in 26% to 28% of patients and 45% to 48% of partners.

CONCLUSION

Experiencing a cardiac arrest may elicit clinical severe PTSD symptoms in patients, but particularly in their partners. Screening patients and partners for acute traumatic stress postresuscitation is warranted to identify those at increased risk of long-term PTSD symptoms.

The value of wearable cardioverter defibrillator in adult patients with recent myocardial infarction: Economic and clinical implications from a health technology assessment perspective

AIMS

Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness.

METHODS & RESULTS

Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis - based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276.

CONCLUSION

WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.

Brain injury after cardiac arrest

As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.

One out of three bystanders of out-of-hospital cardiac arrests shows signs of pathological psychological processing weeks after the incident - results from structured telephone interviews

Background

Witnessing an out-of-hospital cardiac arrest (OHCA) is a traumatic experience. This study analyses bystanders` psychological processing of OHCA. We examined the potential impact of bystanders performing resuscitation and the influence of the relationship between bystander and patient (stranger vs. family/friend of the patient) on the psychological processing.

Methods

A telephone interview survey with bystanders, who witnessed an OHCA of an adult patient was performed weeks after the event between December 2014 and April 2016. The semi-standardized questionnaire contained a question regarding the paramount emotion at the time of the interview. In a post-hoc analysis statements given in response were rated by independent researchers into the categories “signs of pathological psychological processing”, “physiological psychological processing” and “no signs of psychological distress due to the OHCA”.

Results

In this analysis 89 telephone interviews were included. In 27 cases (30.3%) signs of pathological psychological processing could be detected. Bystanders performing resuscitation had a higher rate of “no signs of psychological distress after witnessing OHCA” compared to those not resuscitating (54.7% vs. 26.7%, p < 0.05; relative risk 2.01; 95%CI 1.08, 3.89). No statistical significant differences in the psychological processing could be shown for gender, age, relationship to the patient, current employment in the health sector, location of cardiac arrest or number of additional bystanders.

Conclusions

One out of three bystanders of OHCA suffers signs of pathological psychological processing. This was independent of bystander´s age, gender and relationship to the patient. Performing resuscitation seems to help coping with witnessing OHCA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00945-8.

Caregiver burden and health-related quality of life amongst caregivers of out-of-hospital cardiac arrest survivors

AIMS

To describe burden and health-related quality of life amongst caregivers of out-of-hospital cardiac arrest survivors and explore the potential association with cognitive function of the survivors. Caregivers of patients with ST-elevation myocardial infarction were used as controls.

METHODS

Data were collected from the cognitive substudy of the Targeted Temperature Management-trial. Caregiver burden was assessed with the 22-item Zarit Burden Interview, with scores ≤20 considered as no burden. Health-related quality of life was assessed with the SF-36v2®, with T-scores 47-53 representing the norm. Cardiac arrest survivors were categorized based on the results from cognitive assessments as having "no cognitive impairment" or "cognitive impairment".

RESULTS

Follow-up 6 months post event was performed for caregivers of 272 cardiac arrest survivors and 108 matched myocardial infarction controls, included at an intended ratio of 2:1. In general, caregivers of cardiac arrest survivors and controls reported similar caregiver burden. The overall scores for quality of life were within normative levels and similar for caregivers of cardiac arrest survivors and control patients. Compared to those with no cognitive impairment, caregivers of cognitively impaired cardiac arrest survivors (n = 126) reported higher levels of burden (median 18 versus 8, p < 0.001) and worse quality of life in five of eight domains, particularly "Role-Emotional" (mean 45.7 versus 49.5, p = 0.002).

CONCLUSIONS

In general, caregivers of cardiac arrest survivors and myocardial infarction controls reported similar levels of burden and quality of life. Cognitive outcome and functional dependency of the cardiac arrest survivor impact burden and quality of life of the caregiver.

Follow-up care after out-of-hospital cardiac arrest: A pilot study of survivors and families' experiences and recommendations

Background and objectives

Cognitive and physical difficulties are common in survivors of out-of-hospital cardiac arrest (OHCA); both survivors and close family members are also at risk of developing mood disorders. In the UK, dedicated follow-up pathways for OHCA survivors and their family are lacking. A cohort of survivors and family members were surveyed regarding their experience of post-discharge care and their recommended improvements.

Method

123 OHCA survivors and 39 family members completed questionnaires during an educational event or later online. Questions addressed both the actual follow-up offered and the perceived requirements for optimal follow-up from the patient and family perspective, including consideration of timing, professionals involved, involvement of family members and areas they felt should be covered.

