The Pros and Cons of Witnessed Resuscitation

Within the advent of witnessed resuscitation, there have been many arguments on the pros and cons of regulations and methods. For many, the consideration of witnessed resuscitation at one time was a closed subject, and none were allowed to witness the resuscitation efforts of a loved one, regardless of the age of that loved one. Those ideals have been changing in recent years. It is only recently that it would be realized that witnessing a loved one’s final moments is as important as medical personnel attempting to save that patient’s life. There has in fact been a great deal of research done on witnessed resuscitation and it would be this consideration, what benefits and drawbacks can be found in permitting witnessed resuscitation, that has been discussed on many fronts by many medical authorities worldwide.

The British Medical Journal provides a great deal of evidence toward an understanding of witnessed resuscitation. In their article titled Push to Allow Relatives to Witness Resuscitation, the British Medical Journal discusses a report published by the Resuscitation Council and its recommendations. The recommendations included a consideration to allow witnessed resuscitation attempts by the relatives of the patient and that the medical staff should be trained appropriately in such consideration. The council further recognises that the suggestion is quite controversial in nature and that training and support are necessary for staff to cope with extraneous stress resulting from such interactions. “Perceived advantages were that relatives could see that everything possible was done for the dying person and that their presence might have some positive benefit on the outcome.” (Wise, J; BMJ; 1996) The article by BMJ continues to state that paediatricians are actually in favour of having witnessed resuscitation by relatives but that physicians and anaesthetists would be against such inclusion. The fear would be that the presence of relatives during resuscitation would produce undue increased stress on the staff. Further concerns include the consideration that the resuscitation realities may in fact prove distressing to the relatives themselves. Considerations also have been drawn in whether the presence of relatives as they witness resuscitation when attempts fail and the decision to stop resuscitation attempts in regard to interference, either physical or emotional, which may hinder staff involved in the attempt.

The Royal College of Nursing during their annual congress in Bournemouth heard that the allowance of witnessed resuscitation by relatives may assist them in coming to terms with the loss of a loved one more easily. The call for guidelines for relatives and staff was made. This is important for both relatives and staff, to have the understanding and guidelines to provide them the rights and abilities to treat the patient as swiftly as possible using every possible measure and also to give relatives the ability to oversee without interference, and with the understanding that the nurses and doctors would stop only if there were no response for a certain, specific period of time. There are those who warn that relatives may prove a hindrance and the experience may be traumatic as well. The staff, according to this conference, “must be trained on the issue and relatives must have access to counselling afterwards.” (BBC News; April 6, 2000) Casualty nurse Mike Smith in the BBC News article tells how he before last Christmas would have been against witnessed resuscitation by relatives. His mindset altered this past Christmas upon treating a dying victim from a road crash. “For six hours we tried to resuscitate him and outside his family waited anxiously. As we became aware that we were losing the battle to save him the decision was taken to allow his family – all nine of them – into the resuscitation room.” (BBC News; April 6, 2000)

One such study of witnessed resuscitation was researched by Elaine Cole. The information provided in the study is quite comprehensive and gives both good and bad results that may or may not occur during witnessed resuscitation. This particular research provides actual reasoning behind why relatives should and should not witness resuscitation in certain situations. Two areas of Trusts where witnessed resuscitation is freely allowed in most cases would be ITU and paediatric departments. Ms. Cole continues to state that, “However, it may not be an applicable practice in all wards and departments due to lack of staff and supportive resources. The Trust is currently trying to agree practice guidelines that enable witnessed resuscitation rather than go against relatives’ wishes.” (Cole, Elaine; trauma.org; August 2000) Ms. Cole provides distinct arguments against allowance of witnessed resuscitation including sensory disturbance and confidentiality issues, a staff response, complaints, clinical performance, and also relatives’ emotional response. Ms. Cole furthers her comparison with arguments for witnessed resuscitation including many aspects not considered for many years. Those considerations include: respecting relatives’ wishes, media influences, empirical evidence (specifically from the USA), and empirical evidence (from the UK). In regard to the results of empirical evidence, several things were realized and follow-up was managed with the families considered as part of the study. “Those relatives that were present were followed up after one month to see whether they regretted their decision and after one, six and nine months to examine psychological effects.” (Cole, Elaine; trauma.org; August 2000)

The fact that Ms. Cole goes so far as to examine both sides of this extremely controversial issue provides a clear view of how both staff and relatives have considered the idea of witnessed resuscitation over the years. The work done in her research provides an insightful view. Throughout the portion where Ms. Cole describes the drawbacks of witnessed resuscitation, there are many aspects to consider. Sensory disturbance, as stated, resuscitations are often visually disturbing even to some of the most experienced clinicians. Odours from patient secretions, blood and even from defibrillation may be unpleasant. Patients may cry out as a result of being under-sedated or suffering pain and may make noise causing auditory disturbance for relatives and the team. Confidentiality issues are posed when patients are unconscious at the time of treatment and consent for having relatives present would not be possible in these instances. It is suggested that not only would relatives see all that was going on with the patient but information meant to remain confidential and intensely personal in nature would be overheard as well, this is where many would consider it a problem for witnessed resuscitation ethics.

