Family-Witnessed Resuscitation: Bereavement Outcomes in an Urban Environment

Exposure to a Loved One's Death and Advance Care Planning: Moderating Effects of Age

Background: Despite documented benefits of Advance Care Planning (ACP), it is still under-utilized in the U.S. Our study aimed to examine whether experiencing a loved one's death is associated with one's own ACP behavior among adults in the U.S. and the potential moderating effect of age. Method: Using a nationwide cross-sectional survey design with probability sampling weights, our study included 1006 adults in the U.S. who participated in and completed the Survey on Aging and End-of-Life Medical Care. Three binary logistic regression models were established to investigate the relationship between death exposure and different aspects of ACP (i.e., informal conversations with family members and doctors and formal advance directives completion). The moderation analysis was subsequently conducted to examine moderating effects of age. Results: The exposure to a loved one's death was significantly associated with higher odds of having conversations with family about end-of-life medical care preferences among the 3 indicators of ACP (OR = 2.03, P < .001). Age significantly moderated the association between death exposure and ACP conversations with doctors (OR = .98, P = .017). The facilitation effect of death exposure on informal ACP engagement in discussing end-of-life medical wishes with doctors is stronger among younger adults than older adults. Conclusions: Exploring an individual's previous experience with a loved one's death might be an effective way to broach the concept of ACP among adults of all ages. This strategy may be particularly useful in facilitating discussions of end-of-life medical wishes with doctors among younger adults than older adults.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

The healthcare professionals' perspectives and experiences with family presence during resuscitation: A qualitative evidence synthesis

INTRODUCTION

Family presence during resuscitation (FPDR) is a growing hospital praxis despite lack of high-quality evidence. The aim of this qualitative evidence synthesis review was to synthesize current evidence regarding healthcare professionals (HCP) perspectives on barriers and facilitating factors of FPDR and the potential impact of FPDR on HCP performance.

METHODS

We conducted a systematic literature search May 17, 2023 including primary studies with qualitative study designs. We applied NVivo for data analysis. Data was coded with line-by-line coding and organized into themes and categories following the method for thematic synthesis described by Thomas and Harden to analyse data. The studies underwent quality appraisal by Critical Appraisal Skills Program. We used GRADE CERQual to assess the confidence in the evidence.

RESULTS

We identified 8241 articles suitable for screening, 141 articles were full text screened, and nine studies included from Australia, UK and USA. In total, 134 HCP participated, between 2005 and 2019. Most studies lacked sufficiently rigorous data analysis and findings were appraised to have moderate GRADE CERQual confidence. We identified three analytical themes ("Facilitating factors for FPDR", "Barriers for FPDR" and "How staff are affected by FPDR") with eight descriptive subthemes. One finding was of high GRADE CERQual confidence: a belief that FPDR is "the right thing to do" which was a "Facilitating factor of FPDR."

CONCLUSION

The evidence on HCP perspectives is of low to moderate confidence. The interviewed consent that FPDR is the "right thing to do", and an ethical principle of beneficence is dominant, especially regarding children.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

What Are the Care Needs of Families Experiencing Sudden Cardiac Arrest? A Survivor- and Family-Performed Systematic Review, Qualitative Meta-Synthesis, and Clinical Practice Recommendations

INTRODUCTION

Cardiac arrest care systems are being designed and implemented to address patients', family members', and survivors' care needs. We conducted a systematic review and a meta-synthesis to understand family experiences and care needs during cardiac arrest care to create treatment recommendations.

METHODS

We searched eight electronic databases to identify articles. Study findings were extracted, coded and synthesized. Confidence in the quality, coherence, relevance, and adequacy of data underpinning the resulting findings was assessed using GRADE-CERQual methods.

RESULTS

In total 4181 studies were screened, and 39 met our inclusion criteria; these studies enrolled 215 survivors and 418 family participants-which includes both co-survivors and bereaved family members. From these studies findings and participant data we identified 5 major analytical themes: (1) When the crisis begins we must respond; (2) Anguish from uncertainty, we need to understand; (3) Partnering in care, we have much to offer; (4) The crisis surrounding the victim, ignore us, the family, no longer; (5) Our family's emergency is not over, now is when we need help the most. Confidence in the evidence statements are provided along with our review findings.

DISCUSSION

The family experience of cardiac arrest care is often chaotic, distressing, complex and the aftereffects are long-lasting. Patient and family experiences could be improved for many people. High certainty family care needs identified in this review include rapid recognition and response, improved information sharing, more effective communication, supported presence and participation, or supported absence, and psychological aftercare.

