Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units

A. S. Grice1,2, P. Picton1 and C. D. S. Deakin1

1 Shackleton Department of Anaesthesia, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO9 4XY, UK. 2 Department of Anaesthesia, Poole General Hospital, Longfleet Road, Poole, UK

*Corresponding author. E-mail: alex.grice@doctors.org.uk

Accepted for publication: July 21, 2003


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background. Witnessed resuscitation is widely accepted in paediatric practice and is becoming more common in adult emergency departments, but information on this topic is sparse.

Methods. We gave a questionnaire to 50 intensive care medical and nursing staff and 55 patients and next of kin before elective postoperative admission to the intensive care unit to examine staff opinion about witnessed resuscitation, patient and relatives’ demand for witnessed resuscitation, and their perception of the benefits.

Results. We found that 56% of doctors and 66% of nurses favoured giving relatives the option to stay. If relatives requested to be present, 70% of doctors and 82% of nurses would allow this if the relatives were escorted. The role of the escort was felt to explain, prevent interference, and to provide emotional support. We found that 29% of patients and 47% of relatives wanted to be together during resuscitation, the commonest reasons being to provide support and to see that everything was done. We found that 95% of patients and 91% of relatives felt their views should be formally sought before ICU admission.

Conclusions. Intensive care staff support witnessed resuscitation. Many intensive care personnel have experienced witnessed resuscitation and the majority felt that relatives gained benefit. Almost all agree that the views of both patient and relatives should be sought formally before admission to intensive care.

Br J Anaesth 2003; 91: 820–4

Keywords: intensive care, adult; intensive care, witnessed resuscitation


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The practice of excluding relatives during cardiopulmonary resuscitation has been critically questioned, particularly over the past decade. In 1995, the Royal College of Nursing jointly with the British Association for Accident and Emergency Medicine1 recommended that ‘witnessed resuscitation should be considered and supported if at all possible’. The resuscitation council (UK) shares these views. The presence of relatives may create ethical, moral, and practical dilemmas. Medical confidentiality, conflict with unknown wishes of the patient, the potential for interference, litigation and stress amongst resuscitation staff are all concerns.26 Recent studies show public support and desire for inclusion in resuscitation.7 The benefits for relatives may be considerable and there is now a growing trend to allow relatives to be present during resuscitation attempts in the emergency department.

Approximately 30 000 resuscitation attempts take place each year in the UK.8 Although most of these take place in the emergency department, many will occur in intensive care units, where relatives are often present. The attitudes of staff and relatives to witnessed resuscitation in this setting are not known. Patients’ views on witnessed resuscitation in any circumstance have not been surveyed.

We surveyed medical and nursing staff from our general and cardiothoracic intensive care units to determine their views. We also approached patients and their next of kin to determine their attitudes to witnessed resuscitation, before elective surgery that would require intensive care after surgery.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
After approval from the local Ethics Committee, we identified all trainee and consultant anaesthetists at Southampton University Hospital who had provided clinical care in a general or cardiothoracic intensive care unit over the past 5 yr. These anaesthetists were then asked to complete and return a written, anonymous questionnaire.

We also surveyed the nursing staff working on adult and cardiothoracic intensive care. Every nurse on consecutive morning shifts was approached with a questionnaire and asked to return it completed by the end of the shift. This was continued until we had twenty-five replies from each unit.

We prospectively recruited patients between the age of 18 and 85 yr, about to undergo elective cardiac and major vascular surgery in the last 3 months of 2001 where postoperative admission to intensive care was planned. Each patient was approached indirectly by a nurse who sought permission for the research team to contact the patient. Once permission was given, written consent was obtained by the researchers from the patient and their next of kin. Each person then completed a questionnaire in the presence of a researcher. The questionnaire was a structured document with specific questions, but gave room for open comments. If the next of kin was unavailable or unwilling to participate in the study then the patient’s responses were excluded; only paired replies were analysed.


    Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Staff responses
Fifty replies were received from medical staff with an overall response rate of 88%. Overall composition of the replies from doctors was 22% consultants, 52% registrars and 26% senior house officers. Fifty replies were received from the nursing staff with a response rate of 94%. Overall composition of the replies from nursing staff was 20% G grade, 32% F grade, 24% E grade and 24% D grade (G grade is the most experienced).

Should relatives be present during resuscitation?
Fifty-six per cent of doctors and 66% of nurses felt relatives should be given this option. If the relative asked to be present then more would agree (70% of doctors and 82% of nurses) provided the patient was escorted by a trained member of staff. Eighteen per cent of these doctors and 16% of these nurses were not keen on giving the relatives the option in the first place.