Ms. Cole furthers the consideration of arguments against in regard to relatives’ complaints in regard to hearing remarks during resuscitation delivered by the staff. The concern is increased risk of litigation against doctors and hospitals. Staff response to resuscitation efforts may be efforts to reduce stress and may be misconstrued in the context of the situation as humour is occasionally portrayed in such situations. The response of relatives has been the main argument against witnessed resuscitation and this would in fact be the main concern of clinicians. Clinicians also are concerned by performance pressures affected by relatives’ presence and inhibited discussion.

A second study into witnessed resuscitation efforts was conducted and described in the Academic Education section of Critical Care Nurse in February 2005. This study provides a very interesting portrayal of pros and cons toward witnessed resuscitation including perceived benefits and perceived problems for both family members and healthcare providers. Listed as Table 1 on page 40 the information would be as follows: (Critical Care Nurse: February 2005; p 40)

Perceived Benefits for Family Members	Perceived Benefits for Healthcare Providers
Appreciation for efforts of the code team that “everything possible” was done to save the patient.	Gives staff members a reality check into their patient’s “personhood” when relatives would be present during code situations.
Provides an enhanced feeling of usefulness by offering medical history and actively supporting the patient.	Helps staff provide a more holistic approach to care of the patient during crisis situation.
Gives opportunity for patient’s values to be expressed to staff.	Encourages professional behaviour among staff.
Allows for an increased spiritual connectedness with the patient.	Allows family members of the patients to recognize efforts made by staff members to save the patient.
A reduction in guilt process and anxiety about leaving the patient during a crisis moment.	Reaffirms the nurse’s role as patient advocate.
Facilitates a method toward closure with the patient and the impetus toward the grieving process allowing a chance to say good-bye	Focus is managed for patients’ dignity and privacy for the staff.

This chart shows the potential benefits for allowing witnessed resuscitation. It manages what many fail to recognize in the simplified methodology and description. As can be seen, there are benefits both for relatives and for clinicians involved. Allowing the family to participate or observe gains their respect toward the clinicians in their professionalism and their empathy toward their patients. But, in focusing only on the benefits, we lose out on the entire picture surrounding the consideration for witnessed resuscitation efforts. The entire picture must contain both perceived benefits and perceived problems or drawbacks. Those are described in the chart below. All of this information again is summarised from the Academic Education section of Critical Care Nurse in February 2005 (Critical Care Nurse; February 2005; p 40).

Perceived problems in witnessed resuscitation regarding relatives.	Perceived problems in witnessed resuscitation regarding clinicians.
Pressure to be present even if there is no desire to participate in the situation.	Fear of distraction of staff members by distraught family members.
Insensitivity risk by staff assuming family members would wish to be present.	Unease about potential for litigation by family members viewing codes in the midst of resuscitation.
Fear of the consequence of being emotionally traumatized during a code.	The concern that prolonged code situations may be presented in futile efforts to resuscitate at the presence of relatives’ during witnessed resuscitation efforts.
Concern that there may be unnecessary prolonged use of code measures due to the attendance of family members.	Anxiety regarding a loss of control in the clinical environment and possible disruptive behaviour by family members potentially leading to physical assault.

This particular piece divides the process of considering witnessed resuscitation into manageable segments. Those segments include reviewing the literature involved, reviewing practice guidelines, and defining opposing arguments. In pursuing a consideration for witnessed resuscitation, all of these factors must be brought into true focus and evaluated appropriately. Every situation during a code would in fact be different and thus require fresh examination of the potential benefits and drawbacks toward allowance of family members’ observation of resuscitation procedures.

This particular piece goes on into a specific framework method of clinical ethics analysis that is quite informative. This framework is divided into four sections including: medical indications, patient preferences, quality of life and contextual features. These features are as follows;

Medical Indications

1. What is the patient’s medical problem? History? Diagnosis? Prognosis?
2. Is the problem acute? Chronic? Critical? Emergent? Reversible?
3. What goals of treatment exist?
4. What are the probabilities toward success?
5. What plans are in place in case of therapeutic failure?
6. How can this patient benefit from medical and nursing care and how can harm be avoided?

