Resuscitation 43 (2000) 171 – 176

www.elsevier.com/locate/resuscitation

Review
Witnessed resuscitation by relatives
Russell Boyd *
Department of Emergency Medicine, Hope Hospital, Stott Lane, Salford M6 8HD, UK

Received 22 March 1999; received in revised form 26 March 1999; accepted 21 October 1999

Abstract

Witnessed resuscitation is the process of active ‘medical’ resuscitation in the presence of family members. Witnessed
resuscitation though not as yet wide spread in practice is becoming established. Early reports of programs designed to promote
such a process first appeared in the early 1980s. More recent work appears to show both public support and a desire for inclusion
in the resuscitation process. Some research has been produced that indicates both satisfaction and psychological benefit for those
relatives enabled to witness. Limited work only, exists pertaining to the effects on health care providers and these reports currently
do not show any significant deleterious effects. Approval of witnessed resuscitation programs is not universal amongst all groups
of health care workers. Concerns about the ethics of witnessed resuscitation and its medico-legal implications have been raised.
The quality of the initial witnessed resuscitation reports is however variable and there is a great need for further work to validate
the initial findings particularly in the areas of psychological stressors in staff and risk management implications. © 2000 Elsevier
Science Ireland Ltd. All rights reserved.

Keywords: CPR; Outcome; Out of hospital CPR; Resuscitation; Training; Witnessed cardiac arrest