Reasons for: The most common reason for allowing accompanied witnessed resuscitation was to provide explanation (50% of doctors, 50% of nurses), prevent interference (14% of doctors, 10% of nurses) and to provide emotional support (6% of doctors, 14% of nurses). Eight per cent of nurses also felt the relatives had a right to be present. Table 1 lists the main perceived advantages of witnessed resuscitation. Each doctor or nurse was allowed to list up to three advantages with the doctors listing a total of 91 advantages and the nursing staff listing 86. The ability to see that everything was done was the most common reason listed by both groups (30% of doctors’ replies, 33% of nurses’ replies).


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Table 1 Advantages provided of witnessed resuscitation
 
Reasons against: Twenty-six per cent of doctors and 18% of nurses would not allow relatives to be present, 8% of doctors and 18% of nurses believing this to be too distressing for the relative. Six (12%) doctors based this reply on a bad previous experience and 3 (6%) doctors felt this would leave relatives with a poor last impression. The main perceived disadvantages are listed in Table 2 and again both groups were allowed to list up to three disadvantages. Both groups provided 113 replies and ‘relative distress’ was the most consistently cited major drawback (29% of doctors’ replies, 30% of nurses’ replies).


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Table 2 Disadvantages of witnessed resuscitation
 
Patient and relative responses
Fifty-five patients and their next of kin were enrolled in this study. Eighty-four per cent of patients were presenting for elective cardiac surgery and the remainder were presenting for major vascular surgery.

Should relatives be present during resuscitation?—patients’ views
Twenty-nine per cent of the patients stated they would want their next of kin present during their resuscitation.

Reasons for: Twenty per cent felt their presence would provide support, 5% felt this would allow the relative to see that everything was done and 4% patients felt that witnessing the resuscitation would be less traumatic for the relative than imagining what had happened at a later stage.

Reasons against: Out of the 71% patients that did not wish their resuscitation to be witnessed by next of kin, 55% felt it would be too distressing, and 9% felt their relative may impede the resuscitation. Four per cent of patients also thought it would leave a bad last impression and another 4% of patients thought relative presence made no difference.

Should relatives be present during resuscitation?—relatives’ views
Forty-seven per cent of relatives questioned wished to remain with the patient during resuscitation.

Reasons for: Twenty-four per cent of relatives felt this would provide support, 14% wished to see that everything possible was done, 7% did not wish the patient to die alone and 2% wished to participate in deciding when to discontinue resuscitation.

Reasons against: Out of the 53% relatives that did not wish to be present, the most common reason cited was that they felt it would be too distressing (33%). Sixteen per cent of relatives were concerned they may impede resuscitation, one relative felt she would be too frightened and one relative declined as she felt she would be unable to help.

Twenty-five per cent of the 55 couples interviewed both agreed on wishing to be present. Ninety-five per cent of patients and 91% of relatives felt their views on this should be formally documented before surgery.

When asked if the next of kin would benefit by being present, 38% of patients and 53% of next of kin felt they would. Both groups agreed the most important reason being that they could see everything was done (Table 3). Both patients and next of kin also agreed the most important reason why relatives would not benefit was because it was felt to be too distressing (Table 4).


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Table 3 Reasons offered for relatives benefiting from witnessed resuscitation
 

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Table 4 Reasons offered for relatives not benefiting from witnessed resuscitation
 
Does the patient benefit from the presence of a relative?
Patients’ view: When asked whether the patient benefited from the presence of a relative, 21% patients felt they would. Twelve per cent of patients felt they would be comforted knowing a relative was near and 9% specifically did not wish to be alone at the end. Seventy-nine per cent of patients felt they would not benefit from witnessed resuscitation with 75% stating that they would not be aware. One (2%) patient felt it was an invasion of privacy and one other patient felt relative presence made no difference.

Relatives’ view: When asked whether the patient benefited from the presence of a relative 38% of relatives felt they would. Sixteen per cent of relatives also felt the patient would not wish to be alone and 9% also noted that patients can be aware during resuscitation and would therefore be reassured to know a relative was still present. Nine per cent of relatives felt the patient would benefit from their emotional support, one (2%) felt she could provide information to the patient after the resuscitation and one relative wished to pray during the resuscitation. All (62%) of the relatives who felt witnessed resuscitation did not benefit the patient believed that the patient would not be aware.

Patients’ and relatives’ views of staff attitudes
When the relatives were asked why intensive care staff would ask them to leave the room during resuscitation, 40% thought it was because they would be in the way, 27% thought staff would be concerned about possible distraction, 22% thought staff felt it would be too distressing for relatives to stay, and 11% thought staff were concerned about relatives interfering with patient treatment.