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.

Family presence during resuscitation

BACKGROUND

Patients and their relatives often expect to be actively involved in decisions of treatment. Even during resuscitation and acute medical care, patients may want to have their relatives nearby, and relatives may want to be present if offered the possibility. The principle of family presence during resuscitation (FPDR) is a triangular relationship where the intervention of family presence affects the healthcare professionals, the relatives present, and the care of the patient involved. All needs and well-being must be balanced in the context of FPDR as the actions involving all three groups can impact the others.

OBJECTIVES

The primary aim of this review was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of post-traumatic stress disorder (PTSD)-related symptoms in the relatives. The secondary aim was to investigate how offering relatives the option to be present during resuscitation of patients affects the occurrence of other psychological outcomes in the relatives and what effect family presence compared to no family presence during resuscitation of patients has on patient morbidity and mortality. We also wanted to investigate the effect of FPDR on medical treatment and care during resuscitation. Furthermore, we wanted to investigate and report the personal stress seen in healthcare professionals and if possible describe their attitudes toward the FPDR initiative.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to 22 March 2022 without any language limits. We also checked references and citations of eligible studies using Scopus, and searched for relevant systematic reviews using Epistomonikos. Furthermore, we searched ClinicalTrials.gov, WHO ICTRP, and ISRCTN registry for ongoing trials; OpenGrey for grey literature; and Google Scholar for additional trials (all on 22 March 2022).

SELECTION CRITERIA

We included randomized controlled trials of adults who have witnessed a resuscitation attempt of a patient (who was their relative) at the emergency department or in the pre-hospital emergency medical service.  The participants of this review included relatives, patients, and healthcare professionals during resuscitation.  We included relatives aged 18 years or older who have witnessed a resuscitation attempt of a patient (who is their relative) in the emergency department or pre-hospital. We defined relatives as siblings, parents, spouses, children, or close friends of the patient, or any other descriptions used by the study authors. There were no limitations on adult age or gender. We defined patient as a patient with cardiac arrest in need of cardiopulmonary resuscitation (CPR), a patient with a critical medical or traumatic life-threatening condition, an unconscious patient, or a patient in any other way at risk of sudden death. We included all types of healthcare professionals as described in the included studies. There were no limitations on age or gender.

DATA COLLECTION AND ANALYSIS

We checked titles and abstracts of studies identified by the search, and obtained the full reports of those studies deemed potentially relevant. Two review authors independently extracted data. As it was not possible to conduct meta-analyses, we synthesized data narratively.

MAIN RESULTS

The electronic searches yielded a total of 7292 records after deduplication. We included 2 trials (3 papers) involving a total of 595 participants: a cluster-randomized trial from 2013 involving pre-hospital emergency medical services units in France, comparing systematic offer for a relative to witness CPR with the traditional practice, and its 1-year assessment; and a small pilot study from 1998 of FPDR in an emergency department in the UK. Participants were 19 to 78 years old, and between 56% and 64% were women. PTSD was measured with the Impact of Event Scale, and the median score ranged from 0 to 21 (range 0 to 75; higher scores correspond to more severe disease). In the trial that accounted for most of the included participants (570/595), the frequency of PTSD-related symptoms was significantly higher in the control group after 3 and 12 months, and in the per-protocol analyses a significant statistical difference was found in favor of FPDR when looking at PTSD, anxiety and depression, and complicated grief after 1 year.  One of the included studies also measured duration of patient resuscitation and personal stress in healthcare professionals during FPDR and found no difference between groups. Both studies had high risk of bias, and the evidence for all outcomes except one was assessed as very low certainty.

AUTHORS' CONCLUSIONS

There was insufficient evidence to draw any firm conclusions on the effects of FPDR on relatives' psychological outcomes.   Sufficiently powered and well-designed randomized controlled trials may change the conclusions of the review in future.

Family presence during adult resuscitation from cardiac arrest: A systematic review

AIM

Objective: To conduct a systematic review of the published evidence related to family presence during adult resuscitation from cardiac arrest.

METHODS

This review, registered with PROSPERO (CRD42021242384) and reported according to PRISMA guidelines, included studies of adult cardiac arrest with family presence during resuscitation that reported one or more patient, family or provider outcomes. Three databases (Medline, CINAHL and EMBASE) were searched from inception to 10/05/2022. Two investigators screened the studies, extracted data, and assessed risks of bias using the Mixed Method Appraisal Tool (MMAT). The synthesis approach was guided by Synthesis Without Meta-Analysis (SWiM) reporting guidelines and a narrative synthesis method.

