This document discusses a proposed randomized controlled trial to evaluate the impact of family presence during resuscitation (FPDR) on the psychological health of family members. The trial would divide families into two groups: one that can witness resuscitation and one that cannot. At eight months post-resuscitation, both groups will complete the Impact of Event Scale-Revised (IES-R) questionnaire by phone. The hypothesis is that families who witnessed resuscitation will report significantly lower IES-R scores, indicating better psychological health. Previous studies provide evidence that FPDR does not affect resuscitation outcomes but may improve family member mental health outcomes.

1. Family Presence During Cardiopulmonary
Resuscitation:
8-monthImpactofEventScale–Revised(IES-R)
AssessmentSurvey
Chevelle Maxwell-Miller, RN
Anna Maria College
Paxton, MA

2. Abstract :
Presence of family during a loved one’s last breathe is not a new concept…
Studies indicate that only 13% of patients who receive CPR in a hospital survive to discharge (Balogh-
Mitchell, 2012). There is limited evidence evaluating the effects of offering FPDR upon resuscitation
outcomes and the psychological health of family members. Studies conducted to date provide evidence that
FPDR does not affect resuscitation outcomes, and may improve psychological outcomes in family members.
In a randomized control trial, participants will be divided into 2 groups: those receiving typical interaction
with the care team with resuscitation and those who will be specifically invited to witness resuscitation.
FPDR must be offered as a choice to individual families.
At eight months post-resuscitation, the enrolled family members will be asked to answer a structured
questionnaire by telephone. The clinical significance of small reductions in the Impact of Event Scale-
Revised (IES-R) scores is unknown; although it is reassuring that the evidence points to family members
offered FPDR is a benefit rather than harm.
These benefits include a greater appreciation of resuscitation efforts, increasing the families understanding of
the patient’s condition, decreasing the family members’ guilt and anxiety, increasing staff attention to privacy
and dignity of the patient, enhancing professional behavior among staff, facilitating grieving, giving families
a chance to say goodbye, and promoting holistic patient- and family-centered care (Balogh-Mitchell, 2012;
Jabre et al.,2014; Oczkowski et al., 2015; Patterson, 2002).

3. Clinical Practice Improvement
- Better mental health outcomes for families
Patient & Family Centered Care
- Reduce suffering
- Humanize the situation
- Increase nursing empathy
- Facilitate the grieving process
Offering patients the option for family presence during cardiopulmonary
resuscitation may improve nursing practice by…

4. PICOT
Population–Intervention –Comparison–Outcome-Time
P- Families of coding surgical patients
I - Presence of family members
C- Absence of family members
O - Family ability to cope
T- over the event (code)

5. Research Question
Hypothesis
For families of surgical patients undergoing resuscitation, does
being present during the resuscitation, versus not being present, affect the
psychological health of family members?
Hypothesis:
After families witnessed resuscitation (experimental group) do
families report significantly “lower IES-R scores” as compared to families
who did not witness resuscitation (control group).
H0: µ = 24 IES-R score and H1: µ < 24

6. IsitTimeforFamilyPresenceDuringResuscitation(FPDR)intheOR?
Journal Review 1 of 3
Balogh-Mitchell, C. (2012). Is it time for family presence during resuscitation in the OR? AORN Journal, 96(1) , 14-25.
FPDR has been defined as the presence of 1-2 family members who are able to
see and physically touch their loved one during CPR…qualitative literature review…
 The American Hospital Association’s Patient Bill of Rights lists numerous patients’ rights, one which is
the right to make decisions about the plan of care, so why is FPDR not honored in the OR?
 Patients viewed family presence as a fundamental right.
 Deontology encourages a “duty to care for the patients’ family to meet family needs and the duty to
prevent psychological harm”. The circulating nurse is designated as the patients advocate in the OR, his/her
duties would also include those of the surgical patients’ family members needs as well.
 78% of families believed their presence met the emotional & spiritual needs of the patient.
 Implementation of FPDR policy requires formal training of nurses, chaplains, and physicians
 93% of care providers believed that family members knew that the code team had done their
best to help the patient.

7. OfferingtheOpportunityforFamilytobePresentDuring
CardiopulmonaryResuscitation:1-yearAssessment.
Journal Review 2 of 3
Jabre, P., Tazarourte, K., Azoulay, E., Borron, S. W., Belpomme, V., Jacob, L., et al. (2014). Offering the opportunity for family to be present during
cardiopulmonary resuscitation 1-year assessment. The Journal of Intensive Care Medicine, 40 , 981-987.
Randomized control trial (N=570)…evaluates the psychological consequences among
family members given the option to be present during CPR …compared to those not routinely
offered the option.
 Prolonged grief disorder (PGD) refers to a syndrome consisting of a distinct set of symptoms following
the death of a loved one
 Decreased PGD Syndrome when family members offered the option to witness resuscitation.
 Facilitation of the Grieving Process of family members allowed to remain near the patient
during resuscitation.
 < 30% Physicians willing to allow FPDR; need to more education!
 End-of-Life Decision Making families & patients express desire for a more active role.
 Adverse bereavement may be reduced by adopting specific attitudes and behaviors toward family
presence during resuscitation.

