In-hospital family-witnessed adult resuscitation : Perspectives of patients, families and healthcare professionals

Sammanfattning: Background  Several international organizations recommend family-witnessed resuscitation (FWR) in hospitals, which means that the family should be offered to be present during resuscitation. These recommendations are based on research that shows that it is usually beneficial for the family to be present. The family can see that everything was done for the patient, they can say goodbye, they acknowledge that the patient passed away and the grieving process is facilitated. However, research has yet to examine how FWR affects the patient and family members who were present during the cardiac arrest and what it is like to live on with the shared experience.   Healthcare professionals (HCPs) in general are sceptical of FWR, and current guidelines that recommend FWR have not made a significant im-pact in healthcare. HCPs believe that FWR could worsen the outcome for the patient and that the family could be psychologically damaged by being present during resuscitation.HCPs also express uncertainty about how to act during FWR, because they have not received education or training about FWR. There is a need for research concerning the outcomes of FWR in hospitalized adult patients. Research on the experiences, attitudes, and self-confidence of HCPs in Sweden in relation to FWR, as well as the shared experiences of patients and families, is lacking. There is also lack of research exploring whether an educational intervention can have a positive impact on attitudes and self-confidence among HCPs.   Overall Aim  The overall aim of this thesis was to describe the prevalence, processes, and outcomes of FWR; explore experiences and attitudes towards FWR among patients, families, and HCPs; and to further develop and test an educational intervention addressing HCP.  Methods  This thesis includes four studies, where the first study used a cross-sectional design (I), Study II was a retrospective observational cohort study, Study III was a qualitative study, and Study IV used a quasi-experimental design. The sample size ranged between 15-4846 participants across the studies. Data was collected through web surveys (I, IV), registers (II), and narrative face-to-face interviews (III). Descriptive and correlational statis-tics were used in the quantitative studies (I-II, IV) and interpretative phenomenological analysis (IPA) in the qualitative study (III). A 10-minute educational video was developed, pilot tested, and used as intervention in Study IV. The video was based on previous research covering the prevalence and outcome of FWR, attitudes among HCPs, patient and family experiences, and FWR guidelines.   Results  It was significantly more common that a family member was on site if the cardiac arrest occurred in acute settings such as emergency departments and intensive care units than in hospital wards (44% vs. 26%, p<0.001). In total, 395 patients (12 %) had family on site when the cardiac arrest occurred, in 186 of these cardiac arrests the family chose to witness resuscitation. (II). The mean time from initiation to termination of resuscitation was significantly longer if a family member was present (17.7 vs. 20.7 minutes, p=0.020) (II). There were no significant differences in survival rate between FWR and non-FWR, neither immediately after resuscitation (57% vs. 53%, p=0.291) nor in 30-day survival (35% vs. 29%, p=0.086) (II).  HCPs reported a wide range of experiences regarding FWR (I, IV). More nurses (70%) than physicians (49%) expressed positive experiences in Study I, while in Study IV, the proportions were the opposite, with 52% of physicians and 33% of nurses reporting positive experiences.   Regarding attitudes, the results from Study IV show a more positive attitude towards offering the family the opportunity to be with the patient during CPR compared to Study I. In Study IV, 77.1% of nurses and 58.1% of physicians reported a positive attitude towards FWR, while in Study I, 58.7% of nurses and 29.2% of physicians were positive.   Performing defibrillation, administering drug therapies, and providing chest compressions during FWR were not considered to be a problem for either physicians or nurses. Nevertheless, being able to identify family members who demonstrate appropriate coping behaviours was more difficult, and 27% of nurses and 37% of physicians reported that they had no confidence in performing this task. Furthermore, 52.7% of nurses and 69.4% of physicians were not comfortable encouraging family members to talk to the patient during resuscitation (IV). In Study I, none of the included hospitals reported having local guidelines about FWR, while 18.6% reported that they had guidelines seven years later when Study IV was per-formed.  The results suggest that the educational intervention had a positive influence on HCPs’ self-confidence during FWR (3.83±0.70 to 4.02±0.70, p<0.001) and their attitudes towards FWR (3.38±0.49 to 3.62±0.48, p<0.001) (IV).   Patients and families describe powerlessness in the face of life's fragility, but also faith in life after experiencing and surviving a sudden cardiac arrest together. Even though the participants felt exposed and vulnerable in the care relationship and lacked a sense of control and continuity, they had hope and re-evaluated life, lived in the moment and saw the value in everyday life. The love they felt for people who were important to them and the gratitude for life increased after the cardiac arrest. The desire for freedom and independence also increased (III).  Conclusion  Surviving as well as witnessing an in-hospital cardiac arrest is a critical event making patients and family members vulnerable. To meet their needs, HCPs should routinely invite the family to witness resuscitation if it is deemed to be safe. HCPs need to show compassion and evaluate how family members are coping during the process and provide support and in-formation during and after resuscitation. Processes and outcomes do not seem to be negatively affected by FWR, even though there is some resistance to FWR among HCPs. These obstacles must be considered when planning for the implementation of FWR in daily practice. A short online educational video can be a way to improve the self-confidence and attitudes towards FWR among HCPs. This will likely result in increased compliance with national and local guidelines that recommend FWR.