Manzar Zakaria ( Department of Medicine, CMH, Lahore, Pakistan )
Muhammad Siddique ( Department of Medicine, CMH, Lahore, Pakistan )
To find out the attitudes of health professionals and family members of the deceased, about a witnessed cardiopulmonary resuscitation procedure.Methods:
A cross-sectional analytical study was carried out at Combined Military Hospital Lahore from January 2007 to June 2007. Two hundred and ninety persons related to 190 deceased patients, 40 physicians and 20 nurses were interviewed and were asked to fill a proforma to asses their views about presence of family members during a cardio-pulmonary resuscitation.Results:
Ninety eight percent of the family members wanted to be there while cardio-pulmonary resuscitation of their patient was in progress. None of the physicians favoured a witnessed resuscitation, while 3 out of 20 nurses favoured it.Conclusion:
This study suggests that institutions should consider establishing programmes of witnessed cardio-pulmonary resuscitation for family members (JPMA 58:632; 2008).
Traditionally, in hospitals, family members are not allowed to witness cardio-pulmonary resuscitation (CPR). This practice has been questioned over the last two decades.1-4
The family members want to witness CPR but the common practice is that they are not allowed; as their presence and anxiety distracts health care providers. They cause undue hindrance during the process. It is also possible that the doctors and nurses do not want the relatives to know about their mistakes in the procedure or the non functioning of equipment.5,6
There is a current trend for witnessed resuscitation; as it is seen by the increasing number of articles published in its favour. Some authors have also discussed their own experiences of CPR of a patient where family members were also present and found that the benefits outweigh the risks.4,7-9
In Pakistan, hospitals lack a policy about the presence of family members during cardio-pulmonary resuscitation. No local literature addresses this dilemma. This study was carried out to find out the desires, beliefs and concerns of the family members about the option of their presence during CPR by using a questionnaire proforma. Also a separate questionnaire was used to find the attitudes of health professionals about the presence of family members during resuscitation. The information collected from such a study would help in formulating a policy regarding this issue.
Subjects and Methods
A cross sectional analytical study was carried out at Combined Military Hospital (CMH), Lahore. This is a tertiary care, 700 bed facility, catering both serving and retired personnel from the Armed Forces, and a limited local civil population. The study was carried out for 6 months from 10, January 2007 to June 2007. A questionnaire was developed to determine the option of the presence of family during CPR. Family members of the 301 patients who had died in hospital were asked to fill the questionnaire. The family members of all deceased patients were contacted by telephone within one month from the time of death. An interview was requested with explanation of its purpose and conducted when they needed to visit the hospital for procedural formalities related to death of the patient.
The questionnaire was divided into 2 sections with a total of 11 items. Section 1 consisted of six demographic items. Section II consisted of 5 survey questions (Table I) with one question related to the desires, three to the beliefs, and one question related to the concerns about the family presence. These questions were adapted from the evaluative and retrospective studies conducted at the Foote Hospital in Michigan.8
Demographic data was recorded first, followed by the response to 5 structured survey questions in section II.
A separate questionnaire was given to 40 physicians and 20 qualified nurses who were involved in health care delivery in the intensive care unit (Table 2).Statistical analysis:
Data analysis was conducted using descriptive statistics. [(t1)] [(t2)]
Three hundred and one patients above the age of 18 years died at CMH, Lahore during the 6-month study period. Family members of one hundred and ninety deceased patients consented and reported to the hospital for interview. The ages of deceased patients ranged from 19 to 100 years with a mean of 60.7 ± 14.6 years. Gender distribution was 135 males and 55 females. Two hundred and ninety family members of these patients were interviewed between one to six weeks from the time of patient's death (mean, 4 ± 1.4 weeks). The mean age of family members interviewed was 35 ± 6.8 years (range 22-73 years). Two hundred and twenty four respondents were male and sixty-six were female. Out of these two hundred and eighty six were Muslims and four were Christians. The relationship of the respondent to the patient who died included: parent n=208, (71.72%), child n=41, (14.13%), sibling n=24, (8.27%), spouse n=11, (3.79%), and others n=6, (2.06%).