Patients and relatives were also given the opportunity to state whether they agreed with a list of concerns that had been cited by staff in a previous publication looking at staff attitudes to witnessed resuscitation in the emergency room.8 These replies are detailed in Table 5 and show overall agreement with the concerns of the emergency room staff with the exception of the statement that relatives have ‘no right to be present’. Seventy per cent of both patients and relatives disagreed with this statement.


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Table 5 Patient and relatives’ opinions on staff concerns
 
Outcome of resuscitation
Ninety per cent of patients and relatives had had some previous exposure to resuscitation with 88% admitting to having seen resuscitation on television. Six per cent of patients and relatives have seen community arrests and 8% had witnessed hospital arrests. We also asked each patient and relative to estimate what proportion of patients on intensive care survived resuscitation (to the point of discharge from intensive care). Figure 1 shows that the majority of both patients and relatives estimated success rates between 40–60% and 60–95%. The numbers were too small to determine if there was a difference between patients or relatives whom had seen resuscitation and those who had not.



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Fig 1 Patients’ and relatives’ expectation of resuscitation success.

 

    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Will medical and nursing staff accept witnessed resuscitation?
Studies have shown initial support of witnessed resuscitation varying from 37% to 70%.913 There is little evidence available to predict how this proportion would change after a witnessed resuscitation programme, but in one study, acceptance improved so much that the trial had to be stopped early.14 In this study, 56% of doctors and 66% of nurses surveyed were initially receptive and this improved to 70% and 82% respectively if the relative was accompanied by a trained member of staff.

What needs to be considered when introducing witnessed resuscitation?
Doctors and nurses who were reluctant to endorse witnessed resuscitation felt it was too distressing or would leave a poor last impression. Evidence about this is sparse, but most papers do not support this view. In one paper, 93% of the relatives were pleased they had and with hind-sight would not have changed their minds.15 If this were explained to staff then acceptance may increase.

This study supported the role of the chaperone as an information source for relatives. This would require a trained member of staff and would need to be taken into account when planning the introduction of witnessed resuscitation. Concerns were raised over interference and obstruction by the relative (intentional or otherwise), but again such incidents are notably lacking in any of the accounts of established witnessed resuscitation programs.14 16 These concerns should not hamper attempts to set up such a program in intensive care.

Impression of unstructured witnessed resuscitation
A significant proportion of staff surveyed had already been involved in unstructured witnessed resuscitation and most staff felt positive about it. Fifty-three per cent of these doctors and 55% of nurses felt the relatives had benefited, and 94% of doctors and 85% of nurses felt it had not disadvantaged the patient. This is supported by the psychological impact on relatives of witnessing resuscitation, with less anxiety, depression and grief.14

Is witnessed resuscitation in demand?
The extent to which relatives wish to witness resuscitation has been examined with retrospective postal questionnaires and telephone interviews.17 These studies suggest that between 62 and 72% of relatives would wish to remain present during resuscitation. In our prospective study 47% of the relatives were keen to stay during resuscitation, but only 29% of patients wanted their relatives present, with both patient and relative agreeing in 25% of couples interviewed.

Distress was cited as the main reason why the patients did not wish any relative to be present. If the witnessed resuscitation process were explained (with emphasis on the role of the chaperone) then acceptance may improve (as found in another study14) but if, in spite of this, the patient documents a wish to exclude their relative, then that view must be honoured. The fact that such a low proportion of patients were not keen, reinforces the need to determine views in advance wherever possible. The use of an advance directive was acceptable to both patients and relatives with 95% and 91%, respectively, indicating that it should be sought.

The difficulty arises when the patient’s view is not known (as in most cases) and the relative’s views are unopposed. Faced with a relative asking to be present, some authors feel it is ethically questionable to request that they leave.18 19 Similarly, if resuscitation proves successful then the potential for complaint arising from having followed an unopposed view would also seem to be very slight.20 The Resuscitation Council (UK) has also published a report on this,8 in which they endorse the provision of such choice for the relatives.

What are patients’ and relatives’ expectations?
Fourteen per cent of patients and relatives had encountered resuscitation. This proportion increased to 91% and 89% respectively if media coverage of resuscitation was included. When asked to estimate resuscitation success both patients and relatives estimates (Fig. 1) agreed with el-Banayosy and colleagues21 who examined cardiac arrest after bypass surgery. They determined an arrest incidence of 2.3% with the 70% survival rate. However if these estimates were compared with experience on general intensive care then they were much less representative. In one study patients admitted to general intensive care after cardiac arrest were found to have a 43% chance of intensive care discharge,22 whereas patients arresting during intensive care (in the predominant setting of sepsis) only have a 3% chance of intensive care discharge.23

The influence such unrealistic expectation of resuscitation success has on general intensive care is unclear, and would benefit from further study.24 25 In particular it would be useful to see if the proportion of patients requesting the presence of a relative would alter if the severity of the scenario were explained.

