A Meta-ethnography of Out-of-Hospital Cardiac Arrest Survivors' Meanings on Life and Death

The experiences of cardiac arrest survivors and their key supporters following cardiac arrest: A systematic review and meta-ethnography

AIM

To review qualitative studies on the experience of sudden cardiac arrest survival from the perspective of both survivors and their key supporters, including family/close friends.

METHODS

A seven-step meta-ethnography and synthesis of qualitative evidence was undertaken, informed by the Meta-Ethnography Reporting Guidelines (eMERGe). Four major databases were searched (Medline, EMBASE, CINAHL, PsycINFO; January 1995-January 2022, updated July 2023) for qualitative studies exploring survivors' and/or key supporters' experiences of cardiac arrest survival. The Critical Appraisal Skills Programme checklist and Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) were applied to evaluate the overall confidence in research findings. Constructs were identified from each paper, informing theme and sub-theme development.

RESULTS

From 15,917 unique titles/abstracts and 196 full-text articles, 32 met the inclusion criteria. Three themes captured the survivors' experiences: 1) Making sense of my cardiac arrest; 2) Learning to trust my body and mind; and 3) Re-evaluating my life. A further three themes reflected key supporters' experiences: 1) Emotional turmoil; 2) Becoming a carer: same person but different me; and 3) Engaging with a new and unknown world. However, limited data and some methodological weaknesses in included studies reduced confidence in several themes. The findings were conceived within the overarching concept of 'negotiating a new normal'.

CONCLUSIONS

The enduring psychosocial and physical sequelae of cardiac arrest survival substantially impacts the lives of survivors and their key supporters, requiring negotiation of their 'new normality'. The need for sense-making, physical and psychological recovery, and the new roles for key supporters should be strong considerations in the development of future interventions.

Qualitative research in cardiac arrest research: A narrative review

Qualitative research is defined as "the study of the nature of phenomena", including "their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived". It is a methodology which is becoming extremely valuable in resuscitation science, especially in terms of improving our understanding of the true impact of sudden cardiac arrest on survivors, family members, lay responders and health care providers. This narrative review provides a high-level overview of qualitative methods as well as the current state of the qualitative evidence and key knowledge gaps in resuscitation science. It finishes with discussion of the bright future of qualitative research in our field.

Sex Differences in Patient-Reported Outcomes in the Immediate Recovery Period After Resuscitation: Findings From the Cross-sectional DenHeart Survey

BACKGROUND

A paucity of resuscitation studies have examined sex differences in patient-reported outcomes upon hospital discharge. It remains unclear whether male and female patients differ in health outcomes in their immediate responses to trauma and treatment after resuscitation.

OBJECTIVES

The aim of this study was to examine sex differences in patient-reported outcomes in the immediate recovery period after resuscitation.

METHODS

In a national cross-sectional survey, patient-reported outcomes were measured by 5 instruments: symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), illness perception (Brief Illness Perception Questionnaire [B-IPQ]), symptom burden (Edmonton Symptom Assessment Scale [ESAS]), quality of life (Heart Quality of Life Questionnaire), and perceived health status (12-Item Short Form Survey).

RESULTS

Of 491 eligible survivors of cardiac arrest, 176 (80% male) participated. Compared with male, resuscitated female reported worse symptoms of anxiety (Hospital Anxiety and Depression Scale-Anxiety score ≥8) (43% vs 23%; P = .04), emotional responses (B-IPQ) (mean [SD], 4.9 [3.12] vs 3.7 [2.99]; P = .05), identity (B-IPQ) (mean [SD], 4.3 [3.10] vs 4.0 [2.85]; P = .04), fatigue (ESAS) (mean [SD], 5.26 [2.48] vs 3.92 [2.93]; P = .01), and depressive symptoms (ESAS) (mean [SD], 2.60 [2.68] vs 1.67 [2.19]; P = .05).

CONCLUSIONS

Between sexes, female survivors of cardiac arrest reported worse psychological distress and illness perception and higher symptom burden in the immediate recovery period after resuscitation. Attention should focus on early symptom screening at hospital discharge to identify those in need of targeted psychological support and rehabilitation.

The aftermath of surviving a sudden cardiac arrest for young exercisers - a qualitative study in Norway

BACKGROUND

When surviving a sudden cardiac arrest (SCA), physical, cognitive, and emotional effects of surviving may be present for months or years. The survivors' family and colleagues are also highly affected by the incident. There is little knowledge about experiences of surviving SCA in individuals who prior to the incident were young and reported to exercise regularly. Consequently, the aim of this study was to explore the aftermath of surviving a SCA in young, regular exercisers.

