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Original article

Witnessed resuscitation incritical care: the case againstAlison Newton

The aim of this discussion is to raise awareness of the negative aspects of witnessedresuscitation. The historical precedents associated with the introduction of the concept areoutlined. The disadvantages of introducing witnessed resuscitation are delineated. Theseinclude issues of human dignity, personal privacy and the provision of adequately trainedstaff to help relatives cope with the emotional trauma the experience of being a witnessmay invoke. The paper concludes by calling for more widespread debate and research intothe efficacy of introducing such policies into practice.© 2002 Elsevier Science Ltd. All rights reserved.

Introduction

The following discussion illustrates thecontentious nature of witnessed resuscitationand presents some of the advantages anddisadvantages of allowing relatives entry,highlighting why this is pertinent to nursespractising in critical care. Witnessedresuscitation is the process of active medicalresuscitation in the presence of familymembers. Whilst it is not yet widespread, thepractice is becoming increasingly moreestablished (Boyd 2000). Trends towardsgreater autonomy for patients and theirrelatives originated in the care of children inthe 1980s. Parents became increasinglyinvolved during the treatment of critical illness,anaesthesia and resuscitation (ResuscitationCouncil 1996). Paediatric staff, as a whole,appear to have little problem with witnessedresuscitation, regarding the process as a ‘right’for parents, whereas, from a purely legalviewpoint, relatives in the UK have no rights inthe care of adult patients (Boyd 2000; Connors1996). As a result, relatives have traditionallybeen kept away when resuscitation involvesadults. However, with the increased coverageof these events by the media, relatives feelthey are more aware of what to expect (Rattrie

2000; Woning 1997). This has led to an increasein the number of requests to be present duringadult resuscitation and a change of policy insome hospitals (Resuscitation Council 1996).The idea of witnessed resuscitation originatedin 1982 in Foote Hospital, Michigan, USA. Staffwere forced to question their policy ofexcluding family members duringcardiopulmonary resuscitation (CPR) effortsby two separate incidents in which familymembers demanded to be present (Hanson &Strawser 1992). When these two situationswere evaluated, positive feedback came fromboth families and staff. A follow-up studywhich questioned bereaved relatives foundthat, from 18 relatives surveyed, 72% wouldhave liked to have witnessed the resuscitationattempt. As a result, a programme of witnessedresuscitation began. In 1985, the programmewas audited. The audit demonstrated that, of47 families, 64% felt it was beneficial to thepatient and 76% felt their adjustment of thedeath was made easier. Of the 21 A&E staffwho were questioned at the same time, 71%supported the practice and Foote Hospital hasendorsed it ever since (Hanson & Strawser1992). Further studies have subsequently beenperformed in the USA, Australia and the UK,all of which also endorse the practice of

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doi:10.1016/S0964-3397(02)00003-4, available online at http://www.idealibrary.com on

Witnessed resuscitation in critical care

witnessed resuscitation (Belanger & Reed 1997;Meyers et al. 1998; Mitchell & Lynch 1997;Redley & Hood 1996; Robinson et al. 1998).

Disadvantages of witnessedresuscitationAlthough there are many advocates ofwitnessed resuscitation (Belanger & Reed 1997;Hanson & Strawser 1992; Meyers et al. 1998;Mitchell & Lynch 1997; Redley & Hood 1996;Robinson et al. 1998), there are also manypotential disadvantages which demandconsideration. These are summarised inTable 1. From the literature, it is evident thatthe majority of issues considered relate toeither relatives or staff, yet there is little writtenregarding the effect on patients. Much of theliterature takes the view that resuscitation willnot be successful. Only 10–15% of patientswho receive CPR following a cardiopulmonaryarrest in the hospital environment survive tobe discharged (Schultz et al. 1996). Perhaps thisexplains the current lack of research availableto support the patients’ perspective duringwitnessed resuscitation. However, beforeallowing families to witness the resuscitationof a relative, one must consider whose needsare being met and whose decision it actually

Table 1 Disadvantages of witnessed resuscitation

• The relatives may be a great source of strengthto the patient during CPR, providing comfort andreassurance should there be transient episodes ofconsciousness (Farrell 1998).

• The relatives feel they are doing something in ahopeless situation (Morgan 1997).

• The relative is able to touch the patient while heor she is still warm (alive) (Connors 1996).

• The relative can say whatever he or she needs towhile there is a chance that the patient can hearhim or her (Morgan 1997).

• The relative is able to see rather than simply beingtold that everything possible is being done. Thiscomes from the belief that the reality of the resus-citation room is far less horrifying than the fantasy(Connors 1997; Morgan 1997).

• The grieving process is long and hard enough with-out eliminating any elements that might help ad-justment (Hanson & Strawser 1992).

• The patient is viewed more as part of a lovingfamily and less as a clinical challenge (Grandstrom1989).