8. The Offeringof FamilyPresenceDuringResuscitation.
Journal Review 3 of 3
Oczkowski, S., Mazzetti, I., Cupido, C., & Fox-Robichaud, A. (2015). The offering of family presence during resuscitation: A systematic review and meta-
analysis. The Journal of Intensive Care, 3(41) , 1-11.
Does family presence during resuscitation (FPDR) affect patient mortality and/or
resuscitation quality?...systematic review and meta-analysis of four previously published
randomized control trails (RCT) studies…
 Limited High-quality RCT studies due to the infrequent nature of cardiac arrest, and the relative rarity
of family member presences at the time of arrest.
 Offering FPDR – Adult RCT (3) studies graded as Moderate-quality evidence.
 Does not affect patient mortality or resuscitation quality.
 Can reduce symptoms of anxiety and depression in family members.
 May identify family members at risk for adverse events (suicidal intentions).
 Offering FPDR – Pediatric RCT (1) study graded as Low-quality evidence.
 Does not affect the quality or outcome of resuscitation.
 Parental interference not borne in the study

9. Family Adjustment & Adaptation
Response (FAAR) Model
Dr.JoanM.Patterson, 2002
 Offering FPDR = Regenerative Power – process by which families
restore balance by reducing demands, and increasing capabilities.
On a daily basis, families are engage in relatively stable patterns of balancing the
demands they face with their existing capabilities to achieve a level of adjustment and
adaptation.
Families may find during times of crisis,
demands to adjust far exceed their capabilities to
achieve adaptation.
 Patient & family wishes granted as drivers of care
 Patient focused care during medical crisis (resuscitation)
 Family anticipate loss in impeding death
 Family present during time of death

10. Study Design
Experimental RandomizedControlTrial
 Study will require Institutional Review Board (IRB) approval; prior to initiation of the study.
 The allocated intervention group
will be accompanied by a supporting staff
member who will provide information on
the resuscitation during the code.
 Family members allocated to the control
group will not be given the option to be
presence during CPR.
 Experimental Group –
Family Witnessed Resuscitation (FWR)
 Control Group –
not present during resuscitation
8-Month post-resuscitation, enrolled participants will be asked to
answer a structured questioner by telephone. The family members will
complete an Impact of Events Scale – Revised (IES-R) assessment survey.

11. Sample and Access
Non-probability ConvenienceSampling
The study will be conducted in an urban academic medical center located in
the city of Pittsburgh, PA.
- Place of employment of investigator
- 520-bed tertiary care hospital
- In-house Ambulatory Surgery Center (ASC)
- 22-bed main operating room (OR)

12. Target Population
Patients offeredFPDR
 Target population is the entire population in which a researcher is
interested (Polit & Beck, 2010).
Advantages Disadvantages
- The location
- Swiftly gather data and begin to
extrapolate theories.
- Perfect for quick studies (6-months to
a year of data collection)
- Easy on a “shoe string” budget
- Opportunity for bias
- Participants who do agree to the study
must also meet the hospital’s current (FPDR)
policy.
- Uneven distribution of the study to certain
ethnic groups, due to the urban southwestern
Pennsylvania location

13. Method & Materials
Assessment tools
 The authors recommend using means
instead of raw sums for each of these
subscales scores to allow for comparison.
In general, the IES-R is not used to
diagnosis PTSD, however, cutoff scores for
a preliminary diagnosis of PTSD have been
cited in literature (Weiss & Marmar, 1996).
The enrolled participants will be asked to answer an 8-month post-resuscitation
structured questioner by telephone. The family members (both control and experimental
group) will complete an Impact of Events Scale, Revised (IES-R); a 22-item self-report measure
that assesses subjective distress caused by traumatic events (Weiss & Marmar, 1996).
 Items are rated on a 5-point Likert-
scale ranging from 0 ("not at all") to 4
("extremely"). The IES-R yields a total
score (ranging from 0 to 88)

14. Outcomes
ImpactofEvents Score–Revised(22questions)
This is high enough to suppress your immune system's functioning
(even 10 years after an impact event).
IES-R assessment survey is very helpful in measuring the affect of routine
life stress, everyday traumas and acute stress: scoring range 0 to 88 (Weiss & Marmar, 1996).
 On this test, scores that exceed 24 can be quite meaningful. High
scores have the following associations.
PTSD is a clinical concern. Those with scores this high who do not have
full PTSD will have partial PTSD or at least some of the symptoms.24-32
This represents the best cutoff for a probable diagnosis of PTSD.33-36
37- up

15. References
Balogh-Mitchell, C. (2012). Is it time for family presence during resuscitation in the OR? AORN Journal,
96(1) , 14-25.
Jabre, P., Tazarourte, K., Azoulay, E., Borron, S. W., Belpomme, V., Jacob, L., et al. (2014). Offering the
opportunity for family to be present during cardiopulmonary resuscitation 1-year assessment. The
Journal of Intensive Care Medicine, 40 , 981-987.
Oczkowski, S., Mazzetti, I., Cupido, C., & Fox-Robichaud, A. (2015). The offering of family presence during
resuscitation: A systematic review and meta-analysis. The Journal of Intensive Care, 3(41) , 1-11.
Patterson, J. M. (2002). Intergrating family resilience and family stress theory. Journal of Marriage and
Family, 64 (May) , 349-360.
Polit, D., & Beck, C. T. (2010). Essentials of nursing research: Appraising evidence for nursing practice (7th
edition). Philadelphia, PA: Wolters Kluwer Health / Lippincott Williams & Wilkins.
Weiss, D., & Marmar, C. (1996). The Impact of Event Scale - Revised. . Assessing psychological trauma and
PTSD , 399-411.