Results

Outpatient follow-up was commonly arranged after OHCA (77%). This was most often conducted by a cardiologist alone (80%) but survivors suggested that other professionals should also be involved (e.g. psychologist/counsellor, 64%). Topics recommended for consideration included cardiac arrest-related issues (heart disease; cause of arrest) mental fatigue/sleep disturbance, cognitive problems, emotional problems and daily activities. Most survivors advocated an early review (<1month; 61%). Most family members reported some psychological difficulties (95%); many of them (95%) advocated a dedicated follow-up appointment for family members of survivors.

Conclusions

The majority of OHCA survivors advocated an early follow-up following hospital discharge and a holistic, multidimensional assessment of arrest sequelae. These results suggest that current OHCA follow-up often fails to address patient-centred issues and to provide access to professionals deemed important by survivors and family members.

The second year of a second chance: Long-term psychosocial outcomes of cardiac arrest survivors and their family

AIM

Cardiac arrest (CA) survival has diverse psychosocial outcomes for both survivors and their close family, with little known regarding long-term adjustment and recovery experiences. We explored the psychological adjustment and experiential perspectives of survivors and families in the second year after out-of-hospital cardiac arrest (OHCA).

METHODS

A prospective, mixed-methods study of adult OHCA survivors in Victoria, Australia was conducted. Eighteen survivors and 12 family members completed semi-structured interviews 14-19 months post-arrest. Survivors' cognition, anxiety, depression and post-traumatic stress symptoms were measured using a battery of psychological assessments. A thematic content analysis approach was applied to qualitative interview data by two independent investigators, with data coded and categorised into themes and sub-themes.

RESULTS

Survivors' cognition, depression, anxiety and post-traumatic stress symptoms were not clinically elevated in the second year post-arrest. Subjective cognitive failures were associated with increased anxiety but not with mental state. Depression was significantly correlated with post-traumatic symptoms. Six primary themes emerged from survivors' recovery stories, focused on: awakening and realisation, barriers to adjustment, psychosocial difficulties, integration, protective factors and unmet needs. Family perspectives revealed four primary themes focused on trauma exposure, survivor adjustment problems, family impact, and areas for service improvement.

CONCLUSION

Survivors and their family members describe complex recovery journeys characterised by a range of psychosocial adjustment challenges, which are not adequately captured by common psychological measures. Post-arrest care systems are perceived by survivors and their families as inadequate due to a lack of accurate information regarding post-arrest sequalae, limited follow-up and inconsistent access to allied health care.

Long-term physical and psychological outcomes after out-of-hospital cardiac arrest-protocol for a national cross-sectional survey of survivors and their relatives (the DANCAS survey)

INTRODUCTION

The number of out-of-hospital cardiac arrest (OHCA) survivors is increasing. However, there remains limited knowledge on the long-term physical and psychological problems suffered by survivors and their relatives. The aims of the DANCAS (DANish cardiac arrest survivorship) survey are to describe the prevalence of physical and psychological problems, identify predictors associated with suffering them and to determine unmet rehabilitation needs in order to make recommendations on the timing and content of future rehabilitation interventions.

METHODS AND ANALYSIS

The DANCAS survey has a cross-sectional design involving a survey of OHCA survivors and their relatives. OHCA survivors will be identified through the Danish Cardiac Arrest Registry as having suffered an OHCA between 1 January 2016 and 31 December 2019. Each survivor will be asked to identify their closest relative to complete the relatives' survey. Contents of survivor survey: EQ-5D-5Level, Hospital Anxiety and Depression Scale, Two Simple Questions, Modified Fatigue Impact Scale, 12-item WHO Disability Assessment Scale 2.0, plus questions on unmet rehabilitation and information needs. Contents of relatives' survey: World Health Organisation-Five Well-Being Index, Hospital Anxiety and Depression Scale, Informant Questionnaire on Cognitive Decline in the Elderly-Cardiac Arrest and the Modified Caregiver Strain Index. Self-report outcome data collected through the surveys will be enriched by data from Danish national registries including demographic characteristics, circumstances of cardiac arrest and comorbidities. The survey will be completed either electronically or by post December 2020-February 2021.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. Surveys and registry-based research studies do not normally require ethical approval in Denmark. This has been confirmed for this study by the Region of Southern Denmark ethics committee (20192000-19). Results of the study will be disseminated via several peer-reviewed publications and will be presented at national and international conferences.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Feeling responsible but unsupported: How relatives of out-of-hospital cardiac arrest survivors experience the transition from hospital to daily life - A focus group study

Aim

To generate knowledge about how relatives of out‐of‐hospital cardiac arrest survivors experience the transition between hospital and daily life. The research question was “how do relatives of out‐of‐hospital cardiac arrest survivors experience collaboration and communication with healthcare professionals, and what is emphasized as important in the transition from hospital to daily life”.