1. Objectives [(explode ‘interpersonal-relations’/all subhead-

The aim of this article is to review the literature
to date concerning opinion, consensus and re-
search in the field of witnessed resuscitation. The
article will also highlight certain topics as being of
particular importance for the near future.
2. Methods
Articles were initially identified using the Win-
spirs® format of Medline (1964–December 1998).
The following search strategy was used:
* Fax: + 44-161-787-4844.
E-mail address: rboyd@fs1.ho.man.ac.uk (R. Boyd)
0300-9572/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 3 0 0 - 9 5 7 2 ( 9 9 ) 0 0 1 4 7 - 1
ings) OR (explode ‘Family’/all subheadings) OR
(explode psychol*/all subheadings)] AND [(ex-
plode ‘cardio-pulmonary resuscitation’/all sub-
headings) OR (explode ‘resuscitation’/all
subheadings)]
This search strategy produced 658 references.
From that strategy, 32 articles were deemed rele-
vant. Searching from the identified articles using
the above search strategy yielded a further 19
articles of relevance. Certain articles duplicated
each other and only 29 articles were considered
original.
In addition, letters were sent to leading clini-
cians in the field (within the UK) requesting fur-
ther references if these had not been previously
identified. Finally abstract lists of selected recent
national (UK) and international emergency
medicine conferences (1997/98) were hand
searched for abstracts relating to the previously
described search strategy.
172 R. Boyd / Resuscitation 43 (2000) 171–176
3. Introduction
Witnessed resuscitation has recently become a
popular topic. The debate has ranged from the
medical literature [1] to the television screen [2].
The actual process of witnessed resuscitation has
been with us ever since the old testament in which
the prophet Elisha resuscitated an apparently dead
child by breathing into it at its parents behest.
Modern debate was kindled by early reports from
a witnessed resuscitation program at the Foote
Hospital, Michigan in the mid 1980s [3]. These
initial reports sparked not only debate but also
research into the value and effect of this some-
times controversial process.
As mentioned the debate moves on and, as with
all fields of emergency medicine, current practice is
changing. Patient influence is becoming ever
greater and evidence based practice is encouraged.
Against this background is the increase in accep-
tance or on occasions even encouragement for
family members to witness the active resuscitation
of a loved one. However like all aspects of emer-
gency care the evidence for the benefits, or harm,
of this practice have been called into question.
This article aims to review the published literature
concerning both the opinion and evidence base
relating to witnessed resuscitation.
4. Historical background
The concept of a structured witnessed resuscita-
tion program was initially aired by a multidisci-
plinary group of workers from the Foote Hospital,
MI, USA [4] in 1987. This was the first time that
family members had been encouraged to attend
resuscitation attempts on a systematic basis with
data recorded from those episodes. In addition,
this program introduced the concept of ‘facilitated
participation’, i.e. the use a health care worker to
support relatives who wished to be present whilst
resuscitation was in progress. It is from this report
that the current ‘movement’ to encourage family
participation has sprung. It would seem likely that
some form of structured family participation at
resuscitation must have been occurring prior to
1987 but no literature exists from this. The debate,
and indeed, the practising of witnessed resuscita-
tion remained restricted to North America
throughout the 1980s and early 1990s. The debate
did not reach Europe until 1996 when a series of
articles concerning a high-profile resuscitation at-
tempt at a horse trial at Windsor, UK [1] was
published. Opinion for and against witnessed re-
suscitation was represented in essentially the form
an open debate. First opinions were mixed with
regard to having family members as witnesses.
However since then, the trend of articles produced
has been more towards the acceptance of family
members at resuscitation attempts [5]. Increas-
ingly, in the last 2 years not only has opinion been
published but increasingly robust research based
evidence has been produced to consider the effects
on family members and staff groups during resus-
citation [6,7].
5. Relative’s perception of witnessed resuscitation
Two key areas have attracted attention in this
area. Firstly, relatives desires to be present at
resuscitation and secondly, relatives expectations
of that resuscitation. In terms of the former, a
variety of works has been performed over the last
15 years. The first study, designed to gauge rela-
tives beliefs was performed in the USA and
claimed that 72% of surveyed relatives expressed a
desire to be present during the resuscitation of
their relative [6]. This study could rightly be criti-
cized for its methodology. It was conducted as a
retrospective postal questionnaire with an unspe-
cified and variable interval between event and
sampling. Neither the response rate, nor the selec-
tion criteria for the subjects were quoted. In addi-
tion, the actual numbers surveyed were small
(n=18). Despite its methodological flaws, this
study did stimulate further investigation in this
field.
Further, perhaps more systematically collected
data on relatives’ desires to witness was produced
in the UK in 1997 [9]. The authors interviewed
bereaved relatives using a combined postal and
telephone questionnaire. With this methodology a
defined (albeit low) response rate of 51% was
obtained. The case mix again was variable in this
study. All types of resuscitation episodes were
studied including trauma and cardio-respiratory
disorders. Results showed 69% of relatives would
have liked to have been offered the chance to
witness resuscitation and 62% stated they would
actually have utilized that opportunity. The results
 R. Boyd / Resuscitation 43 (2000) 171–176
were obtained with a somewhat stricter methodol-
ogy against a different cultural background yet
yielded similar results.
Further work does exist to strengthen evidence
supporting relatives desires to witness. A prospec-
tive randomized controlled trial aimed at assessing
the psychological impact on relatives of witnessed
resuscitation [7] suggested that relatives were sig-
nificantly more satisfied with being allowed to
witness resuscitation than to be excluded. Again
the numbers included were small (n= 25) but the
improved response rate at 84% and the prospective
methodology lend greater credence to the results.
Relatives’ perception or expectations of resusci-
tation have been surveyed on two occasions. The
initial study to report on this, ascertained that
relatives remembered being offered access to resus-
citation in 83% of cases but actually recall details
in only 80% of these cases [4]. More recently, a
further study using an open-ended questionnaire
received a wide but apparently conflicting set of
responses [8]. As previously mentioned, flaws may
exist especially in the former report concerning
this data. However it would appear to indicate
that relatives have no fixed perceptions of the
process to which they wish admission. This seems
to be reinforced by recent debate in the USA
concerning recent media ‘misrepresentation’ of
cardiopulmonary resuscitation [9]. Although many
emergency physicians may view this debate as
unscientific the media appears to be the main
source of information concerning resuscitation
scenarios and procedures [2]. There are also a
considerable number of cases in which relatives
have little if no recollections afterwards [8]. This
has obvious implications in terms of the ability to
gain assent for inclusion at the resuscitation and
also must reflect the enormity of the stresses that
relatives do experience particularly in such an
unfamiliar environment.
6. Staff perceptions of witnessed resuscitation
The concerns and perceptions of resuscitating
staff are obviously a key concern in any debate
concerning witnessed resuscitation. It would ap-
pear differing staff groups have often markedly
contrary viewpoints. Paediatric staff, as a whole,
