Local factors may influence decision

EDITOR, - The debate on allowing relatives to watch resuscitation1 has extensively addressed all the main points and leaves the impression of a consensus that relatives' wishes should be accommodated. This attitude is based on the idea that people will let doctors do their job and will cooperate with them. Unfortunately it is extremely rare, in my experience at least in southern Italy, to obtain a minimum of self control or cooperation from the relatives of a patient to be resuscitated.

The emotional distress and despair are always expressed by an aggressive attitude, even towards the doctors and the paramedics who are trying to reach the patient through a crowd of screaming or fainting relatives and spectators. Some colleagues have even been wounded as they tried to put a patient in the ambulance or to make some space to start resuscitation procedures. This is not just a matter of education, since this attitude is found in every social class.

In a country like Italy, in which charges of malpractice and misconduct have landed ministers and vice ministers for public health in jail, people prefer to rely on “magic thinking.” This stems from the cultural attitude of the “Latin soul” towards tragedy and a deep mistrust of doctors who, while trying to resuscitate a patient, are often physically assaulted by relatives who get the feeling that “something” is going wrong. It may even happen that a dying patient would be carried into a church, rather than into a nearby hospital.

Relatives can be helpful

EDITOR, - The question of whether relatives should be allowed to watch resuscitation was posed for me two weeks before I read Sarah Adams's article and the commentaries,1 when a 3 year old child with a thermal injury to 55% of his body had a cardiac arrest while on a ventilator for treatment of a deteriorating pneumonia. I am happy to report that the resuscitation was successful, although the period of hypoxia was prolonged and brain damage was feared until his successful weaning 10 days later.

There is little time to think in such circumstances; reintubation (the tracheal tube was displaced more than once in this crisis) and giving drugs were the only thoughts in my mind. The man at the end of the bed was helpfulness itself, responding intelligently to my (fortunately calm) requests to hold this, hang on to that; my eyes were meanwhile fixed on the child and the monitors. It was not until the heart rate was restored and there was time to relax a little that I realised that my helper had been the child's father. Furthermore, the nurses had sized up the situation a little more quickly than I, had instantly decided that any “damage” was already done, and had allowed him to continue his excellent work.

I asked him later, when his shock and worry had faded somewhat, how he had felt at the time. Like those mentioned in this series of papers, he had found it helpful to be involved. He had not considered it unusual, and had just reacted instinctively, knowing he was contributing to his son's welfare.

I am, however, left with one concern: what might I have said to him, in the heat of the moment, if, still mistaking him for a professional helper, I had found him less helpful? Would I have berated him for incompetence, and would he have understood or been deeply hurt? I am sure that, though like the authors I favour allowing relatives the choice of whether to remain for a resuscitation, I will henceforth always spare just two seconds to make myself aware whether they are present and think with just a small part of my brain of their wishes. I am also left with a strong feeling that asking this man to leave would have been a greater distraction to my work than allowing him to remain.

May affect doctors' performance

EDITOR, - The major discussion about whether relatives should be allowed to watch resuscitation seemed to be in relation to a death in a public area.1 We would like to report our experience of a hospital setting.

The philosophy of our department has facilitated exposure of relatives to the care being given to their family members in the resuscitation room. The relatives have been briefed by a senior member of nursing staff and then are brought into the resuscitation room by the nurse and given a continuous explanation of the procedures going on.

Records are not kept, but our impression is that some part of one in 20 adult resuscitations are watched by a relative, but over half of children's resuscitations are witnessed by the parents. All relatives are offered the opportunity to view the body after unsuccessful resuscitation.

The effect of observing relatives on the confidence of doctors is constantly borne in mind. We never allow relatives to stay unless all the staff present are comfortable with their presence.

Follow up of relatives, particularly parents, who have witnessed resuscitation attempts shows 100% to be appreciative of the experience, and they report benefits in terms of grieving and coming to terms with an unsuccessful resuscitation.

This is a routine service that we offer in our department, and we commend it to all other accident and emergency departments, although it must be recognised that it requires time and experience for everyone involved in the resuscitation team to become comfortable with the concept and to be prepared to put the necessary effort into looking after the relatives.

Effect on relatives needs study

EDITOR, - Most of the writers considering whether relatives should be allowed to watch resuscitation were in favour, using Sarah Adams's account as strong evidence.1 We should keep in mind, however, that her account is the account of only one relative. It is noteworthy that her mother chose to remain outside the screens while her son was being resuscitated. Had she given her account of that tragic incident, it may very well have given us a completely different perspective.

Peter Bloomfield notes that ambulance staff report that “witnessing resuscitation is a terrible experience for relatives.” Before we start advocating that relatives might be present during resuscitation procedures we should have more formal studies of the short term and long term effects of such an experience on relatives who have attended such procedures previously - mainly those relatives present when ambulance staff carry out resuscitation procedures at home.

I feel that Bloomfield's view was the most practical of those presented - ask the relatives to leave in a way that allows those who feel they must remain to do so; keep the relatives fully informed; and allow sufficient time for the relatives to remain with the body immediately after death. Simple counselling should be given to the relatives immediately after that, emphasising that they could not have done anything more had they stayed and that the patient was unconscious and would not have been aware of their presence. This would aid in preventing or alleviating feelings of guilt.

A successful American Programme

EDITOR, - Sarah Adams's account of her brother's death at an equestrian event raised several issues regarding the rights of relatives to be present during resuscitation.1 The account and the subsequent viewpoints of eminent doctors, who mostly supported the rights of the relatives, mirrored a debate among American emergency room nurses that began with a letter in their official journal in 1991 supporting the rights of relatives to be present during resuscitation2

The Foote Hospital in Jackson, Michigan, USA, has operated a planned programme of family member presence during resuscitation since 1982.3 This programme stemmed from two incidents in which relatives demanded the right to be present: in the first case the relative had been in the ambulance during the initial resuscitation attempts, and in the second case the relative belonged to the family of a police officer who had been shot. The staff of the emergency room at the Foote Hospital questioned whether it was ethically correct to exclude relatives and close friends during resuscitation, as had previously been the norm. Since the hospital's programme began, no resuscitation attempts have been interfered with. Relatives or close friends have occasionally fainted or become hysterical but they have quickly been escorted from the room.

The key to the programme's success stems from several factors, which were suggested by Peter Bloomfield.1 Chief among these is the need for a trained person, in addition to those in the resuscitation team, who can discuss the procedure with relatives or close friends and offer to stay with them during resuscitation. They should be able to enter and leave as they wish; in fact, most relatives and close friends stay for only a short time. The resuscitation team allows them to hold the patient's hand or just to sit close by.

Malone suggests that it is ethically questionable to exclude relatives or close friends from such a procedure. 4 Exclusion may devalue the death to a clinical procedure or a failure of treatment rather than a unique human event that touches the lives of others. But if close friends or relatives are admitted to an event that is traditionally the reserve of health care professionals then loose talk and black humour, occasionally used to defuse a tragic situation, may have to be carefully monitored. Of major concern is the grieving relative or friend holding the patient's hand, who may be unfamiliar with terminology such as “Everyone clear!”