In conclusion, many intensive care personnel support the idea of allowing relatives to stay during resuscitation and this proportion increases if the relative is escorted. The main objections from staff are not supported by previous reports and support for witnessed resuscitation may increase if this is explained. Many staff have experienced unstructured witnessed resuscitation and most believed that the relatives benefited by being present. Only half the relatives interviewed and a third of the patients interviewed favour witnessed resuscitation, but >90% of each group felt that admitting teams should document the views of patients and relatives before elective surgery requiring postoperative intensive care.


    References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
1 Royal College of Nursing and British Association for Accident and Emergency Medicine. Bereavement Care in A&E Departments—Report of the Working Group, RCN Re-order number 000 523, 1995

2 Adams S, Whitlock M, Higgs R, Bloomfield P, Baskett PJ. Should relatives be allowed to watch resuscitation? Br Med J 1994; 308: 1687–92[Free Full Text]

3 Mehanna H. Should relatives watch resuscitation? Effect on relatives needs study. Br Med J 1994; 309: 407[Free Full Text]

4 Stewart K, Bowker L. Resuscitation witnessed by relatives. Might lead to a complaint for breach of confidentiality. Br Med J 1997; 314: 145[Free Full Text]

5 Crisci C. Should relatives watch resuscitation? Local factors may influence decision. Br Med J 1994; 309: 406[Free Full Text]

6 Zoltie N, Sloan JP, Wright B. Should relatives watch resuscitation? May affect doctors’ performance. Br Med J 1994; 309: 406–7[Free Full Text]

7 Hanson C, Strawser P. Family presence during cardio-pulmonary resuscitation. Foote Hospital Emergency Department’s nine-year perspective. J Emerg Nurse 1992; 18: 104–6[Medline]

8 Resuscitation Council. Should relatives witness resuscitation? A report from a project team of the Resuscitation Council, UK. London, 1996

9 Hatchett R. Should relatives watch resuscitation? A successful American programme. Br Med J 1994; 309: 407[Free Full Text]

10 Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accid Emerg Nurse 1996; 4: 145–51

11 Osuagwu C. More on family presence during resuscitation. J Emerg Nurse 1993; 19; 276–7[Medline]

12 Mitchel MH, Lynch MB. Should relatives be allowed in the resuscitation room? J Accid Emerg Med 1997; 14: 366–9[Abstract]

13 Back D, Rooke V. The presence of relatives in the resuscitation room. Nurs Times 1994; 90: 34–6

14 Robinson SM, Campbell-Hewson GL, Egelston CV, Prevost AT, Ross SM. The psychological impact on relatives of witnessing resuscitation. Lancet 1998; 352: 614–17[CrossRef][ISI][Medline]

15 Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med 1987; 16: 107–9

16 Morgan J. Introducing witnessed resuscitation in Accident and Emergency. Emerg Nurse 1997; 5: 13–18

17 Barrat F, Wallis DN. Relatives in the resuscitation room—their point of view. J Accid Emerg Med 1998; 15: 109–11[Abstract]

18 Malone R. The ethics of exclusion and the myth of control. J Emerg Nurse 1993; 19: 33–4

19 Rosenczweig C. Should relatives witness resuscitation? Ethical issues and practical considerations. CMAJ 1998; 158: 617–20[Abstract/Free Full Text]

20 McLauchlan CA. Allowing relatives to witness resuscitation. Br Med J 1997; 314: 145[Free Full Text]

21 el-Banayosy A, Brehm C, Kizner L, et al. Cardiopulmonary resuscitation after cardiac surgery: a two-year study. J Cardiothorac Vasc Anesth 1998; 12: 390–2[ISI][Medline]

22 Denton R, Thomas AN. Cardiopulmonary resuscitation: a retrospective review. Anaesthesia 1997; 52: 324–7[ISI][Medline]

23 Lipman J, Wilson W, Kobilski S, et al. High-dose epinephrine in adult in-hospital asystolic cardiopulmonary resuscitation: a double-blind randomised trial. Anaesth Intens Care 1993; 21: 192–6[ISI][Medline]

24 Baer NA. Cardiopulmonary resuscitation on television. Exaggerations and accusations. N Engl J Med 1996; 334: 1578–82[Abstract/Free Full Text]

25 Boyd R. Witnessed resuscitation by relatives. Resuscitation 2000; 43: 171–6[CrossRef][ISI][Medline]