Physicians have traditionally helped close the curtain around hospital death, ushering families away during the attempt at resuscitation. Separating them from their sick relative may spare the family a trauma and protect the physician’s professional engagement with the experience.
But increasingly, it seems physicians might be doing our patients and their families a disservice.
Because the moments preceeding death are often unpredictable, the family may have difficulty accepting and understanding the death of the patient in such a precarious context. But escorting them away may deprive the family of an experience that helps them to develop a sense of acceptance or closure.
The first formalized trial that asked whether families might benefit from being present during a code begins almost confessionally, with the authors’ concerns that it was not fair to exclude families.
Since that first trial, there have been heated debates as to whether this practice should become standard. Several professional guidelines (Emergency Nurses Association in 1993, American Heart Association in 2010, European Resuscitation Council in 2010) have recommended the practice for the reasons mentioned above, but critics point out that evidence is mixed and is often limited by small sample sizes and observational design. The critics also worry that families may experience trauma or that they may distract the medical team in addition to possible medicolegal ramifications.
This week’s NEJM presents the results of the first large randomized controlled trial that attempts to settle this debate. Jabre et al focused on resuscitation offered by emergency medical service units in France – essentially mobile intensive care units consisting of an ambulance driver, a nurse and a physician – and had them offer families either standard care or the option of witnessing the resuscitation attempt. Ninety days after the resuscitation they called the family and performed surveys to evaluate the family member for symptoms of PTSD and depression or anxiety. They also asked whether the healthcare team experienced any negative effects from the presence of the family, and looked for any medicolegal events.
Overwhelmingly, their results were in favor of family-witnessed resuscitation. Both in the intention to treat and the as-treated analyses showed significantly more PTSD symptoms in the families who did not witness CPR, along with more symptoms of anxiety. 12% of the family members who did not witness CPR expressed regret at being absent compared to 3% who regretted being present. There was no significant difference in stress of the medical teams, and there were no reports of medicolegal conflict.
This trial had several limitations. It centered on mobile ambulance units and consequently the results may not apply to resuscitation efforts in hospitals. Ambulance teams work in the field and may be more accustomed to performing resuscitation in front of families compared to hospital staff. Hospital resuscitations may also be more invasive and frequently involve large numbers of staff.
Ultimately, more research will be necessary, and hospital workers may benefit from training in how to best perform resuscitations in front of families. Nonetheless, this trial is reassuring. It suggests that although codes are difficult to watch, pulling back the curtain may provide comfort. Physicians’ experience of a code is unique. One cannot know what a code means to a family – and perhaps physicians should not be the ones to decide.
Natalie Volkes is a fourth-year medical student at Harvard Medical School. She recently matched at Brigham and Women’s Hospital for her residency.