Emergency

Family-witnessed CPR: yes or no?

Allowing family members to witness Cardiopulmonary resuscitation of their loved ones is a contentious debate currently facing emergency departments.

CPR is used to resuscitate a person who has gone into cardiac arrest.

Fiona Stanley Hospital Emergency Department Head of Services Mark Monaghan says the vast majority of patients who undergo CPR are elderly people with heart conditions.

Dr Monaghan explaining a life support chart

Dr Monaghan explaining a life support chart.

“The percentage of survival is very, very small,” Dr Monahan says.

“It’s like one or two per cent, so they’re older patients who’ve got heart disease who have a cardiac arrest out on the street and don’t get to be early defibrillated.”

For children and young adults, this number is much more favourable, however there is no definitive percentage as it depends on the circumstances surrounding each particular situation.

CPR can be extremely confronting to witness, especially for people who may never have spent much time in hospitals, and Dr Monaghan says they are often very shaken and dazed.

“Most of the time when people have come in and their family member’s had a cardiac arrest, they’re not absorbing anything and they’re shocked,” he says.

“They’re not thinking about anything except their family member dying.”

Resuscitation bay at Fiona Stanley Hospital from a family member's point of view

Resuscitation bay at Fiona Stanley Hospital from a family member’s point of view.

Fiona Stanley Hospital does not have a direct set of rules regarding witnessed CPR, but families are usually given the opportunity to be present in the resuscitation bay.

“We almost always universally offer it to the family unless we really think there’s some compelling reason why that would be harmful,” Dr Monaghan says.

“In 99.9 per cent of cases it isn’t [harmful] and we would offer that because … it’s our experience that people actually recover better from knowing what was done to their family member.”

Dr Monaghan says that being able to witness CPR as it happens may make it easier for families to cope with a negative outcome.

“For them to understand that we’re doing everything we can and there’s a lot of us working on the person … really, really important for them to … help interpret what’s happened,” he says.

IMG_5113“Most of these deaths that occur that we’re talking about are sudden, unexpected deaths: cardiac arrest, young trauma, things like that and for a family to cope with that and to make sense of it.

“The important thing is that they’ve seen that everything’s been done to resurrect their family member.

“If you don’t do that then they never really knew what went on inside and one minute their family member was alive and next minute they’re dead and they haven’t seen that.”

On the other hand, there are also reasons as to why families should not be present.

“Sometimes it goes wrong,” Dr Monaghan says.

“Sometimes there’ll be a family member who … is distraught.

“We certainly have cases where they’ve gotten in the way of trying to resuscitate their child, for example, because they just want to hold them and they’re scared and they’re not thinking.”

This can be extremely traumatic, and many people may not be prepared for the scene in the resuscitation bay.

IMG_5102

Flowchart states the CPR process as performed on adults.

“You’re bringing in the family while you’re making decisions, while you’re resuscitating somebody. And some people, depending on their level of confidence, may find that challenging,” Dr Monaghan says.

Resuscitation bays are crowded with staff who are doing many different things to the patient at once and, depending on the family’s cooperation, it can be difficult for the nurses and doctors to perform their duties efficiently.

“There will be a time where you actually can’t bring the family members in,” Dr Monaghan says.

“If you’ve got people all around the bed popping lines and tubes into people, having a family member in the way will mean that it impacts on your care.”

Sometimes families choose not to come in.

“They may think it’s traumatic, they may think that we just need to do our job and then come out and explain,” Dr Monaghan says.

A St John's Ambulance worker demonstrates chest compressions on a training mannequin.

A St John Ambulance worker demonstrates chest compression on a training mannequin.

Despite reasonable justification for both sides of the argument, Dr Monaghan says it is the timing of when exactly during the CPR procedure to let families in that is vital.

“They would see [us] often doing cardiac massage, so chest compressions,” he says.

“The patient … they’d be unconscious, they’d have a tube down their throat, we’re ventilating them, so we might have a bag and mask for ventilating them, they might have lines everywhere, there might be blood, we might be doing other procedures on them.

“We may have to put a chest tube, like a big tube, into the side of somebody’s chest.

“I wouldn’t want a family member watching that because you have to push quite hard and cut them and we tend to sort of be sensitive to the timing of that.”

Depending on the seriousness of their condition, the procedure can be quite undignified for the patient.

“They are often exposed so that can be confronting,” Dr Monaghan says.

“We tend to get [the family] in after we have covered them up.”

D97A7491

A demonstration of the placement of defibrillation paddles.

Staff need to consider that families may struggle seeing their loved ones in such a vulnerable state.

“You can’t just, without thinking, keep the family in for the whole time because you could do them harm,” he says.

“It’s about being mature and sensitive about what would help and what wouldn’t help.”

Ashanti Suriyam witnessed CPR at 13 when her father went into cardiac arrest in the living room of her family’s home in Leeming in Perth’s southern suburbs.

One of the neighbours was a nurse who administered CPR until paramedics arrived and used a defibrillator to successfully regain a heartbeat before taking him to hospital.

Ms Suriyam, now 34, says that at the time, viewing the procedure seemed neither good nor bad.

“The outcome at the end of the day was good,” Ms Suriyam says.

One of the training rooms at St John's Ambulance in Belmont.

One of the training rooms at St John Ambulance in Belmont.

“But if the outcome wasn’t good, I’m not sure that my position would be the same.

“It would be a painful memory, not a memory where I know that all that was happening saved his life.”

Although the event occurred in her home, Ms Suriyam does not agree that family members should be present during CPR in emergency rooms.

“The doctors, nurses and medical staff should be able to act unhindered and in the best interests of the patient,” she says.

“[Families] will be distracting to the medical staff.

“Lay people do not have the education to understand the procedures undertaken in the ER.

“Their presence will only inhibit the medical staff’s abilities to do what’s best.”

Former paramedic Richard Love also disagrees with witnessed CPR as many people do not understand how much of a physical act it is.

Some clothing needs to be removed for defibrillation, patients can bleed from the mouth, vomit, defecate and there is a strong possibility of cracking ribs while performing compressions.

D97A7509“You’re looking at trying to compress the thoracic cavity around about a third, so you’re going down about two inches,” Mr Love says.

Mr Love says that despite this, the response from St John Ambulance is quite methodical.

“You start compressions … the other individual’s getting intubation ready, you carry on your compressions until they’re ready and then when they say they’re ready, you stop, they tube them within a minute … then you’re back into CPR so it’s very controlled pressure … but it looks very busy to an outsider,” he says.

Many people have preconceived expectations from medical TV shows, such as the patient’s body rising violently when shocked with defibrillators and regaining a pulse after having flatlined.

“We still need electrical output in the heart for that to be able to work,” Mr Love says.

“So if it’s actually a flatline and there’s no electrical output, you can shock them all day and it’s never going to happen.”

A chart explaining when to perform CPR.

A chart explaining the procedure and survival rate for when CPR is administered on a patient.

He says that the decision on whether or not to be present for CPR is the family’s personal choice.

“If it was just a general member of the public and that may be their first interaction to what happens in a hospital I think it could be quite confronting for them,” he says.

“It comes down to how do they want to remember their family member.”

Photos by Joanne Fernandez.

 

Categories: Emergency, Health

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