Patient Preferences

1. What preferences were expressed by the patient in regard to treatment?
2. Does the patient have information regarding benefits and risks and has the patient understood and given consent?
3. Would the patient be mentally capable and legally competent and what evidence would there be of incapacity?
4. Has the patient expressed prior preferences, such as advanced directives?
5. If the patient would be incapacitated, who would the appropriate surrogate be? Is the surrogate utilizing appropriate standards?
6. Is there an unwillingness or inability toward cooperation by the patient in regard to medical treatment? If so, why?
7. Is the patient’s right to choose being respected to all possible extents relative to ethics and law?

Quality of Life

1. What prospects toward a return to patient’s normal life would exist with or without treatment?
2. What biases may prejudice the provider’s evaluation of the patient’s quality of life?
3. What mental, physical or social deficits would the patient likely experience should the treatment be successful?
4. Would the present or future condition of the patient alter the perception of what the patient might view as desirable or undesirable living conditions?
5. Would any plan or rationale exist to forgo treatment?
6. Are there plans for comfort and palliative care?

Contextual Features

1. Do family issues exist that may influence treatment decisions?
2. Would the provider (physicians and nurses) have issues which may influence treatment decisions?
3. Do financial or economic factors exist?
4. Are there religious or cultural factors?
5. Is a breach of confidentiality justified?
6. Is resource allocation problematic?
7. Are there legal implications to the treatment decisions?
8. Would clinical research or teaching be involved in treatment?
9. Would there be either a provider or institutional conflict of interest?

The points garnered from this chart were originally provided by Jonsen et. al. with permission from McGraw-Hill Companies and copyright in 1998, reproduced in Critical Care Nurse in February 2005 page 40 and 41. The benefits of understanding this particular research would be toward any nursing student in regard to how to handle or even consider witnessed resuscitation. This journal, much like the previous case, provides us with viewpoints that are both positive and negative in regard to witnessed resuscitation. The viewpoints are such that they give potential problems and benefits for both clinicians and relatives and this in fact is of benefit for framing policy in regard to witnessed resuscitation.

Witnessed resuscitation is considered beneficial in paediatric wards for both the patients and the relatives. Yet there are situations where such witnessing would not be beneficial for either staff members or relatives and this is the reason for a need in regard to framework for allowance in regard to witnessed resuscitation. From the viewpoint of a nurse in the assessment ward consideration toward allowance of witnessed resuscitation is important based on all those benefits and drawbacks mentioned. The addition of a framework specifically in relation to witnessed resuscitation efforts is a vital necessity for assessment ward nurse for many reasons.

Rationale for such efforts by staff to allow for witnessed resuscitation includes a swift assessment of the patient’s mental state and whether the added mental states of relatives may actually prove beneficial or detrimental in treatment situations. Without realizing the potential drawbacks along with the benefits for witnessed resuscitation, assessment ward nurses would have a very traumatic experience both for themselves as well as the relatives and the potential harm this can manage toward the patient would also be tragic. The four pieces considered for witness resuscitation provide a portrait of reasoning that supports or criticizes the process of witnessed resuscitation.

The undeniable benefits for the family members are quite obvious in their existence. Yet, patient benefits toward this ideal are not always easily seen. This is especially true when the patient dies even after every possible method has been managed toward saving the patient’s life. What is also unseen is the true benefit for clinicians in the desire to provide answers in regard to a patient’s care. Yet again, the line must be written in the framework of such allowances prior to allowance for witnessed resuscitation efforts. As a nurse in an assessment ward, the consideration for witnessed resuscitation should be a consideration written into the framework of treatment. The benefit to the grief process or even to the recovery process is uncharted for both patients and clinicians, yet, without witnessed resuscitation, such study cannot adequately be performed.

Bibliography Cited;

Journals:

• Wise, Jacqui; Push to Allow Relatives to Witness Resuscitation; BMJ; October 12, 1996; https://bmj.bmjjournals.com/cgi/content/full/314/7086/1044
• Witnessing Resuscitation: Guidance for Nursing Staff; Royal College of Nursing; Published by the Royal College of Nursing; London; April 2002; https://www.rcn.org.uk/members/downloads/witnessing_resuscitation.pdf
• Witnessing Resuscitation: Guidance for Nursing Staff; Royal College of Nursing; Published by the Royal College of Nursing; London; April 2002; https://www.rcn.org.uk/members/downloads/witnessing_resuscitation.pdf

Electronic:

• Relatives Should Witness Resuscitation; BBC News; April 6, 2000; Copyright BBC 2003; https://news.bbc.co.uk/2/hi/health/703945.stm
• Relatives Should Witness Resuscitation; BBC News; April 6, 2000; Copyright BBC 2003; https://news.bbc.co.uk/2/hi/health/703945.stm
• Cole, Elaine; Witnessed Trauma Resuscitation – can relatives be present?; trauma.org 5:8August 2000; https://www.trauma.org/nurse/witness.html
• Cole, Elaine; Witnessed Trauma Resuscitation – can relatives be present?; trauma.org 5:8 – August 2000; https://www.trauma.org/nurse/witness.html