Design

Qualitative design.

Methods

Six semi‐structured focus group interviews were conducted with 23 relatives of out‐of‐hospital cardiac arrest survivors who participated in a residential rehabilitation course. Data was collected between November 2018 and March 2019. Transcripts were analysed using a phenomenological hermeneutic approach.

Results

The analysis generated three themes “a necessary presence,” “communication with healthcare professionals on the cardiac ward” and “the abrupt disappearance of the system.” Relatives of out‐of‐hospital cardiac arrest survivors feel a great responsibility when coping and adjusting to their new life. In the transition to daily life, a focus on systematic involvement and collaboration with relatives should be an essential part of the post‐cardiac arrest pathway.

Associations between posttraumatic stress symptoms and quality of life in cardiac arrest survivors and informal caregivers: A pilot survey study

•

About 1 in 4 cardiac arrest survivors showed significant posttraumatic stress.

•

Over 1 in 3 informal caregivers showed significant posttraumatic stress.

•

Greater posttraumatic stress was associated with worse quality of life.

Aim

To estimate the proportion of significant posttraumatic stress (PTS) in both cardiac survivors with good neurologic recovery and informal caregivers, and to pilot test the hypothesis that greater PTS are associated with worse quality of life (QoL) in both cardiac arrest survivors and informal caregivers of cardiac arrest survivors.

Methods

We distributed an online survey to survivor and caregiver members of the Sudden Cardiac Arrest Foundation. Participants provided demographic and cardiac arrest characteristics and completed the PTSD Checklist-5 (PCL-5), the Lawton Instrumental Activities of Daily Living scale, and the WHOQOL-BREF. We identified covariates through bivariate correlations or linear regressions as appropriate. Six multiple regression models (three each for survivors and caregivers) examined associations between PCL-5 scores with each QoL subscale, adjusted for covariates identified from the bivariate models.

Results

We included 169 survivors (mean months since arrest: 62.8, positive PTS screen: 24.9%) and 52 caregivers (mean months since arrest: 43.2, positive PTS screen: 34.6%). For survivors, the following showed significant bivariate associations with QoL: Lawton scores, daily memory problems, sex, months since arrest, age, and income; for caregivers, months since arrest, age, and income. In adjusted models, greater PCL-5 scores were associated with worse QoL (β: −0.35 to −0.53, p < .05).

Conclusions

Our pilot results suggest that PTS are prevalent years after the initial cardiac arrest and are associated with worse QoL in survivors and informal caregivers. Further study is needed to validate these findings in a larger, representative sample.

Long term outcomes of participants in the PARAMEDIC2 randomised trial of adrenaline in out-of-hospital cardiac arrest

AIMS

We recently reported early outcomes in patients enrolled in a randomised trial of adrenaline in out-of-hospital cardiac arrest: the PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) trial. The purpose of the present paper is to report long-term survival, quality of life, functional and cognitive outcomes at 3, 6 and 12-months.

METHODS

PARAMEDIC2 was a pragmatic, individually randomised, double blind, controlled trial with an economic evaluation. Patients were randomised to either adrenaline or placebo. This paper reports results on the modified Rankin Scale scores at 6-months, survival at 6 and 12-months, as well as other cognitive, functional and quality of life outcomes collected at 3 and 6 months (Two Simple Questions, the Mini Mental State Examination, the Informant Questionnaire on Cognitive Decline Evaluation for Cardiac Arrest, Hospital Anxiety and Depression Scale, the Post Traumatic Stress Disorder Checklist - Civilian Version, Short-Form 12-item Health Survey and the EuroQoL EQ-5D-5L).

RESULTS

8014 patients were randomised with confirmed trial drug administration. At 6-months, 78 (2.0%) of the patients in the adrenaline group and 58 (1.5%) of patients in the placebo group had a favourable neurological outcome (adjusted odds ratio 1.35 [95% confidence interval: 0.93, 1.97]). 117 (2.9%) patients were alive at 6-months in the adrenaline group compared with 86 (2.2%) in the placebo group (1.43 [1.05, 1.96], reducing to 107 (2.7%) and 80 (2.0%) respectively at 12-months (1.38 [1.00, 1.92]). Measures of 3 and 6-month cognitive, functional and quality of life outcomes were reduced, but there was no strong evidence of differences between groups.

CONCLUSION

Adrenaline improved survival through to 12-months follow-up. The study did not find evidence of improvements in favourable neurological outcomes. (ISCRTN 73485024).