RESULTS

The search retrieved 9,459 citations of which 31 were included: 18 quantitative studies (including two RCTs), 12 qualitative studies, and one mixed methods study. The evidence was of very low or low certainty. There were four major findings. High-certainty evidence regarding the effect of family presence during resuscitation on patient outcomes is lacking. Family members had mixed outcomes in terms of depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and experience of witnessing resuscitation. Provider experience was variable and resuscitation setting, provider education, and provider experience were major influences on family presence during resuscitation. Finally, providers reported that a family support person and organisational guidelines were important for facilitating family presence during resuscitation.

CONCLUSION

The effect of family presence during resuscitation varies between individuals. There was variability in the effect of family presence during resuscitation on patient outcomes, family and provider outcomes and perceptions.

Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial

OBJECTIVES

Guidelines recommend family presence to be offered during cardiopulmonary resuscitation (CPR). Data on the effects of family presence on the quality of CPR and rescuers' workload and stress levels are sparse and conflicting. This randomised trial investigated the effects of family presence on quality of CPR, and rescuers' perceived stress.

DESIGN

Prospective randomised single-blind trial.

SETTING

Voluntary workshops of educational courses.

PARTICIPANTS

1085 physicians (565 men) randomised to 325 teams entered the trial. 318 teams completed the trial without protocol violation.

INTERVENTIONS

Teams were randomised to a family presence group (n=160) or a control group (n=158) and to three versions of leadership: (a) designated at random, (b) designated by the team or (c) left open. Thereafter, teams were confronted with a simulated cardiac arrest which was video-recorded. Trained actors played a family member according a scripted role.

MAIN OUTCOME MEASURES

The primary endpoint was hands-on time. Secondary outcomes included interaction time, rescuers' perceived task load and adherence to CPR algorithms.

RESULTS

Teams interacted with the family member during 24 (17-36) % of the time spent for resuscitation. Family presence had no effect on hands-on time (88% (84%-91%) vs 89% (85%-91%); p=0.18). Family presence increased frustration (60 (30-75) vs 45 (30-70); p<0.001) and perceived temporal (75 (55-85) vs 70 (50-80); p=0.001) and mental demands (75 (60-85) vs 70 (55-80); p=0.009), but had no relevant effect on CPR performance markers. Leadership condition had no effects.

CONCLUSIONS

Interacting with a family member occupied about a quarter of the time spent for CPR. While this additional task was associated with an increase in frustration and perceived temporal and mental demands, family presence had no relevant negative effect on the quality of CPR.

TRIAL REGISTRATION NUMBER

DRKS00024759.

Families' experiences of grief and bereavement in the emergency department: A scoping review

AIM

Death is a frequent event in the emergency department, and many family members experience grief and bereavement. However, little is known about what families experience. The aim of this study was to explore previous findings about families' experiences of grief and bereavement in the emergency department to clarify and understand their experience.

METHODS

A scoping review was chosen as the design for this research. Studies were searched from four electronic databases. The obtained studies were screened independently by two reviewers and selected by mutual agreement of the entire team based upon the eligibility criteria. All relevant data were extracted, and thematic analysis was conducted to assess families' grief and bereavement experiences in the emergency department.

RESULTS

The database searches initially resulted in 982 studies; these were finally narrowed to 20 studies for data extraction. Publication years ranged from 1987 to 2020. The studies were conducted across nine countries; most were from the United States and had a qualitative research design. Analysis elicited the following themes: "lack of information," "breaking bad news," "being present during resuscitation," "chaotic environment," "psychosocial reaction in bereavement," and "support and care needs from healthcare professionals."

CONCLUSION

These themes reveal challenges in providing support and care from emergency nurses to bereaved families, including inadequate provision of information, poor design of the emergency department due to the lack of privacy, and families' unmet support and care needs. Emergency nurses need to better understand families' experience of grief and bereavement.

The Needs of Families During Cardiac Arrest Care: A Survivor- and Family-led Scoping Review Protocol

INTRODUCTION

Sudden cardiac arrest is a leading cause of death. Family members often witness the event and attempt resuscitation. The physiological and psychological impact of a loved one's death, witnessed or unwitnessed, can be significant and long-lasting. However, little is known about the care needs of families during the cardiac arrest care of a loved one. This scoping review protocol was designed with, and will be performed in partnership with, persons with lived experience of sudden cardiac arrest (survivors and family members of survivors and nonsurvivors alike).