METHODS

The study had a qualitative design, conducting in-depth individual interviews with SCA survivors < 50 years of age reporting to exercise ≥ 5 h/week and/or who suffered SCA during or less than 60 min after exercise. The data were analysed using systematic text condensation in-line with recommendations from Malterud.

RESULTS

18 of 31 eligible participants were included in the study. Through analysis we identified 'Establishing a new everyday life' as superordinate category, with subordinate categories a) being part of my surroundings, b) expecting normality but facing a new reality and c) lucky to be alive!

CONCLUSION

This study adds knowledge about young and regular exercisers' experiences after surviving a SCA. The obligations of everyday life in young survivors of SCA often imply a high work load and complex tasks, e.g. due to being in the beginning of their career or even still studying. Healthcare personnel, as well as the society, need to acknowledge that although lucky to be alive and apparently well-functioning, young survivors of SCA may have persistent challenges that cause frustration and reduced quality of life.

Surviving cardiac arrest - what do we know about recovery & survivorship?

PURPOSE OF REVIEW

There has been increasing interest in examining how cardiac arrest survivors and their families experience life after sudden cardiac arrest (SCA). Understanding their experiences provides a basis to study tools and interventions to improve short- and long-term recovery and rehabilitation.

RECENT FINDINGS

Qualitative interview and survey-style studies explored the lived experience of SCA survivors and revealed common themes (e.g., need for recovery expectations and long-term follow-up resources). A heightened awareness for the unique needs of family and loved ones of survivors led to qualitative studies focusing on these members as well. Methodology papers published portend prospective assessment and follow-up cohort studies. However, no investigations evaluating discharge processes or specific interventions directed at domain impairments common after SCA were identified in the review period. International work continues to identify patient and family-centered priorities for outcome measurement and research.

SUMMARY

In line with increased recognition of the importance for recovery and rehabilitation after SCA, there has been a commensurate increase in investigations documenting the needs of survivors and families surviving SCA. Pediatric and underserved populations continue to be understudied with regards to recovery after SCA.

Prevalence of anxiety, depression, and post-traumatic stress disorder after cardiac arrest: A systematic review and meta-analysis

AIM

Quality of life after surviving out-of-hospital cardiac arrest (OHCA) is poorly understood, and the risk to mental health is not well understood. We aimed to estimate the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) following OHCA.

METHODS

In this systematic review and meta-analysis, databases (MEDLINE, EMBASE, and PsycINFO) were searched from inception to July 3, 2021, for studies reporting the prevalence of depression, anxiety, and PTSD among OHCA survivors. Data abstraction and quality assessment were conducted by two authors independently, and a third resolved discrepancies. A single-arm meta-analysis of proportions was conducted to pool the proportion of patients with these conditions at the earliest follow-up time point in each study and at predefined time points. Meta-regression was performed to identify significant moderators that contributed to between-study heterogeneity.

RESULTS

The search yielded 15,366 articles. 13 articles were included for analysis, which comprised 186,160 patients. The pooled overall prevalence at the earliest time point of follow-up was 19.0% (11 studies; 95% confidence interval [CI] = 11.0-30.0%) for depression, 26.0% (nine studies; 95% CI = 16.0-39.0%) for anxiety, and 20.0% (three studies; 95% CI = 3.0-65.0%) for PTSD. Meta-regression showed that the age of patients and proportion of female sex were non-significant moderators.

CONCLUSION

The burden of mental health disorders is high among survivors of OHCA. There is an urgent need to understand the predisposing risk factors and develop preventive strategies.

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).

Moving from physical survival to psychologic recovery: a qualitative study of survivor perspectives on long-term outcome after sudden cardiac arrest

Background

Over 400,000 adults suffer out-of-hospital cardiac arrests (OHCA) each year in North America. Despite a very high mortality rate, even 10% survival means that a minimum of 3500 people return to their lives and their families. However, their experience of living and their health-related quality of life after such a life-changing event are quite variable, much more complex than just having lived or died, and should not be reduced to crude measures of neurological functioning.

Methods

We conducted 32 in-depth qualitative interviews with survivor/family member dyads at various stages of survival. The interviews focused on the recovery journey, long-term issues most important to them and how measuring such concepts could help. Interviews were audio-taped, transcribed verbatim and analyzed using constant comparative thematic analysis techniques.

Results

During in-depth interviews with more than 30 survivors and caregivers we have heard that despite being a relatively high functioning group, their lives have been deeply affected by their cardiac arrest experience. They speak about the importance of both psychologic and physical recovery, the impact of return to work or changes in work identity and the necessity of support from family members in the recovery process. Spouses/family members also mentioned differences in perspective on their loved one’s recovery and how they manage the fear of recurrence.

