RUNNING HEAD: INTEGRATIVE REVIEW

Integrative Review of Literature Regarding

Family Presence during Resuscitation
Nur4122 Nursing Research
Sophie Guillot
April 28, 2016
I Pledge

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Abstract

The purpose of this integrative review is to assess current literature in an effort to provide insight
on whether family should be present during a loved ones resuscitation. Much debate has taken
place among healthcare personnel about the issue; however, there is limited evidence for
providers to base their practice off of. The research design is an integrative review including 5
articles to provide evidence for the PICO question: how does being present during
cardiopulmonary resuscitation compared to not being in the room affect coping of family
members to the patient receiving resuscitation. All articles were obtained by the Bon Secours
Health Systems eLibrary. The findings indicated that more research is required to know the full
effects of witnessing CPR may have on coping. However, families should be given the
opportunity to make their own decision regarding being present during their loved ones
resuscitation and end of life.

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Introduction/Background

This integrative review serves to evaluate current literature in an effort to help determine
whether or not family members should be present when a loved one is receiving
cardiopulmonary resuscitation. Throughout the years, this has been a highly debated issue among
the health care community. Supporters of family resuscitation cite that family presence during
CPR and end of life fulfills the idea of holistic patient centered care, allows family to know that
everything that could be done for their loved one was, and helps family through the grieving
process. Those who oppose family presence during resuscitation efforts cite that it puts added
stress on healthcare personnel performing resuscitation, increases risk of litigation, and does not
contribute to family coping, but can put witnesses at increased risk for emotional burden.
In order to create and implement evidence based recommendations and policies regarding
this topic, there must be research to support one side or the other. To know whether or not family
should be present during resuscitation efforts, it is necessary to know the effect it has on their
bereavement and coping. Therefore, this integrative review is guided by the PICO question of:
how does being present during cardiopulmonary resuscitation compared to not being in the room
affect coping of family members to the patient receiving resuscitation. For the purposes of this
research resuscitation is defined as cardiopulmonary resuscitation (CPR).
Design, Search methods
The design for this research is an integrative review including critique and interpretation
of 5 academic, peer reviewed journals. The articles are all published within the past five years
from the date of the research including articles published in 2011 through 2016. The Bon Secours
Health Systems eLibrary search engine producd the 5 articles which came from the Nursing

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Reference Center, PubMed, Science Direct, and BMJ publishers databases. Key words including
family presence, CPR, family witnessed, and resuscitation were used to populate
thousands of articles. The search was limited to full text, peer reviewed articles written in
English. Further exclusion criteria consisted of articles that included pediatric populations,
articles that included invasive procedures, articles that defined resuscitation as efforts other than
CPR, and articles that did not contain original research. Because research focused on family
coping after witnessed resuscitation is sparse, articles associated with any research regarding
family presence during resuscitation was included. From the 5 articles chosen, 3 are quantitative
research articles, and 2 are qualitative research articles.
Findings/Results
Each article is either associated with the evidence for or the feasibility of putting a policy
in place regarding allowing family presence during resuscitation. There were slight discrepancies
between research, which indicates the need for further studies regarding the effects of witnessed
resuscitation on family coping. The articles can be categorized by the subjects or participants
involved in the study, the 2 qualitative articles included interviews of health care personnel, 1
quantitative article included interviews of family members who witnessed resuscitation efforts, 1
quantitative article included surveys of the general population and 1 quantitative article included
surveys of family members who witnessed resuscitation and the health care personnel who
performed the resuscitation.
Health Care Personnel
The qualitative research conducted by Maria Walker (2014) included a hermeneutical
phenomenological study that consisted of face to face interviews of ambulance staff and

