Observational and qualitative studies have suggested positive benefits associated with family presence during cardiopulmonary resuscitation (CPR). Family presence may help alleviate the emotional burden and improve the bereavement process. Concerns about interference with resuscitative efforts and medicolegal ramifications have yet to be answered in rigorously designed studies. Patricia Jabre and colleagues in France conducted a multicenter, randomized controlled trial to determine if family presence during CPR was associated with a reduction in the likelihood of posttraumatic stress disorder (PTSD)-related symptoms. Results were published in the March 14 issue of The New England Journal of Medicine.

This prospective, cluster-randomized controlled trial was performed in the prehospital environment in France from 2009 to 2011. At least one first-degree relative per patient was included. Control groups consisted of emergency medical teams that did not routinely give the option for family members to be present during CPR. The experimental group used a communication guide to invite the relative to the resuscitation scene. Ninety days after resuscitation, a trained psychologist conducted a series of assessments for anxiety, depression and PTSD-related symptoms. The primary end point was the proportion of relatives with PTSD-related symptoms, while secondary end points included the effect of family presence on medical efforts at resuscitation, the well-being of the healthcare team, and the filing of medicolegal claims.
 
Of the 570 family members enrolled in an intention-to-treat analysis, 79% of the experimental group witnessed resuscitation versus 43% in the control group. Seventeen percent (n=95) of family members did not complete the 90-day post-event psychological assessment. There were no significant differences between the two groups in the characteristics of the resuscitation procedure, survival or characteristics of patients or enrolled family members. Twenty-seven percent of family members in the experimental group had PTSD-related symptoms versus 41% in the control group (P=0.01). Anxiety was significantly higher in the control group (24%) than in the intervention group (16%; P<0.001). Less than 1% of family members in either group interfered with the resuscitation effort.

One significant limitation to this work was the prehospital environment; the results from this trial deserve replication in an intensive care unit. It is possible that social and cultural norms and religious differences may pose a threat to external generalizability in other countries. The study results, which demonstrate several beneficial effects when family members are allowed to be present during CPR, require further investigation in the intensive care unit.  

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO, PhD. Each installment highlights journal articles most relevant to the critical care practitioner.