METHODS

The review will be performed in accordance with accepted methods such as the Arksey and O'Malley methodology framework and the Levac extension. We will search multiple databases, and Google Scholar for both qualitative and quantitative scientific literature. Articles will be screened, extracted, and analyzed by a team with lived experience of cardiac arrest. Two reviewers will conduct all screening and data extraction independently. A descriptive overview, tabular and/or graphical summaries, and a directed content analysis will be carried out on extracted data.

DISCUSSION

This protocol outlines a planned literature review to systematically examine the nature of existing evidence to describe what the care needs of families experiencing the cardiac arrest of a loved one are. Such evidence will contribute to the development of strategies to meet identified care needs. Persons with lived experience participated in the creation of this protocol, and they will also participate in the execution of this review as partners and coinvestigators, not as research subjects or participants. The results of the scoping review will be disseminated upon completion of the work described in this protocol.

Managing Death in the Field: Prehospital End-of-Life Care

CONTEXT

Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected.

OBJECTIVES

The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care.

METHODS

This exploratory study used mixed methods in a sequential nondominant two-stage convergent quantitative and qualitative design. Phase I involved the collection of survey data. Phase II involved in-person semistructured interviews.

RESULTS

Surveys were completed by 239 participants, and 50 follow-up interviews were conducted. Survey data suggested that 73.7% felt confident when there was a DNR order and they did not initiate resuscitation, and 58.2% felt confident working through family disagreement when cardiopulmonary resuscitation was requested but there was a DNR; 66.1% felt confident explaining the dying process when death was imminent, and 55.7% felt comfortable telling a family that a patient was dying. Four themes emerged: changing standards of care; eliminating false hope; transitioning care from patient to family; and transferring care after death.

CONCLUSION

Prehospital providers provide support and care when they tell families that someone has died. Being able to comfort and be present with acute grief on scene is an important and evolving role for prehospital providers who manage death in the field.

Post-traumatic Stress Disorder in Family-witnessed Resuscitation of Emergency Department Patients

Introduction

Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event.

Methods

We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age.

Results

A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], −8.73 to −0.75; P<.05). Additionally, the FWR group had significantly higher mean score for the subscales of avoidance (10.6 vs 8.1; 95% CI, −4.25 to −0.94; P<.005) and a trend toward higher score for the subscale of intrusion (13.0 vs 11.4; 95% CI, −3.38 to .028; P = .054). No statistical significant difference was noted between the groups in the subscale of hyperarousal (6.95 vs 6.02; 95% CI, −2.08 to 0.22; P=.121). All findings were consistent after controlling for age, gender, and immediate family member (spouse, parent, children, and grandchildren).

Conclusion

Our results suggest that family members who witness ED resuscitations may be at increased risk of PTSD symptoms at one month. This is the first study that examines the effects of family visitation for an unsorted population of very sick patients who would typically be seen in the critical care section of a busy ED.

Losing a close person following death by sudden cardiac arrest: Bereaved family members' lived experiences

The death of a close person has profound impact on people's lives, and when death is sudden there are no possibilities to prepare for the loss. The study aimed to illuminate meanings of losing a close person following sudden cardiac arrest. A qualitative interpretive design was used, and twelve bereaved family members were interviewed. The results show a transition from pending between life and sudden loss during resuscitation and proceeding with life after the sudden loss. These results of being in liminality illuminate the family members' essential narration and the importance of compassionate care throughout this challenging transition.

Nurses' perceptions and experiences of caring for patients who die in the emergency department setting

INTRODUCTION

The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected.

AIM

This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED.

METHODS

Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically.

RESULTS

211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected.

CONCLUSIONS

ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework

OBJECTIVES

Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM.

METHODS

The American College of Emergency Physicians Palliative Medicine Section assembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine.

RESULTS

The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators.

CONCLUSIONS

Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

Family presence during resuscitation - The experiences and views of Polish nurses

Understanding healthcare professionals perceptions of family presence during resuscitation (FPDR) may help in choosing an effective strategy of implementing this concept in everyday clinical practice.

OBJECTIVES

To determine the experiences and views of Polish nurses about family witnessed resuscitation.

DESIGN

A cross sectional survey study.

