Emergency resuscitation can be grisly. But people who watched it performed on their family members reported less anxiety and depression after the event -- regardless of whether the person lived or died.
From the other side of the wall, in the hallway or waiting room, the accomplishments of emergency resuscitation can seem miraculous. On the inside, it's cold and disquieting. As Dr. Rosemarie Fernandez, an associate professor of emergency medicine at the University of Washington, told The New York Times, "It's not like on Baywatch*, where somebody gets pulled out of the water and you do a few compressions and they walk away."
When someone's heart stops beating in a hospital, doctors, nurses, and technologists run to their room. One will stand over the patient on a tall stool to get a vantage where they use the leverage of their entire upper body to compress the patient's chest. It's not uncommon to hear and feel ribs cracking under their fingers as they press. Keeping the person's airway open can mean passing a large tube down their throat. Shocks of electricity are delivered that can make their limp body convulse. Doctors often need to insert a large I.V. through the side of the patient's neck in order to give the drugs that help restart their heart, which can be a bloody procedure.
Holding this curtain back as far as possible is best for patients. It seems like it's best for their families, too.
We know that the support of friends and family during illness is of great benefit. The traditional wisdom around them being present during resuscitation, though, is that it's best for them to stay out of the room. The patient is not conscious -- at points, not even alive -- and they are being handled in an indelicate, impersonal way. Dire circumstances require it. It's not an idyllic last memory of a loved one.
In research published this morning in the New England Journal of Medicine, though, French physicians found that family members were ultimately better off when they watched CPR. Of 570 people, the 211 who witnessed resuscitation of a family member later reported significantly fewer symptoms of PTSD -- and less anxiety and depression -- at checkups following the event, regardless of whether the person survived.
The cases here, though, took place outside of hospitals. They happened wherever emergency medics got to the people. Resuscitation is usually less invasive when performed, say, in someone's home. There may also be more space to work. A hospital room gets crowded, and people become physical barriers. Some doctors argue that family being present disrupts the process in other ways, too. Emergency resuscitation is a choreographed procedure; one where stopping to address questions or console spectators could throw everything off.
In the New England Journal study, though, they found that the presence of family did not interfere with medical efforts or result in the health care team feeling more stress.
Dr. James Downar at Toronto General Hospital writes in an accompanying editorial that he rarely invites families into a room during resuscitation, and that he is hesitant to change his practice based on this research. "Cardiac arrests that occur at home are different in that family members actually 'invite' EMS to be present for the resuscitation, rather than the reverse," he notes.
Dr. Patricia Kritek at University of Washington offered a slightly more optimistic take. She believes that, when possible, families should have "the opportunity to be in the room in what may be the last minutes of [a patient's] life." She offers the thoughtful caveat, though, that it would be inappropriate to invite them in without also providing a liaison that could talk them through what's happening.Kritek also gets to the point that immediately struck me. Emergency resuscitation is still, to many people, a mysterious process. Understanding the "brutal" nature of what we sometimes put people through is integral to any advance directive decision. When someone dies and is resuscitated, they do not bounce immediately back to normal. Their family is likely going to be speaking for them, making medical decisions on their behalf. When a family witnesses what "do everything possible" entails, it will inform future decisions. It will inform an increasingly transparent culture, where everyone has an accurate sense what resuscitation is and means before they opt into or out of it.
When people tell me they'd like extensive measures taken to revive their 105-year-old grandmother with advanced dementia and terminal cancer, it's hard to believe they'd say the same if they'd witnessed a similar resuscitation. Holding this curtain back as far as possible is best for patients. It seems like it's best for their families, too.
* Baywatch was a TV fiction series that premiered in 1989. It starred Pamela Anderson and David Hasselhoff, and nothing it portrays should be mistaken for reality.
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