• Closer relationships are formed between nursingstaff and the patient’s relatives (Hanson & Strawser1992; Robinson et al. 1998).

is, as consent from the patient would bepractically impossible (Osuagwn 1993). In apilot study performed by Robinson et al.(1998), three patients survived witnessedresuscitation attempts. Although these patientsstated they did not feel their dignity orconfidentiality had been compromised, withthe absence of any further literature to suggestsimilar positive findings, it would seem rash toconsider a change in practice. In addition, nodetails were given concerning when patientswere questioned about their experience,whether or not they still felt the same sometime after the event or whether, had they beengiven an informed choice before the event,they would have still agreed for their family tobe present. One’s own death is a subject notoften discussed and in a cardiac arrest situationthe patient is unlikely to be able to expresstheir wishes (Boyd 2000). According to Dight(1999), a patient’s dignity is the last matter tobe considered during CPR. Would patientsprefer that their relatives remember themwhen they were well, rather than rememberthem lying exposed on a bed with the arrestteam dispassionately performing a variety ofaggressive and invasive procedures on them?Woning (1997) questions whether this imagecan be viewed as a successful encounter forthe observing relative. An incident whichhighlights this view further can be seen in thecase of Airedale NHS Trust versus AnthonyBland (Thomas 1993). Anthony Bland was ayoung man who had been in a severepersistent vegetative state following a crushinjury at the Hillsborough disaster. His parentsfought for the right for medical intervention tobe withdrawn to enable their son to die withdignity, so that they could remember him as acheerful and carefree teenager—not an object ofpity. Perhaps the same view can be consideredto the patient undergoing CPR. Thomas (1993)states that human dignity and personal privacybelong to every person, whether living ordying. He believes that the sheer invasivenessof the treatment and the manipulation of thehuman body which it entails, together with thehumiliating helplessness of the patient’s state,invoke all these values. Dight (1999) believesthat it is condescending to speculate as towhether witnessing CPR helps relatives toaccept their death more easily. He suggests

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that, although CPR is a routine process in acritical care setting, it can strike fear and dreadinto those who have not been blinded byfamiliarity. Whilst most members of the publicwill have seen CPR on television, this hardlycompares to the real-life resuscitation of aloved one. CPR subjects the patient to hideousviolence in their last moments and many thingscan go wrong (Woning 1997). Family membersmay not understand resuscitation proceduresand it could be considered cruel to let them in.Dight (1999) believes that witnessing CPR isnon-therapeutic, regretful and traumaticenough to haunt the relatives for as long asthey live. Staff have reservations about thepresence of family during CPR for a variety ofreasons. They fear that relatives may interfereverbally, emotionally or physically with theresuscitation because they feel something isgoing wrong (Mitchell & Lynch 1998; Offord1998; Woning 1997), and therefore the dangersof any distractions during defibrillation mustbe considered. Although witnessedresuscitation is advantageous in that it placesthe patient into the context of a family, staffhave experienced increased stress in trying tocontrol their own emotions, finding it easier toview the patient as a clinical challenge (Hanson& Strawser 1992; Redley & Hood 1996). As aresult of this, they may find it more difficult tomake a decision to stop a resuscitation attempt(Mitchell & Lynch 1997). Staff have alsoexpressed concern about offending relatives bytheir apparently unconcerned, blasé approachand insensitive comments, which aresometimes made as a coping mechanismduring CPR (Mitchell & Lynch 1997; Woning1997). One final consideration which needs tobe examined is that the initiation of a policy toinvite relatives to witness CPR would alsoincur cost (Edwards & Shaw 1998). Not onlywould finance be needed to provide staff witheducation and training, but inter-departmentaland hospital-wide protocols would need to beestablished to assist families during witnessedresuscitation (Belanger & Reed 1997). Atpresent, all of the studies have been undertakenin the A&E setting (Hanson & Strawser 1992;Meyers et al. 1998; Mitchell & Lynch 1997;Redley & Hood 1996; Robinson et al. 1998). Toimplement a policy of witnessed resuscitationin one department and not another can surely

only impair continuity of care for both patientsand relatives. In order to assist with the care ofthe family, the role of a ‘family support nurse’is recommended (Rattrie 2000; Woning 1997).The nurse would remain with the familythroughout the resuscitation, providinginformation and emotional support, and notbecome involved in the procedure. The role ofthe support nurse is likely to be stressful andtherefore support networks would need to bedeveloped (Morgan 1997; Redley & Hood1996). The introduction of guidelines, staff andfamily support, and the ongoing evaluation ofthe practice would need to be funded (Offord1998). However, many critical care settingsmay not have adequate staffing levels to makethis facility available and it would be difficultto argue for higher staffing levels in theabsence of a research base which testifies to thevalue of this practice (Edwards & Shaw 1998).