The response of family members is given in Table 3.Out of the 290 respondents 273 (94%) wanted to be present into the room of their loved one just before death while CPR was going on. The second, third and fourth questions measured the family members beliefs. Ninety eight percent of the respondents believed that the family members should be with their loved one before death. Only 54% of the respondents believed that their presence might have eased the suffering of the deceased. Fifty two percent of the family members thought that their presence with the deceased in their last moments could have helped their sorrows and sadness.
In the last question family was asked about their concerns. The major themes that emerged included the outcome of the procedure, seriousness of the condition and concern that everything possible is being done. The family members were not concerned about what they see or hear. They were also not worried that their presence could disturb or obstruct the resuscitation procedure. Others were unsure as they had never seen or had knowledge about the resuscitation procedure.
All of the health care professionals (60) approached answered the questionnaire. Ninety five percent (n= 57) health care professionals were not in favour of witnessed cardio-pulmonary resuscitation. The reasons given by them were, a) it is an emotionally traumatic experience 68% (n= 41), b) family members may find faults in the procedure 80% (n= 48), c) there is not much space available for the viewers 78% (n= 47), d) they may obstruct the procedure of cardio-pulmonary resuscitation 36% (n= 22), e) they may inadvertently think that health professionals are contributing to the death of the patient 40% (n= 24), f) during cardio-pulmonary resuscitation the conversation between the health professionals may not be liked by the relatives 60% (n= 36). None of the health care professionals favoured a witnessed resuscitation. Three out of 20 nurses interviewed were in favour of a witnessed resuscitation.
This study showed that an overwhelming majority of family members (94%) wanted to be with their loved ones during resuscitation. In similar studies carried out by Doyle6, Meyers8
, 72%, 80% and 73% of family members respectively wanted to be with their loved one. Close family-ties in the oriental culture may explain the difference. In our study 98% of the family members believed that the individuals have the right to be with their loved ones if they desire as compared to 96% of the family members who gave a similar response in another study by Meyers et al.10
Most physicians and nurses do not favour allowing family members to be present during resuscitation procedures9
. This study shows physicians are generally even more reluctant than nurses to accept the presence of the family. In a pilot study conducted in the United States of America, eighty five percent of the health professionals were comfortable with the presence of family members.10
In the same study ninety seven percent of the health professionals found the behaviour of the attendants appropriate. Unfortunately no study is available in the local literature for comparison. Health care providers view that watching CPR may be emotionally traumatic for the family members; they fear physical assault by the family members increases threats of liability suits and loss of control over the situation.11
None of these fears have been substantiated in the reported literature.12
There are numerous benefits of witnessed resuscitation. These benefits have been touchingly highlighted by personal accounts in medical journals.1-4 American College of Critical Care Medicine Task Force 2004-2005 has recommended the presence of family members during rounds and resuscitation.5
Patients who survived resuscitation also reported that they were comforted by the presence of family members.13
These recommendations were adopted after reviewing more than three hundred articles. In the case of patients who died during resuscitation efforts, family members have reported that seeing the patient one last time helped them with the bereavement process.14-18
In a few instances, family members have physically interfered with resuscitation activities. These incidents occurred in institutions that did not have established policies and procedures for the presence of family members.11
The best documented programmes of witnessed resuscitation in literature have been reported at the Foote Hospital, and at the Parkland Health and Hospital System. There were no instances of actual interference with resuscitation activities, even when family members were overcome with grief.10,12
There were certain shortcomings in this study. The hospital is located in an urban area, respondents came from a specific background i.e. most were veterans or their relatives and educational status of the respondents was not recorded. People from other segments of population may respond differently.
The study suggests that institutions should carry out pilot studies for offering family members the option to be present during resuscitation procedures. Such programmes should include an assessment to determine the family's emotional and behavioural suitability and wishes, preparation of the family members for what they will witness, and support for them during and after the experience. It is suggested that the social work officer should be involved in such a programme. Since resuscitation is largely unplanned, the success of a programme depends on the widespread dissemination of information about it, including education designed to change the attitudes of health care providers. The knowledge about the emotional aspects of resuscitation should be included in the curricula of medical and nursing schools.
We find a discrepancy between healthcare workers and relatives of the deceased towards the concept of family witnessed resuscitation. Health care providers should not discourage the family members to witness the cardiopulmonary resuscitation. If family members want to be with their loved ones on the way to death they should be allowed. However there is a need to carry out pilot studies in which family members are permitted to witness resuscitation procedure of their loved ones before making a paradigm shift of policy in our country.
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