Journals:

• Halm, Margo A. RN, Ph.D., CCRN, BC; Family Presence During Resuscitation: A Critical Review of the Literature; American Journal of Critical Care; November 2005 Vol. 14, No. 6; pp. 494-512; https://ajcc.aacnjournals.org/cgi/reprint/14/6/494
• Nibert, Ainslie T., RN, Ph.D.; Teaching Clinical Ethics Using a Case Study Family Presence During Cardiopulmonary Resuscitation; Academic Education; Critical Care Nurse; Vol. 25, No. 1, February 2005; https://ccn.aacnjournals.org/cgi/reprint/25/1/38
• McClenathan, Bruce M. & Torrington, Kenneth G & Uyehara, Catherine F. T.; Family Member Presence During Cardiopulmonary Resuscitation: A Survey of US and International Critical Care Professionals; Chest Journal; American College of Chest Physicians; www.chestjournal.org; https://www.chestjournal.org/cgi/reprint/122/6/2204
• Nolan, R.P., Ph.D. & Wilson, E., Ph.D. & Schuster, M., Ph.D. & Rows, B. H., MD & Stewart, D., MD & Zambon, S.; Readiness to Perform Cardiopulmonary Resuscitation: An Emerging Strategy Against Sudden Cardiac Death; https://www.psychosomaticmedicine.org/cgi/reprint/61/4/546
• Wise, Jacqui; Push to Allow Relatives to Witness Resuscitation; BMJ; October 12, 1996; https://bmj.bmjjournals.com/cgi/content/full/314/7086/1044
• Witnessing Resuscitation: Guidance for Nursing Staff; Royal College of Nursing; Published by the Royal College of Nursing; London; April 2002; https://www.rcn.org.uk/members/downloads/witnessing_resuscitation.pdf
• Blomfield, R.A. Relatives in the Resus Room: Don’t Overlook the Patient!; Accident & Emergency Nursing; Copyright 2000 Harcourt Publishing; p 52-53; https://www.hcc.uce.ac.uk/webmodules/GM50G3/relatives%20in%20resus.pdf
• Creamer, Kevin M. LTC & McClenathan, Bruce M CPT & Uyehara, Catherine F. T. & Torrington, COL Kenneth G.; Family Witnessed Resuscitation; Chest 2003; https://www.chestjournal.org/cgi/reprint/124/2/769
• Pisarcik Lenehan, Gail, RN, EdD, FAAN; Current Affairs: Heroes, SARS, Staffing, and Family Presence; Journal of Emergency Nursing; June 2003; p 201; https://cmbi.bjmu.edu.cn/cmbidata/SARS/pdf/90.pdf
• Grice, A.S. & Picton, P & Deakin, C.D.S.; Study Examining Attitudes of Staff, Patients and Relatives to Witnessed Resuscitation in Adult Intensive Care Units; British Journal of Anaesthesia; 2003; https://bja.oxfordjournals.org/cgi/reprint/91/6/820

Electronic:

• Riwitis, Cheryl, BSN, RN, CEN; A Tertiary Teaching Hospital’s Experience with Family-Witnessed Resuscitation; Emergency Care Issues; November 12, 2005; https://stti.confex.com/stti/bcclinical38/techprogram/paper_25904.htm
• Addenbrooke’s Encouraged By the Findings of the Commission for Health Improvement’s Report; Cambridge University Hospitals; NHS Foundation Trust; February 2002; https://www.addenbrookes-archive.org.uk/news/news2002/feb/chi_200202.html
• Sugg, Diana K.; Present at Loved One’s Last Moments: Some Hospitals Let Families Stay at CPR; February 24, 2002; Baltimore Sun; Orlando Sentinel News; Copyright 2006; https://www.orlandosentinel.com/news/bal-sugg0224,0,6062137.story?page=1
• Spittler, Karen; Family Presence During CPR and Invasive Procedures; Pulmonary Reviews.Com Trends in Pulmonary and Critical Care Medicine; Vol. 11, No. 3; March 2006; https://www.pulmonaryreviews.com/mar06/family.html
• Relatives Should Witness Resuscitation; BBC News; April 6, 2000; Copyright BBC 2003; https://news.bbc.co.uk/2/hi/health/703945.stm
• Cole, Elaine; Witnessed Trauma Resuscitation – can relatives be present?; trauma.org 5:8 – August 2000; https://www.trauma.org/nurse/witness.html