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registered nurses. The purpose of the study was to evaluate the experiences health care personnel
had with family presence during resuscitation efforts. From the experiences, Walker identified 3
viewpoints of exposure to all persons involved in the resuscitative process: the patient being
exposed to the family, the family being exposed to the event, and the staff being exposed to
witnesses of their efforts (2014). Walker also identified 2 parts to the resuscitation, the
prehospital setting and the hospital setting, which ought to be consistent and collaborative among
ambulance staff and hospital staff to deliver quality, holistic care during this process (2014).
The research conducted by Lederman et al. (2014) was originally part of a mixed
methods study; however, the information presented in this particular article focuses solely on the
qualitative responses of hospital staff regarding their insights to family presence during
resuscitative efforts. The qualitative computer based questionnaire survey was sent to 100
emergency department staff and asked if and why they think family members should be present
during CPR; if and why they think family members would want to be present, and to describe
any relevant experiences they had with the subject (Lederman et al., 2014). The results revealed
that 77% of staff members did support family being present during CPR and 76% did believe
that family members would want to be present during CPR as well as provided examples of
staffs personal experiences regarding family presence during resuscitative attempts (Lederman
et al., 2014).
Family Member
The research conducted by Compton et al. (2011) was a prospective, quasi-experimental,
comparison group study in which the intervention group was given the opportunity for one
family member to witness the resuscitative efforts in the hospital setting, and the control group

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remained in the waiting room. The consenting 65 subjects were interviewed by telephone at 30
and 60 days to assess for poor bereavement using the Center for Epidemiological Studies
Depression Scale, and the PTSD Symptom Scale Self Report (Compton et al., 2011). The
researchers concluded that there were no significant differences in the variable and control
groups in regards to depression or PTSD symptoms which were considered relatively high
among both groups, and no subjects reported participation in any hospital-based bereavement
support services (Compton et al., 2011).
General Population
The research conducted by Dwyer (2015) was a cross-sectional population based survey
in which 1208 people over the age of 18 were survey via land line telephone to discover how
they felt about being present when a family member was receiving CPR, or if they would want
family present in the event they themselves were receiving CPR. The survey results revealed that
slightly more than half of the subjects would want to be present if a family member was
receiving CPR (Dwyer, 2015). Most participants who would not want to be present cited not
wanting to be in the way of the medical team, or thought it may be too upsetting to observer
(Dwyer, 2015). However, over 75% of the subjects reported that they would want to be present if
it was their child receiving CPR (Dwyer, 2015). Finally, half of the subjects reported wanting
their family to be present if they themselves were receiving CPR (Dwyer, 2015). A trend
emerged indicating that people with prior experience of witnessing CPR were more likely to
want to be present again (Dwyer, 2015).
Family Member and Health Care Personnel

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The most widely referenced research of all the other articles is the study conducted by
Jabre et al. (2013) in which a prospective, cluster-randomized controlled trial involving 15
prehospital service units were recruited to either offer family the option of being present during
resuscitative efforts, or not offer and continue with resuscitation. Willing subjects in either group
were evaluated by a trained psychologist 90 days after the resuscitation using the Impact of
Event Scale and Hospital Anxiety Depression Scale to measure coping (Jabre et al., 2013). In
addition to obtaining the psychological assessment of family members Jabre et al. also included
observations of the family members made during resuscitative efforts, observations of the
medical team during the resuscitations, and any record of ligation after resuscitations (2013).
Jabre et al. found that the incidence of PTSD symptoms was lower in family members who
witnessed resuscitation, there were no differences in medical teams level of stress, or influence
on the effectiveness of the resuscitation, and no lawsuits following resuscitations (2013).
Discussion/Implications
The purpose of this integrative review was to evaluate 5 articles as they pertain to the
PICO question: how does being present during cardiopulmonary resuscitation compared to not
being in the room affect coping of family members to the patient receiving resuscitation. The
research conducted by Jabre et al. was the most substantial involving 570 subjects for the
psychological evaluation and contributed the most information regarding the benefits and risks of
family presence during resuscitation (2013). The results showed that witnessing CPR can help
family cope after their loved ones loss, and there was no perceived stress among healthcare
providers, and no ligation following resuscitation. A similar study conducted by Compton et al
found no significant differences in bereavement among individuals who witnessed resuscitation
and those who did not (2011). The other 3 articles assess the perceptions of other stakeholders