Conclusions

This work purposively brings a unique lens to the concept of cardiac arrest outcomes by placing priority on what is important to survivors and their families and what we may be missing in standard outcomes measures. There is a clear need for a more patient-centred outcome set for this population and our work indicates that psychologic assessment, return to work status and family input are key domains to be considered.

"We don't talk about his heart": Narrative sense-making and long-term readjustment among older out-of-hospital cardiac arrest survivors and their spouses

Aim of the study

Globally, there has been an increase in the survival rate and the average age of survivors from out-of-hospital cardiac arrest (OHCA). However, little is known about the joint OHCA-associated experiences among older survivors and their spouses in a long-term perspective. The aim of this study was to explore how narrative sense-making processes following OHCA shapes everyday life in a long-term perspective among older survivors and their spouses.

Methods

Five older male survivors and their female spouses were interviewed individually using narrative methods. Arthur Frank’s theory on illness narratives informed the analysis. Participant observation at two meetings for survivors and relatives regarding cardiac arrest was used for qualification of the interview guide.

Results

Five married couples participated. The mean age of the survivors and spouses was 70,4 and 71,4 years respectively, and time since OHCA varied from 12 to 66 months. Two themes of the dyadic experience emerged: 1) experiences during OHCA, and 2) experiences in life following OHCA. Subthemes differed with survivors emphasising a desire to return to the same life as before the OHCA, and the spouses narrating feelings of anxiety. Potential complications of the OHCA were often explained with reference to ageing processes, and the OHCA was contextualised in relation to previous life-changing events.

Conclusion

In a long-term perspective, OHCA shapes the life trajectory of both the survivor and the spouse, and the relationship between them, underscoring a need for patient-centred care with a greater focus on the relationship of the dyads.

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Unmet needs among survivors and spouses should be addressed by follow-up dialogue.

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Life after OHCA is embedded in the context of age and biography.

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A narrative approach in encounters could strengthen the support for couples.

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Survivors and spouses’ experiences contrasted pointing towards individual needs.

Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association

Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.

Trapped in a disrupted normality: Survivors' and partners' experiences of life after a sudden cardiac arrest

AIM OF THE STUDY

Advances in resuscitation science have resulted in a growing number of out-of-hospital cardiac arrest (OHCA) survivors. However, we know very little about the natural history of recovery and the unmet needs of survivors and their partners. This qualitative study sought to address this knowledge gap to improve understanding of the consequences of surviving cardiac arrest.

METHODS

In-depth qualitative interviews were undertaken separately with survivors and their partners between 3 and 12-months following the cardiac arrest. An interpretative phenomenological approach (IPA) to data analysis was adopted. Developing themes were discussed between members of the research team.

RESULTS

8 survivors (41-79 years; 5 male; mean time 6.3 months post-hospital discharge) and 3 partners (1 male) were interviewed. The key (super-ordinate) theme of being 'trapped in a disrupted normality' was identified within the data. Five related subordinate themes included: existential impact, physical ramifications, emotional consequences, limiting participation in social activities and altered family roles.

CONCLUSION

Recovery for survivors is hindered by a wide range of physical, emotional, cognitive, social and spiritual challenges that disrupt perceptions of 'normality'. Survivors and their carers may benefit from focussing on establishing a 'new normal' rather than striving to achieve a pre-cardiac social and physical position. Survivor-centred assessment should support rather than undermine this goal.

Content Analysis in Critical and Emergency Care: A Discussion Paper

Introduction

Content analysis, although firstly introduced in social sciences as a qualitative research method, has become a popular method for inquiry in healthcare sciences, including emergency and critical care nursing.

Aim

The aim of content analysis is to interpret qualitative data through coding and analytical identification of themes or schemas.

Results

There are different forms of content analysis, according to the aim of the study, (a) the conventional approach, (b) the direct approach, and (c) the summative approach. The depth of the analysis is defined by the degree to which the researcher reveals the covered meanings included in data. The range of the analysis is defined by the number of the identified themes and relevant categories of themes, and mainly of how abstract is the identified association among the different categories of themes. Balancing the strengths against the researcher-identified limitations and other weaknesses of the study, the researchers determine the value or trustworthiness of study findings, aiming to increase the transferability of the findings to other populations.

Conclusion

Qualitative research is under-used as a research method in emergency and critical care despite the limitless variations of clinical research questions that can be investigated through this method of inquiry and relevant study designs, including content analysis.

The lived experience of delirium in intensive care unit patients: A meta-ethnography

OBJECTIVES

The objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state.

REVIEW METHODS

The study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search.

DATA SOURCES

MEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool.

RESULTS

Based on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, "a perturbing altered reality" and four main themes were identified: "disturbed sense of time", "omnipresent feeling of fear", "impact of human connection", and "perceiving surreal events". These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU.

CONCLUSIONS

Critically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.