SETTING

Delegates (n = 720) attending the Polish Association of Anaesthesia and Intensive Care Nurses conference participated in the study. A total of 240 questionnaires were correctly completed and returned.

MAIN OUTCOME MEASURES

Validation of the Polish version of the tool was undertaken. Exploratory factor analysis extracted three main factors: staff opinions on the benefits of FPDR (α-Cronbach 0.86), opinions on the negative effects (α-Cronbach 0.74) and general views on this practice (α-Cronbach 0.54). These three extracted factors were defined as dependent variables.

RESULTS

Out of the sample, 113 (47%) nurses worked in adult intensive care units (ICUs) and 127 (53%) in other acute clinical settings. ICU nurses reported having experiences of FPDR (n = 66, 54%); out of this group 12 (10%) had positive encounters and 46 (38%) reported negative ones. ICU nurses had undetermined opinions on the benefits and potential negative effects of FPDR. Having positive experiences with FPDR influenced ICU nurses' views on the negative effects of FPDR (Z = -2.16, p< 0.03).

CONCLUSION

A positive experience of FPDR influences a nurse's views and attitudes in this evolving area of practice.

How do clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation?

AIMS AND OBJECTIVES

To examine how clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation.

BACKGROUND

Family presence during resuscitation has important benefits for family and is supported by professional bodies and the public. Yet, many clinicians restrict family access to patients during resuscitation, and rationales for decision-making are unclear.

DESIGN

Secondary analysis of an existing qualitative data set using deductive category application of content analysis.

METHODS

We analysed 20 interview transcripts from 15 registered nurses, two doctors and three paramedics who had experienced family presence during resuscitation in an Australian hospital. The transcripts were analysed for incidents of beneficent decision-making when allowing or denying family presence during resuscitation.

RESULTS

Decision-making around family presence during resuscitation occurred in time poor environments and in the absence of local institutional guidelines. Clinicians appeared to be motivated by doing "what's best" for patients and families when allowing or denying family presence during resuscitation. However, their individual interpretations of "what's best" was subjective and did not always coincide with family preferences or with current evidence that promotes family presence during resuscitation as beneficial.

CONCLUSIONS

The decision to allow or deny family presence during resuscitation is complex, and often impacted by personal preferences and beliefs, setting norms and tensions between clinicians and consumers. As a result, many families are missing the chance to be with their loved ones at the end of life. The introduction of institutional guidelines and policies would help to establish what safe and effective practice consists of, reduce value-laden decision-making and guide beneficent decision-making.

RELEVANCE TO CLINICAL PRACTICE

These findings highlight current deficits in decision-making around FPDR and could prompt the introduction of clinical guidelines and policies and in turn promote the equitable provision of safe, effective family-centred care during resuscitation events.

Psychological effects on patient's relatives regarding their presence during resuscitation

Introduction: Presence of family and patients’ relatives throughout resuscitation procedure is one of the most challenging concerns.

Methods: In an interventional (quasi-experimental) study that was conducted during a 6 months period, the patients’ relatives were randomly divided into two groups of intervention (the relatives who were eager to be present throughout the resuscitation procedure- under the family protection protocol, all of the procedure steps were explained to the relatives by an expert nurse who was not involved in the resuscitation procedure and control group (those who were not invited routinely to be present throughout the resuscitation procedure. However, if the control group were eager to be present, they were allowed to observe the procedure (these people were not supported by the protocol). After 90 days, subjects were contacted through telephone and filled standard questionnaires (Hospital Anxiety and Depression Scale [HADS]) and Impact of Event Scale (IES) were completed for all subjects. These questionnaires focus on anxiety, depression and post-traumatic stress disorder (PTSD). The obtained data were analyzed.

Results: One hundred thirty three relatives were divided into two groups of control (59 subjects) and intervention (74 people). No significant difference was observed between two groups regarding demographic features. The evaluation after 90 days revealed depression, anxiety disorders and PTSD to be significantly more prevalent in control group than the intervention group (P < 0.0001 ).

Conclusion: Emotional and psychological support and intervention on the patients’ relatives are efficient and can prevent the emergence of psychological disorders.

Distress in Caregivers Accompanying Patients to an Emergency Department: A Scoping Review

BACKGROUND

Despite substantial research interest in caregiver distress in the emergency department (ED), no recent review of the literature exists.

OBJECTIVE

Our aims were to map primary research on caregiver distress in the ED, synthesize key concepts underpinning the literature, identify gaps, and provide guidance for future work.

