20. Family Presence During Resuscitation

Quick Recap

Miscellaneous / Cross-Cutting, new protocol (final protocol in the complete 45-topic revised plan). Companion to Crisis Resource Management and Bedside Resternotomy & Tamponade in the Cardiac Surgery ICU (both addressing team performance during resuscitation) and Conflict Resolution & Family Meetings (addressing family communication more broadly) — addresses whether family members should be offered the choice to witness resuscitation, with a genuinely instructive tension between one strong positive RCT and a more cautious systematic review.

1. Definition

Family presence during resuscitation (FPDR): offering family members/significant others the choice to witness CPR being performed on their loved one — "the effect of family presence during CPR on the family members themselves and the medical team remains controversial," per the authors of the largest trial addressing this question directly. This protocol treats that controversy honestly rather than resolving it artificially.

2. The PRESENCE Trial — A Genuinely Strong, Counterintuitive Positive Result

Jabre et al., NEJM 2013: a prospective, cluster-randomized controlled trial across 15 prehospital emergency medical service units in France, enrolling 570 relatives of patients in cardiac arrest receiving CPR. Units were randomized to systematically offer the family member the choice to observe CPR (intervention) versus standard practice (control, no systematic offer).

Results directly contradict the intuitive clinical fear that witnessing CPR would traumatize family members:

• 79% of relatives in the intervention group witnessed CPR, versus 43% in the control group
• The frequency of PTSD-related symptoms at 90 days was SIGNIFICANTLY HIGHER in the control group (i.e., those NOT systematically offered the choice to be present) — adjusted OR of 1.7 for PTSD symptoms in those not offered presence
• Anxiety and depression symptoms were also higher in those who did not witness CPR
• A 1-year follow-up found a favorable effect on the "work of grieving" in the intervention group
• Critically, the study found NO evidence that family presence affected resuscitation success rates, medical team stress levels, or led to increased medicolegal claims — directly addressing the most commonly cited provider concerns about offering family presence

This protocol treats the PRESENCE trial's core message as genuinely important and counterintuitive: withholding the opportunity to be present, not offering it, was associated with worse family psychological outcomes in this specific, large, well-conducted trial — the opposite of what many clinicians might instinctively assume when considering whether to "protect" family members by excluding them.

3. A More Cautious Systematic Review — A Genuine Tension Worth Naming

Despite PRESENCE's strong result, a 2023 Cochrane systematic review found only 2 trials met rigorous inclusion criteria (total n=595, including PRESENCE itself as the dominant contributor of 570/595 participants) and concluded "there was insufficient evidence to draw any firm conclusions on the effects of FPDR on relatives' psychological outcomes" — explicitly noting that "sufficiently powered and well-designed randomized controlled trials may change the conclusions of the review in future."

This protocol treats this honestly as a genuine tension, not a contradiction to be explained away: a single large, well-conducted RCT (PRESENCE) shows a clear, statistically significant benefit, while the broader systematic review standard (requiring multiple high-quality trials for a "firm conclusion") has not yet been met given how few rigorous trials exist on this specific question. This is analogous to other single-strong-trial-versus-cautious-meta-analysis situations addressed elsewhere in this library (cross-reference the DanGer Shock/network-meta-analysis tension in Mechanical Circulatory Support Selection in Cardiogenic Shock, Cardiovascular System) — the appropriate response is neither dismissing PRESENCE's finding nor treating it as definitively, universally settled.

4. Genuinely Conflicting Evidence on Team Performance

Data on the effects of family presence on CPR quality and rescuers' workload/stress are described in the literature itself as "sparse and conflicting" — a directly honest acknowledgment worth preserving:

• Some observational studies found no meaningful effect of family presence on team performance
• Other observational studies found an INCREASE in PTSD-related symptoms among family members — the opposite direction from PRESENCE's finding, illustrating genuine heterogeneity across different study designs/settings/populations
• A dedicated simulation-based RCT (1,085 physicians, 325 teams, scripted actor playing a family member during a simulated cardiac arrest) was specifically designed to address the team-performance question given how conflicting the existing observational data was

This protocol treats provider-side concerns (team performance, stress, workload) as a genuinely separate empirical question from the family-outcome question addressed by PRESENCE — both deserve independent evidentiary attention rather than assuming a favorable family-outcome finding automatically implies no team-performance cost, or vice versa.