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whose opinions and support would be required to implement a practice change. Walkers
research indicated how views differ among health care providers including hospital staff and
ambulance staff regarding family presence during CPR which would require further study
(Walker, 2014). The research by Lederman et al also assess the attitudes of hospital staff
regarding family presence during CPR and indicated that most staff felt that family would want
to be present (2014). Lastly, Dwyers research focused on the general publics opinion, finding
that slightly over half of the subjects would want to be present if a family member were to
receive CPR (2051). Collectively this research reveals that although opinions and personal
choices vary about family presence during resuscitation, there is strong evidence that people may
want to be present, and that seeing the resuscitation may help with coping their loved ones loss.
Because of this, health care providers with appropriate education regarding family presence and
resuscitation should offer family the opportunity to witness the resuscitation.
Limitations/Conclusion
There are multiple limitations acknowledged by the researcher including that only one
researcher with limited experience in analyzing research was involved in conducting and
analyzing the research. In addition, only 5 articles were included in the review all obtained
through Bon Secours Health System resources. Despite the limitations above, the research
indicated that many factors must be taken into consideration when appraising whether or not
family should be present during a loved ones resuscitation. More research is required to truly
gauge the effects witnessing CPR has on coping. With the current evidence, it is indicated that
health care workers should offer the option for family to be present during resuscitative efforts,
and have a designated person to assess the familys needs during the situation.

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References

Compton, S., Levy, P., Griffin, M., Waselewsky, D., Mango, L., Zalenski, R., (2011). FamilyWitnessed Resuscitation: Bereavement outcomes in an urban environment. Journal of
Palliative Medicine, 14 (6), 715-721. Doi: 10.1089/jpm.2010.0463
Dwyer, T. A., (2015). Predictors of Public Support for Family Presence During Cardiopulmonary
Resuscitation: A population based study. International Journal of Nursing Studies, 52,
1064-1070. Doi: 10.1016/j.ijnurstu.2015.03.004
Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., . . . Adnet, F.,
(2013). Family Presence During Cardiopulmonary Resuscitation. The New England
Journal of Medicine, 368 (11), 1008-1018. doi: 10.1056/NEJMoa1203366
Lederman, Z., & Wacht, O. (2014). Family Presence During Resuscitation: Attitudes of YaleNew Haven Hospital staff. Yale Journal of Biology and Medicine, 84, 63-72.
Walker, W, M. (2014). Emergency Care Staff Experiences of Lay Presence During Adult
Cardiopulmonary Resuscitation: A phenomenological study. Emergency Medicine
Journal, 31, 453-458. Doi: 10.1136

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First Author
(Year)/Qualifications
Background/Problem
Statement

Conceptual/theoretic
al Framework

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Compton- Ph.D. New Jersey Medical School,

Department of Emergency Medicine; Wayne State
University School of Medicine, Department of
Emergency Medicine
Compare markers of adverse bereavement outcomes
among family members who remain in the waiting room
with those who are invited to witness active CPR in an
urban ED setting
No theoretical framework clearly identified

Design/
Method/Philosophical
Underpinnings

Prospective, quasi-experimental comparison group

study.

Sample/
Setting/Ethical
Considerations

Total 65 subjects 18 years old and older English

speaking persons, primarily African American. 24
Witnessed CPR. 24 Nonwitnesses. Study was approved
by the Wayne State University Institutional Review
Board
Variable group- family spokesperson was invited to
witness resuscitation attempt with an escort. Control
group- family member waited in waiting room.
Consenting subjects were contacted via telephone 30
and 60 days after the encounter.

Major Variables
Studied (and their
definition), if
appropriate
Measurement
Tool/Data Collection
Method

Measured adverse bereavement as symptoms of

depression and PTSD using the Center for
Epidemiological Studies Depression Scale, and the
PTSD Symptom Scale-Self Report via telephone
interview

Data Analysis

Independent t tests, or nonparametiric analogs, to

compare the mean depression scores and the mean
PTSD scores between groups and report results using
mean differences associated 95%

Findings/Discussion

Participants demonstrated an overall high level of

depression and PTSD symptoms during bereavement,
but these outcomes did not differ significantly between
the two groups

Appraisal/Worth to

Many limitations involved in the study, but the only study

of its kind to quantitatively evaluate the coping of family

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practice

First Author
(Year)/Qualifications
Background/Problem
Statement

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witnessed CPR compared to non witnessed CPR in an
urban setting.