METHODS

We used a five-stage scoping review with tandem screening and data extraction.

RESULTS

Of 2121 records, 29 studies were included. The majority were small, conducted in North America or Europe, and published after 2000. Numerous methodologies and definitions of distress were represented. The majority involved children, with just five studies restricted to adults. Many involved higher-acuity scenarios, such as resuscitations or invasive procedures. The most common research topic was anxiety of parents of children undergoing procedures. Effects of witnessed resuscitation were also addressed. Parental presence may reduce anxiety during venipuncture, while only waiting room music reduced anxiety in parents of children not undergoing a procedure. No study explored interventions to reduce distress in caregivers of adults. While heterogeneity precluded evidence-based recommendations, clinically relevant observations emerged, including that anxiety can be worsened if a caregiver believes their patient has been forgotten; that parents are sensitive about being perceived as neglectful; and that sympathy and confidence ease distress, as does sensitivity toward end-of-life issues. Several studies suggested that negative staff behaviors affect caregiver anxiety.

CONCLUSIONS

Future studies should use validated measures of distress; include larger samples; and capture adult, geriatric, and rural populations. A focused systematic review might yield evidence-based guidance for clinicians.

Health care professionals' concerns regarding in-hospital family-witnessed cardiopulmonary resuscitation implementation into clinical practice

BACKGROUND

In-hospital, family-witnessed cardiopulmonary resuscitation of adults has been found to help patients' family members deal with the short- and long-term emotional consequences of resuscitation. Because of its benefits, many national and international nursing and medical organizations officially recommend this practice. Research, however, shows that family-witnessed resuscitation is not widely implemented in clinical practice, and health care professionals generally do not favour this recommendation.

AIM

To describe and provide an initial basis for understanding health care professionals' views and perspectives regarding the implementation of an in-hospital, family-witnessed adult resuscitation practice in two European countries.

STUDY DESIGN

An inductive qualitative approach was used in this study.

METHODS

Finnish (n = 93) and Polish (n = 75) emergency and intensive care nurses and physicians provided written responses to queries regarding their personal observations, concerns and comments about in-hospital, family-witnessed resuscitation of an adult. Data were analysed using inductive thematic analysis.

FINDINGS

The study analysis yielded five themes characterizing health care professionals' main concerns regarding family-witnessed resuscitation: (1) family's horror, (2) disturbed workflow (3) no support for the family, (4) staff preparation and (5) situation-based decision.

CONCLUSION

Despite existing evidence revealing the positive influence of family-witnessed resuscitation on patients, relatives and cardiopulmonary resuscitation process, Finnish and Polish health care providers cited a number of personal and organizational barriers against this practice. The results of this study begin to examine reasons why family-witnessed resuscitation has not been widely implemented in practice. In order to successfully apply current evidence-based resuscitation guidelines, provider concerns need to be addressed through educational and organizational changes.

RELEVANCE TO CLINICAL PRACTICE

This study identified important implementation barriers for allowing families in critical care settings to be present during resuscitation efforts. These results can be further used in developing and adjusting clinical practice policies, protocols and guidelines related to family-witnessed resuscitation.

Current practices related to family presence during acute deterioration in adult emergency department patients

AIMS AND OBJECTIVES

To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department.

BACKGROUND

Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration.

DESIGN

Descriptive exploratory study using nonparticipatory observation.

METHODS

Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis.

RESULTS

Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take.

CONCLUSIONS

Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration.

RELEVANCE TO CLINICAL PRACTICE

This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research.

A literature review examining the barriers to the implementation of family witnessed resuscitation in the Emergency Department

BACKGROUND

Caring for people near death in the Emergency Department (ED) is challenging for professionals, duty bound to respond to the needs of the dying. Family witnessed resuscitation (FWR) is practiced internationally, allowing relatives to be present at the time of a patient's death, offering comfort to the dying and aiding the bereaved along a healthy grief trajectory.

AIM

The literature review elicits barriers to the implementation of FWR in the ED, examining why practice is sporadic despite numerous professional bodies calling for implementation. FWR is often met with opposition from staff, subsequently largely dependent upon who is on duty as opposed to adherence with best practice guidelines, risking inconsistent idiosyncratic practice.

FINDINGS

Barriers include; a lack of organisational support; shortage of manpower for provision of a family support person; absence of champions for the concept; willful non-adherence due to personal beliefs; restriction on coping strategies reliant upon the ability to emotionally detach, enhancing staff resilience facing repeated exposure to emotionally labile events.