5. What Family Members Themselves Report — Qualitative Findings

A qualitative sub-study of PRESENCE trial participants (30 interviews, sequential explanatory design) found genuinely mixed individual experience even within a trial demonstrating overall benefit: one identified theme suggested the experience of watching resuscitation may be traumatizing for some individuals, even as the aggregate trial result favored presence — this protocol treats "aggregate benefit" and "uniformly positive individual experience" as distinct claims, consistent with this library's general practice of not assuming a population-level finding applies identically to every individual.

Regret data: minimal regret was found in both families who were, and were not, present during resuscitation — but among family members who were absent (regardless of the specific reason), 55% wished they had been given the opportunity to be present — a genuinely important finding suggesting the value may lie substantially in being OFFERED the choice, not necessarily in the specific decision made — consistent with PRESENCE's actual intervention (systematically offering the choice), not a compulsory presence mandate.

6. Practical Synthesis

1. Systematically offer family members the choice to be present during resuscitation — per PRESENCE's actual intervention design and its favorable psychological outcome findings, rather than making the decision for them by default exclusion
2. Do not force presence on a family member who does not wish it — the value demonstrated is in offering genuine choice, not in mandating attendance
3. Address common provider concerns directly with the evidence: PRESENCE found no impact on resuscitation success, team stress, or medicolegal claims — these commonly-cited objections are not well-supported by the strongest available trial data
4. Acknowledge the genuine tension between PRESENCE's strong result and the more cautious Cochrane review — don't present this as fully, universally settled, while still treating the systematic offer of choice as a reasonable, evidence-informed default practice
5. Have a team member specifically supporting the family if present (explaining what's happening, providing emotional support) rather than leaving them unsupported in the room — consistent with structured approaches described in the broader literature
6. Recognize individual experience varies even within a population-level favorable finding — be prepared to gently offer the family the option to step out if the experience becomes overwhelming

7. Consultation Matrix

8. Documentation & Medicolegal Checklist

• Offer of presence (and family's decision) documented
• Support staff assignment for the present family member documented

9. Key Guidelines

• International Liaison Committee on Resuscitation (ILCOR) 2022 Consensus on Science with Treatment Recommendations — recommends offering family presence during resuscitation
• ANZCOR Guideline 10.6, Family Presence during Resuscitation

10. Landmark Evidence

11. Controversies

• The tension between PRESENCE's strong, statistically significant positive result and the Cochrane review's more cautious "insufficient evidence" conclusion is the central, honestly-preserved issue in this protocol — this reflects a genuine methodological reality (few trials meeting rigorous inclusion criteria) rather than a flaw in either the trial or the review; this protocol supports systematic offering of choice as a reasonable current practice while acknowledging the evidence base technically remains thinner than a single strong trial might suggest.
• Data on family presence's effect on team performance and rescuer stress is explicitly "sparse and conflicting" in the literature's own words — this protocol does not claim family presence is cost-free for the resuscitation team, treating this as a genuinely separate, still-developing evidentiary question from the family-outcome question PRESENCE addressed.
• Individual experience genuinely varies even within a population-level favorable finding — the qualitative sub-study's finding that witnessing resuscitation can be traumatizing for some individuals is a real, coexisting truth alongside the trial's aggregate benefit, not a contradiction requiring resolution.

12. References

1. Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368(11):1008-1018.
2. Rubin MA, Svensson TLG, Herling SF, Jabre P, Møller AM. Family presence during resuscitation. Cochrane Database Syst Rev. 2023;5(5):CD013619.
3. Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial. PLOS One. 2016.
4. Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial. 2022.
5. Effect of family presence during resuscitation in adult cardiac arrest on patient, family, and health care provider outcomes. ILCOR EIT Task Force Systematic Review, 2022.
6. ANZCOR Guideline 10.6: Family Presence during Resuscitation.

See also: Crisis Resource Management (ICU Leadership, Communication & Systems section) for the team-performance principles relevant to managing family presence during a resuscitation; Conflict Resolution & Family Meetings (ICU Leadership section) for the broader family-communication framework; Bedside Resternotomy & Tamponade in the Cardiac Surgery ICU and Traumatic Cardiac Arrest (Cardiac Surgery Critical Care/Surgical ICU System) for the specific resuscitation contexts this protocol's family-presence question applies within.

This completes the full revised 45-topic plan. The ICU Protocol Library now totals 172 (original) + 45 (new) = 217 pages across all systems, with every new protocol built to full 24-section depth, Quick Recap sections, and searchable database entries.