Cognitive impairment and psychopathology in out-of-hospital cardiac arrest survivors in Denmark: The REVIVAL cohort study protocol

INTRODUCTION

Cognitive impairment and psychopathology caused by brain hypoxia and the traumatic impact of critical illness are common in cardiac arrest survivors and can lead to negative consequences of everyday life functioning, and further impact mental health in relatives. Most studies have dealt with the mere survival rate after cardiac arrest and not with long-term consequences to mental health in cardiac arrest survivors. Importantly, we face a gap in our knowledge about suitable screening tools in the early post-arrest phase for long-term risk prediction of mental health problems. This study aims to evaluate the efficacy of a novel screening procedure to predict risk of disabling cognitive impairment and psychopathology 3 months after cardiac arrest. Furthermore, the study aims to evaluate long-term prevalence of psychopathology in relatives.

METHODS AND ANALYSES

In this multicentre prospective cohort study, out-of-hospital cardiac arrest survivors and their relatives will be recruited. The post-arrest screening includes the Montreal Cognitive Assessment (MoCA), the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale-Revised (IES-R) and the Acute Stress Disorder Interview (ASDI) and is conducted during hospitalisation. In a subsample of the patients, functional MRI is done, and cortisol determination collected. At 3-month follow-up, the primary study outcomes for 200 survivors include the Danish Affective Verbal Learning Test-26 (VAMT-26), Delis-Kaplan Executive Function System tests (trail making, colour-word interference, word and design fluency), Rey's Complex Figure and Letter-number sequencing subtest of Wechsler Adult Intelligence Scale-IV, HADS and IES-R. For the relatives, they include HADS and IES-R.

ETHICS AND DISSEMINATION

The study is approved by the local regional Research Ethics Committee (H-18046155) and the Danish Data Protection Agency (RH-2017-325, j.no.05961) and follows the latest version of the Declaration of Helsinki. The results will be published in peer-reviewed journals and may impact the follow-up of cardiac arrest survivors.

Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation

More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.

Are survivors of cardiac arrest provided with standard cardiac rehabilitation? - Results from a national survey of hospitals and municipalities in Denmark

AIM

To quantify the provision of standard cardiac rehabilitation to Danish survivors of cardiac arrest at a programme level, and to analyse whether organizational factors influenced the provision.

METHOD

We mapped the provision of cardiac rehabilitation core components to survivors of cardiac arrest and compared this with a reference group of patients after acute myocardial infarction using data from a cross-sectional programme-level survey among all hospitals (n = 34) and municipalities (n = 98) in Denmark. Organizational factors of potential importance to service provision were considered: health care region, size of catchment area/population, type of department/municipality and socioeconomic index.

RESULTS

Response rates for the provision of each core component of cardiac rehabilitation ranged from 64% to 98%. All hospitals and municipalities provided some aspect of cardiac rehabilitation to survivors of cardiac arrest. Across hospitals, provision of four core components of cardiac rehabilitation to survivors of cardiac arrest was lower compared with post acute myocardial infarction patients: patient education (relative risk (RR) = 0.45 (95% confidence interval (CI) 0.27 to 0.75)), exercise training (RR = 0.69 (95% CI 0.49 to 0.98)), screening for anxiety and depression (RR = 0.64 (95% CI 0.46 to 0.90) and nutritional counselling RR = 0.76 (95% CI 0.62 to 0.93)). No difference was found in the provision of core components across municipalities. Overall, the provision of cardiac rehabilitation to survivors of cardiac arrest was not affected by organizational factors.

CONCLUSION

This study indicates a need for future research to inform the development, adoption and implementation of equal access to all components of cardiac rehabilitation for survivors of cardiac arrest in Denmark.

The Process of Patient Engagement in Cardiac Rehabilitation: A Model-Centric Systematic Review

This study aimed to compile existing evidence about the proposed relationships among variables at three stages of the model of therapeutic engagement (MTE): patient intention to engage in cardiac rehabilitation (CR), CR initiation, and sustained engagement. This model has not been tested in any rehabilitation setting. Therefore, this systematic literature review is key to future research and application of MTE to predict and enhance patient engagement in CR. Model-centric systematic literature reviews have been conducted for each stage of the MTE. A coherent approach to understanding and monitoring the process of patient engagement in CR is absent. Few relevant studies included in the model-centric reviews met the criteria: eight in stage 1, four in stage 2, and six in stage 3 of the MTE. In total, the tenets of the MTE were supported in patient intention to engage in CR. However, there was less evidence quantifying the proposed relationships among variables that impact on CR initiation and sustained engagement. There is a scarcity of research examining rehabilitation engagement in depth to better understand the complicated process contributing to behavioural outcomes. No decision-support models currently exist to alert patients and healthcare provider to the factors that influence non-engagement.