CONCLUSION

All resuscitation efforts can be successful, whether the patient lives or dies, if practice supports healthy grieving. The challenge remains with such divided, entrenched and passionate views, how FWR can be adopted as accepted practice.

Factors influencing decision-making around family presence during resuscitation: a grounded theory study

AIM

The aim of this study was to examine factors impacting family presence during resuscitation practices in the acute care setting.

BACKGROUND

Family presence during resuscitation was introduced in the 1980s, so family members/significant others could be with their loved ones during life-threatening events. Evidence demonstrates important benefits; yet despite growing support from the public and endorsement from professional groups, family presence is practiced inconsistently and rationales for poor uptake are unclear.

DESIGN

Constructivist grounded theory design.

METHODS

Twenty-five health professionals, family members and patients informed the study. In-depth interviews were undertaken between October 2013-November 2014 to interpret and explain their meanings and actions when deciding whether to practice or participate in FPDR.

FINDINGS

The Social Construction of Conditional Permission explains the social processes at work when deciding to adopt or reject family presence during resuscitation. These processes included claiming ownership, prioritizing preferences and rights, assessing suitability, setting boundaries and protecting others/self. In the absence of formal policies, decision-making was influenced primarily by peoples' values, preferences and pre-existing expectations around societal roles and associated status between health professionals and consumers. As a result, practices were sporadic, inconsistent and often paternalistic rather than collaborative.

CONCLUSION

An increased awareness of the important benefits of family presence and the implementation of clinical protocols are recommended as an important starting point to address current variations and inconsistencies in practice. These measures would ensure future practice is guided by evidence and standards for health consumer safety and welfare rather than personal values and preferences of the individuals 'in charge' of permissions.

Family-witnessed resuscitation: focus group inquiry into UK student nurse experiences of simulated resuscitation scenarios

Aims

To describe the impact of family members’ presence on student nurse performance in a witnessed resuscitation scenario. To explore student nurses’ attitudes to simulated family-witnessed resuscitation and their views about its place in clinical practice.

Background

Family-witnessed resuscitation remains controversial worldwide. Hospital implementation remains inconsistent despite professional organisation support. Systematic reviews of international literature indicate family members wish to be involved and consulted; healthcare professionals express concerns about being observed while resuscitating. Student nurse perspectives have not been addressed.

Design

Qualitative, focus groups.

Methods

Participants: UK university second-year student nurses (n=48) who participated in simulated resuscitation scenarios (family member absent, family member present but quiet or family member present but distressed). Data generation 2014: focus group interview schedule—five open-ended questions and probing techniques. Audio recordings transcribed, analysed thematically. Research ethics approval via University Research Ethics committee.

Findings

Overarching theme=students’ sense making—making sense of situation (practically/professionally), of themselves (their skills/values) and of others (patients/family members). Students identify as important team leader allocating tasks, continuity of carer and number of nurses needed. Three orientations to practice are identified and explored—includes rule following, guidance from personal/proto-professional values and paternalistic protectionism.

Discussion

We explore issues of students’ fluency of response and skills repertoire to support family-witnessed resuscitation; explanatory potential to account for the inconsistent uptake of family-witnessed resuscitation. Possible future lines of inquiry include family members’ gaze as a motivational trigger, and management of guilt.

Psychological impact on dispatched local lay rescuers performing bystander cardiopulmonary resuscitation

AIM

We studied the short-term psychological impact and post-traumatic stress disorder (PTSD)-related symptoms in lay rescuers performing cardiopulmonary resuscitation (CPR) after a text message (TM)-alert for out-of-hospital-cardiac arrest, and assessed which factors contribute to a higher level of PTSD-related symptoms.

METHODS

The lay rescuers received a TM-alert and simultaneously an email with a link to an online questionnaire. We analyzed all questionnaires from February 2013 until October 2014 measuring the short-term psychological impact. We interviewed by telephone all first arriving lay rescuers performing bystander CPR and assessed PTSD-related symptoms with the Impact of Event Scale (IES) 4-6 weeks after the resuscitation. IES-scores 0-8 reflected no stress, 9-25 mild, 26-43 moderate, and 44-75 severe stress. A score ≥ 26 indicated PTSD symptomatology.