Dwyer, RN, NR (Cert); ICU (Cer); BHIScn;

BCFlexLr: MClinEd; PhD
Identify factors that predict public support for having
family present during cardiopulmonary resuscitation

Conceptual/theoretic
al Framework

No theoretical framework clearly identified

Design/
Method/Philosophical
Underpinnings

Cross sectional population based study via landline

telephone interview

Sample/
Setting/Ethical
Considerations

1208 subjects participating over the age of 18 age

ranges 47+/- 15 years almost equal male and female

Major Variables
Studied (and their
definition), if
appropriate

N/A

Measurement
Tool/Data Collection
Method

Trained interviewer collected data via telephone

Data Analysis

Data analyzed using SPSS version 19 for Windows and

a series of chi-square tests were conducted

Findings/Discussion

52.5% of subjects would want to be present should a

family member require CPR, more would want to be
present if it were their child receiving CPR and 51% of
subjects would support their family member being
present should they themselves require CPR.

Appraisal/Worth to
practice

The study adds information on the beliefs of the general

public towards family presence during CPR

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First Author
(Year)/Qualifications
Background/Problem
Statement

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Jabre- M.D., PhD
To determine whether offering a relative the choice of
observing CPR might reduce the likelihood of PTSDrelated symptoms. Also assessing the effect of family
presence on the medical efforts at resuscitation, the
well-being of the health care team, and the occurrence
of medicolegal claims

Conceptual/theoretic
al Framework

None identified

Design/
Method/Philosophical
Underpinnings

relatives of patients receiving CPR by 15 prehospital

emergency medical service units were evaluated for
PTSD symptoms while the medical efforts and wellbeing of the health care team were being observed.

Sample/
Setting/Ethical
Considerations

570 subjects participated 266 in the intervention group

and 304 in the control group

Major Variables
Studied (and their
definition), if
appropriate

Intervention group was given the offer to witness

resuscitative efforts. Control group had prehospital staff
continue with their standard manner of conducting CPR

Measurement
Tool/Data Collection
Method

90 days after resuscitation subjects were contacted via

telephone by a trained psychologist and were assessed
using the Impact of Event Scale and the Hospital
Anxiety Depression Scale

Data Analysis

Scores were obtained for the IES and HADS

assessments, and other information was collected
including demographic and clinical data, level of stress
observed in the medical team

Findings/Discussion

The frequency of PTSD-related symptoms was

significantly higher in the control group than in the
intervention group

Appraisal/Worth to
practice

Large extensive quantitative study that thoroughly

collected and assessed all relevant data

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First Author
(Year)/Qualifications

Lederman, MD; PhD candidate Centre of

Biomedical Ethics, National University of
Singapore

Background/Problem
Statement

Assess the attitudes of Yale Emergency Department

health care personnel toward family presence during
resuscitation

Conceptual/theoretic
al Framework

None identified

Design/
Method/Philosophical
Underpinnings

Qualitative computer-based survey

Sample/
Setting/Ethical
Considerations

100 Yale New Haven Hospital ED staff, study approved

by the Yale Human Investigation Committee

Major Variables
Studied (and their
definition), if
appropriate

N/A

Measurement
Tool/Data Collection
Method

Questionaire sent via email asking four open ended

questions

Data Analysis

Data was read and coded and finalized for analysis by

two researchers

Findings/Discussion

77% of staff members favored allowing the option of

family presence during CPR. 66% of staff believed that
family would want to be present

Appraisal/Worth to
practice

Offers hospital staff perspective and experiences via

qualitative design

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First Author
(Year)/Qualifications

Background/Problem
Statement
Conceptual/theoretic
al Framework

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Walker, Doctor of philosophy, Master of
Science with distinction, health studies;
Postgraduate Diploma, Adult Education;
Bachelor of Science with First Class
Honours, Nursing Studies; BPS, RCN,
CIPD, AUA, HEA
Insight into the phenomenon of lay presence during
adult CPR from the perspectives of ambulance staff and
RNs
None identified

Design/
Method/Philosophical
Underpinnings

Hermeneutical phenomenological study

Sample/
Setting/Ethical
Considerations

8 ambulance staff and 12 RNs

Major Variables
Studied (and their
definition), if
appropriate

N/A

Measurement
Tool/Data Collection
Method

Semistructured, face-to-face interviews

Data Analysis

Recorded interviews were transcribed verbatim and

subjected to thematic analysis and interpretation based
on the ideas of van Manen, Attride-Stirling and
Denscombe

Findings/Discussion

Divergent practices within and across the contexts of

care were revealed. The concept of exposure emerged
as the essence of this phenomenon.

Appraisal/Worth to
practice

Quality face-to-face interviews with health care

personnel who have been a part of family witnessed
CPR