Legal implicationsAs nurses, we are under a duty of care to ourpatients to act always in their best interests andrefrain from doing anything which may causethem harm (UKCC 1996). The first principle tobe considered is that of confidentiality. No one,not even a relative, is entitled to informationwhich the patient does not want them to have(UKCC 1996). In witnessing CPR, not onlywould the relative see what was happening tothe patient, they would also hear informationof an intensely personal nature. It would beimpossible for nurses to ascertain the patient’swishes unless in the unlikely event that theyhad expressed them beforehand (Boyd 2000).All the nurse could do would be to rely on therelative’s version of consent to information,which is fraught with legal difficulty (Stewartet al. 1998). Watt (1997) illustrates the issue ofconsent further. She highlights the example ofDiane Blood, who sought permission from thecourts to be inseminated with her deadhusband’s sperm. Her argument was that thiswas her husband’s wish—an argument whichmay be used by many relatives wishing towitness resuscitation. However, Watt (1997)believes it is doubtful that unwitnessed oralexchange between husband and wife can beseen as formal consent and that one cannotgive valid consent after one falls permanently

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unconscious or dies. If the patient survivesCPR, it would be possible to bring a claim ofnegligence if confidentiality were breached insuch a manner as to cause them harm(Fulbrook 1998). There is also a risk of relativessuffering from nervous shock or psychologicalinjury (Rattrie 2000). The fact that a personwitnessing events harmful to a relative orloved one can suffer psychological trauma isrecognised by law (Fulbrook 1998). Kelly(1999) outlines the control mechanisms used inlaw for persons claiming to sufferpost-traumatic stress disorder. These are:

• There must be a close tie of love andaffection between the plaintiff (relative) andthe victim (patient).

• The plaintiff must have been present at theaccident or its immediate aftermath.

• The psychiatric injury must have beencaused by direct perception of the accidentor its immediate aftermath and not byhearing about it from someone else.

By inviting relatives to be present during CPR,we put them in a position to fit all of thesecriteria. Expressed consent to witness CPR,and therefore, potential to be harmed, wouldbe needed before any exposure to resuscitativeprocedures and the inherent risks wereexperienced (Fulbrook 1998). Should a relativedecide after the event to pursue a claim basedon their real suffering, nurses could be at riskfrom a legal claim for compensation based onnegligence (Fulbrook 1998; Stewart et al. 1998).Another aspect fraught with difficulty is apractical one. If a relative was actually hurtwhilst witnessing resuscitation, for example,being bumped by a piece of equipment orpunctured with a needle, they could claimagainst the hospital and staff for a physicalharm (Fulbrook 1998). This scenario isreasonably foreseeable given the reality of theresuscitation environment, the pace ofprocedures being undertaken and therestrictions of space coupled with the numberof people attending to the patient (Boyd 2000).

However, there are several authors whobelieve that inviting relatives to witness CPRis, from a legal perspective, good riskmanagement (Grandstrom 1989; Hanson &Strawser 1992; Matthews 1993; Mitchell &Lynch 1997; Rattrie 2000), arguing that most

people would be there to support a loved one,not to judge the standard of care. Grandstrom(1989) believes that most lawsuits frequentlygrow out of a family’s emotional response to aperceived injustice rather than real negligenceand that the family who feel involved and caredabout, who see you doing all you possibly canto help the patient, are less likely to sue. Asyet, there have been no documented casesreferring strictly to witnessing a CPR attemptin hospital (Offord 1998), but neither can oneignore these very real legal implications on thebasis simply of a promise of goodwill.

ConclusionThe arguments used for suggesting thatrelatives should be allowed in to witness theresuscitation of a loved one stem from a desireto assist relatives to come to terms with theirexpected and traumatic loss (Fulbrook 1998).However, real-life resuscitation does notcompare to TV’s portrayal (Offord 1998) andthe potential long-term effects on relatives is anaspect that requires further exploration (Offord1998; Woning 1997). In addition, a nurse’sresponsibility is to act in the patient’s bestinterest (UKCC 1996) and it would be difficultto know whether allowing the relatives toobserve resuscitation would really be in thepatient’s best interest when little research isavailable which takes into account thepatient’s perspective. Although much of theresearch advocates the practice of witnessedresuscitation, it must be acknowledged that allthe studies relate only to A&E departments,many were performed abroad and only smallsample sizes have been used (Hanson &Strawser; 1992; Meyers et al. 1998; Mitchell &Lynch 1997; Redley & Hood 1996; Robinsonet al. 1998). Therefore, whether these researchfindings can be generalised to incorporateother critical care settings without consideringthe departmental and cross-culturaldifferences, and indeed the legal implications,is questionable. However, the practice alreadyexists in many A&E departments and toadvocate it in one department and not anotherwill impair continuity of care for both patientsand their relatives. There are at present fewdata to demonstrate any long-term effects,detrimental or beneficial to the patient, relatives

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or staff (Offord 1998; Resuscitation Council1996). Perhaps one possible solution would beto perform a much more detailed research oflarger samples and longer study periods invarious settings (Rattrie 2000). Until researchof this kind is conducted and hospital-widepolicies implemented, the question of whetherrelatives should be allowed to witnessresuscitation will remain a highly contentiousissue (Edwards & Shaw 1998).

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