RESULTS

Of all alerted lay rescuers, 6572 completed the online questionnaire. Of these, 1955 responded to the alert and 507 assisted in the resuscitation. We interviewed 203 first arriving rescuers of whom 189 completed the IES. Of these, 41% perceived no/mild short-term impact, 46% bearable impact and 13% severe impact. On the IES, 81% scored no stress and 19% scored mild stress. None scored moderate or severe stress. Using a multivariable logistic regression model we identified three factors with an independent impact on mild stress level: no automated external defibrillator connected by the lay rescuer, severe short-term impact, and no (very) positive experience.

CONCLUSION

Lay rescuers alerted by text messages, do not show PTSD-related symptoms 4-6 weeks after performing bystander CPR, even if they perceive severe short-term psychological impact.

Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment

PURPOSE

To evaluate the psychological consequences among family members given the option to be present during the CPR of a relative, compared with those not routinely offered the option.

METHODS

Prospective, cluster-randomized, controlled trial involving 15 prehospital emergency medical services units in France, comparing systematic offer for a relative to witness CPR with the traditional practice among 570 family members. Main outcome measure was 1-year assessment included proportion suffering post-traumatic stress disorder (PTSD), anxiety and depression symptoms, and/or complicated grief.

RESULTS

Among the 570 family members [intention to treat (ITT) population], 408 (72%) were evaluated at 1 year. In the ITT population (N = 570), family members had PTSD-related symptoms significantly more frequently in the control group than in the intervention group [adjusted odds ratio, 1.8; 95% confidence interval (CI) 1.1-3.0; P = 0.02] as did family members to whom physicians did not propose witnessing CPR [adjusted odds ratio, 1.7; 95% CI 1.1-2.6; P = 0.02]. In the observed cases population (N = 408), the proportion of family members experiencing a major depressive episode was significantly higher in the control group (31 vs. 23%; P = 0.02) and among family members to whom physicians did not propose the opportunity to witness CPR (31 vs. 24%; P = 0.03). The presence of complicated grief was significantly greater in the control group (36 vs. 21%; P = 0.005) and among family members to whom physicians did not propose the opportunity to witness resuscitation (37 vs. 23%; P = 0.003).

CONCLUSIONS

At 1 year after the event, psychological benefits persist for those family members offered the possibility to witness the CPR of a relative in cardiac arrest.

Family presence during brain death evaluation: a randomized controlled trial*

OBJECTIVE

To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress.

DESIGN

Randomized controlled trial.

SETTING

Four ICUs at an academic tertiary care center.

SUBJECTS

Immediate family members of patients suspected to have suffered brain death.

INTERVENTIONS

Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated "understanding brain death" survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention.

MEASUREMENTS AND MAIN RESULTS

Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1-2) if present versus 0 (interquartile range, 0-0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention "understanding" scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250).

CONCLUSIONS

Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Family presence during cardiopulmonary resuscitation

BACKGROUND

The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial.

METHODS

We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with post-traumatic stress disorder (PTSD)-related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims.

RESULTS

In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims.

CONCLUSIONS

Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts. (Funded by Programme Hospitalier de Recherche Clinique 2008 of the French Ministry of Health; ClinicalTrials.gov number, NCT01009606.).

Family witnessed resuscitation: nationwide survey of 337 prehospital emergency teams in France

OBJECTIVE

To assess the practices and opinions of prehospital emergency medical services (EMS) with regard to family witnessed resuscitation (FWR) and to analyse the differences between physicians' and nurses' responses.

DESIGN

An anonymous questionnaire (30 yes/no questions on demographics and FWR) was sent to all prehospital emergency staff (physicians, nurses and support staff) working for the 377 Mobile Intensive Care Units in France.

RESULTS

Of the 2689 responses received 2664 were analysed. Mean respondent age was 38 ± 8 years, the male to female ratio was 1:2. 87% of respondents had already performed FWR and 38% had offered relatives the option to be present during resuscitation. Most respondents (90%) felt that FWR might cause psychological trauma to the family; 70% thought that FWR might impact on the duration of resuscitation and 68% on EMS team concentration. In the 28% of cases when relatives had asked to be present, 59% of respondents had acquiesced but only 27% were willing to invite relatives to be routinely present.

CONCLUSIONS

Prehospital EMS teams in France seems to support FWR but are not yet ready to offer it systematically to relatives. Following our survey, written guidelines are currently in development in our department. These guidelines could be the first step of a national strategy for developing FWR in France. We await results from other studies of family members' opinions to compare prehospital practitioners' and family members' views to further develop our practice.