Published on 09 May 2023
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.
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.
The authors also wanted to investigate the effect of FPDR on medical treatment and care during resuscitation. Furthermore, they wanted to investigate and report the personal stress seen in healthcare professionals and if possible describe their attitudes toward the FPDR initiative.
The authors searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to 22 March 2022 without any language limits. They also checked references and citations of eligible studies using Scopus, and searched for relevant systematic reviews using Epistomonikos. Furthermore, they 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).
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.
The study 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. Relatives were defined 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.
Patients were defined 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. They included all types of healthcare professionals as described in the included studies. There were no limitations on age or gender.
Data collection and analysis
The authors checked the 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, the authors synthesized data narratively.
The electronic searches yielded a total of 7292 records after deduplication. Including 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 favour of FPDR when looking at PTSD, anxiety and depression, and complicated grief after 1 year. One of the included studies also measured the duration of patient resuscitation and personal stress in healthcare professionals during FPDR and found no difference between groups. Both studies had a high risk of bias, and the evidence for all outcomes except one was assessed as very low certainty.
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 review's conclusions in future.
Implications for practice
There was insufficient evidence to draw any firm conclusions on the effects of family presence during resuscitation on relatives' psychological outcomes.
Sufficiently powered and well‐designed randomized controlled trials may change the conclusions of the review in future.
Implications for research
This review highlights the lack of evidence for the effect of family presence during resuscitation (FPDR).
Several reasons can account for the lack of comparative research in this field, as follows.
- Evaluation of FPDR often takes place in difficult conditions and a hostile environment.
- Many confounding factors (e.g. the degree of trauma, the success/failure of the resuscitation, the length of time the patient had chronic disease, the skill or sympathy of the staff, and the way the staff are affected) must be considered.
- The important clinical, cultural, and personal heterogeneity between relatives requires large‐scale studies allowing specific subgroup analyses.
- From a practical point of view, cluster‐controlled trials seem to be the most reasonable study design for assessing the psychological effects of FPDR. However, with this type of design, other outcomes such as patient mortality and healthcare professional performance and stress could be biased.
- The main trial included in this review was at risk of attrition bias; future studies should ensure that they take the necessary actions to reduce dropout and loss to follow‐up.
The area of FPDR should also be investigated more by qualitative research, which could elaborate on the phenomenon in relation to the whole triangular relationship of patient, relative, and healthcare professional.