appear to have little problem with witnessed resus-
citation [10]. This group seems to regard the pro-
173
cess as a ‘right’ for parents [11]. In fairly marked
contrast, staff involved in the resuscitation of
adults appear to be divided over the concept.
The initial work in this area has again been
performed in MI, USA. A survey of Emergency
Room (ER) staffs was performed [4,12]. This was
a convenience sample with a small number of
participants (n=21). Attempts at including a mul-
tidisciplinary population were made but there was
incomplete coverage of all participating staff. The
results suggested 71% of staff endorsed the process
of witnessed resuscitation. Subsequent reports
from surveys of Advanced Life Support Providers
[13] suggested that a majority were against allow-
ing relatives participation. However though the
sample size was larger (n =80), accurate interpre-
tation of the data was not possible as the survey
methodology was not included. Four further stud-
ies purporting to survey health care staff attitudes
to witnessed resuscitation have been published. All
of these have included both nursing and medical
personnel. The only survey of Accident and Emer-
gency department staff unfortunately contained no
attempt to control for selection bias [14]. Here
75% of surveyed staff were ‘for’ witnessed resusci-
tation. A ‘convenience’ sample was again used to
survey staff attitudes in a mixed medical and
nursing group from undetermined hospital special-
ities in a UK hospital. This found that 68% of
responders were ‘positive’ to witnessed resuscita-
tion [15]. However lack of detail in the methodol-
ogy for participant selection again makes this
study difficult to interpret although the 100% re-
sponse rate certainly suggests an ‘interested’
group. The only non-UK survey, from Vic. in
Australia, again produced similar results with 74%
giving a positive response to having relatives in-
cluded [16]. Here nursing staff appeared more
likely to give a positive response to witnessed
resuscitation than physicians but this was not
statistically tested. Once again selection methods
are not available but the larger sample size and
greater breadth of staff type included make the
results perhaps more noteworthy.
Perhaps the strongest survey from a methodol-
ogy viewpoint was performed in the UK [17]. This
study surveyed medical staff from ‘all’ specialities
but only nursing staff from the Accident and
Emergency department. As before, selection meth-
ods were not clearly defined and the heterogeneity
of the sample makes the overall response difficult
174 R. Boyd / Resuscitation 43 (2000) 171–176
to interpret. Overall there was a positive response
for a relatives inclusion in only 37% of cases.
Interestingly a far more favorable response from
nursing staff was noted. A wide difference in
responses amongst medical staff existed depending
on their seniority. Increasing seniority was associ-
ated with a trend towards a positive response to
witnessed resuscitation. Those studied were from a
heterogeneous set of sources and the results have
not been the subject of strict statistical analysis.
Nevertheless they appear to indicate a positive
attitude to witnessed resuscitation amongst nurs-
ing staff with lesser support from medical, in
particular junior medical staff.
7. The effect of witnessing upon relatives
In many of the articles reviewed reference was
made to the potential resultant effect on the rela-
tive allowed to witness resuscitation [5]. However,
of these articles only two have attempted to quan-
tify this. Doyle’s original work [4] using a postal
questionnaire showed that 76% of relatives en-
abled to witness felt that they had had an easier
grieving process. This subjective assessment was in
an uncontrolled group. Not until 1997 had this
topic been revisited [6]. In a well conducted
prospective randomized controlled trial, lower lev-
els of anxiety, depression and grief were found
(using validated psychological questionnaires) in
relatives enabled to witness resuscitation. This was
a statistically non-significant trend possibly due to
the small numbers included in the study (n =34).
Both studies would seem to support a trend to a
beneficial process in witnessing resuscitation but
definite evidence is still lacking. This study was
also performed in a northern European commu-
nity. The applicability to other cultures has been
questioned in the past [18].
8. The effect on staff of witnessed resuscitation
Staff actively involved in resuscitation have ex-
pressed their concerns about the possible deleteri-
ous effects on themselves [15]. The original work
performed by Doyle et al. did contain some evalu-
ation of the effect upon staff as a direct result of
the inclusion of relatives at a resuscitation attempt
[4]. A relatively crude questionnaire assessed if
staff had felt ‘constrained’ by a relative’s presence.
Of the staff questioned, 30% stated that it had.
This again was an uncontrolled sample of small
numbers (n =18) and the questionnaire details are
not available. Later work from Canada [19] sug-
gested that provision of resuscitation is in itself a
stressful event. This is based upon the findings of
high rates of anger and intrusive ruminations after
resuscitation ‘events’ in emergency medical techni-
cians. It was claimed that these symptoms, similar
to those associated with the post traumatic stress
disorder, were found in 10 of 14 studied Emer-
gency Medical Technicians. All had performed
CPR in the field but the presence or absence of
relatives was not recorded. The work also stated
that although most resuscitation appears stressful,
symptoms were worse if the personnel felt them-
selves to have control over outcome. This control
aspect has been found in recent UK work [7]. In
an Accident and Emergency department based
study, staff recorded an increased stress response
when involved in a successful resuscitation at-
tempt. This work also demonstrated no significant
difference in stress responses in staff either with
relatives’ presence or absence. This study was per-
formed prospectively with a relatively large data
set. It was also set exclusively in an emergency
department with staff trained to handle relatives in
such situations. As such it may represent a ‘best
case’ scenario. Despite this, 25% of staff overall
did appear to suffer stress responses but the pres-
ence of relatives was not proven to alter these
responses.
9. Medico-legal aspects of witnessed resuscitation
programs
The literature concerning this area is limited and
no judicial decisions have been recorded in this
field. Health care staff are however, concerned
about the medico-legal implications of empower-
ing relatives to attend resuscitation attempts. That
the first article produced was North American
focused was not unsurprising [20]. It concluded
that there were no grave legal concerns about
witnessed resuscitation, and went on to even sug-
gest that a relative’s attendance could be sound
risk management. This is based on the high rates
of satisfaction that relatives, who do enter the
resuscitation room, report with respect to the ef-
 R. Boyd / Resuscitation 43 (2000) 171–176
forts of the resuscitation staff [4]. However this
work does assume that all staff are sufficiently
trained and briefed in handling both resuscitation
and bereaved relatives. Further North American
work in the pre-hospital care environment sug-
gested high satisfaction rates with resuscitating
staff working in a relative’s presence [21]. Rela-
tives were satisfied with care in 96% of resuscita-
tion episodes. The resuscitation was recorded as
being witnessed by a family member in 95% of
cases.
Further concerns have however been raised not
so much with the potential for litigation in terms
of the competency of resuscitation but rather in
terms of liability for any harm caused to relatives
during their experience as a witness [22]. The
potential for physical injury is real and well recog-
nised but the potential for liability due to psycho-
logical injury is relatively novel. Although no
successful case to date has been brought, this
article suggests the potential for liability. The only
recourse to this potential liability appears to be by
gaining informed consent prior to any potential
exposure. [23]. