Many years ago, the presence of family members during cardiopulmonary resuscitation was verboten. The reigning principles were two-fold. Family members would get in the way of allowing the team to save the loved one. And they would be emotionally scarred forever.

The medical literature has dispelled the myth that the family can’t handle the visual imagery of the team trying to resuscitate their loved one. A randomized controlled trial concluded that those who witnessed CPR on a relative had lower rates of symptoms of post-traumatic stress disorder (PTSD) than those who did not. Relatives left in the waiting room experienced more depression and anxiety.

Those relatives who were offered the opportunity to be present during CPR had less intrusive imagery, post-trauma avoidance behavior, and symptoms of grief when assessed three months[1] and one year[2] later. Witnessing resuscitation can inform the family about the severity of their loved one’s condition and can provide reassurance that all measures were taken to save the patient’s life[3],[4]. In the event that the resuscitation is not successful, being present can facilitate the grieving process for the family by allowing the opportunity for a last goodbye, aiding in closure and bringing a sense of reality to the loss so as to avoid a prolonged period of denial [5],[6], [7].

But, is witnessing CPR the same as watching a loved one fileted open in the trauma bay. Are the benefits to the family member equivalent? Is the risk to the patient unchanged?

A survey of members of American Association for Surgery of Trauma (AAST) suggests witnessing CPR and trauma resuscitation is not an apples to apples comparison. Almost 98% of survey respondents stated that the presence of family members during all phases of trauma resuscitation is inappropriate. Of those who reported experience with family members witnessing a trauma resuscitation, nearly ¾ stated they were negative.

The key argument is that a trauma resuscitation is organized chaos. While studies on family presence during CPR have concluded the family does not directly disrupt resuscitation efforts, the increased crowding and commotion might unnecessarily distract the team.

Helmer et al. compared the resuscitation of a critically injured trauma patient to the operation of an aircraft in that both require fast assimilation of data and quick decision making. They discuss the Federal Aviation Administration’s “sterile cockpit rules” that prohibit unauthorized persons on the flight deck as well as crew member participation in nonessential activities during critical moments of aircraft operation and suggest that keeping potential distractions to a minimum in the trauma setting would be advisable as well.[1]

And somewhat surprisingly, patients themselves have suggested they may not want any family present. Or at least control which family members were present.

In one survey of patients’ and family members’ opinions on [Family Presence During Resuscitation], 22 percent of respondents wanted no family presence and 43 percent only wanted certain, predefined family to be present. [1]

Finally, in one study, PTSD symptoms were higher among witnesses (compared to non-witnesses) of out-of-hospital resuscitations where the atmosphere is less controlled than a well-run code on a sterile hospital floor.[1]

So, should family members be allowed to witness a trauma bay resuscitation?

It probably comes down to the unsatisfactory conclusion of “it depends.”

The two chief benefits would be allaying any doubt that everything reasonable had been done to save their loved one. And, it would allow a distraught relative one last chance to lay eyes (and be with) their family, assuming the outcome is death. In many situations, there should be a controlled way to keep the family from interfering with proper delivery of care.[2]

Still, I can imagine any number of scenarios where the better answer would be to Just Say No.

What do you think? Let us know below.

[1] Compton S, Grace H, Madgy A, Swor RA. Post-traumatic stress disorder symptomology associated with witnessing unsuccessful out-of-hospital cardiopulmonary resuscitation. Acad Emerg Med. 2009;16(3):226-229

[2] Traylor M. Should family be permitted in the trauma bay? AMA Jl of Ethics. 2018; 30(5): 455-463.

[1] Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004;11(7):750-753.

[1] Helmer SD, Smith RS, Dort JM, Shapiro WM, Katan BS. Family presence during trauma resuscitation: a survey of AAST and ENA members. J Trauma. 2000;48(6):1015-1022.

[1] Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368(11):1008-1018.

[2] Jabre P, Tazarourte K, Azoulay E, et al. Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive Care Med. 2014;40(7):981-987.

[3] Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16(6):673-675.

[4] Mian P, Warchal S, Whitney S, Fitzmaurice J, Tancredi D. Impact of a multifaceted intervention on nurses’ and physicians’ attitudes and behaviors toward family presence during resuscitation. Crit Care Nurse. 2007;27(1):52-61.

[5] Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18(2):104-106

[6] Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998; 352(9128):614-617.

[7] Kübler-Ross E. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families. New York, NY: Simon and Schuster; 1969.352(9128):614-617.

MJS Consultation CTA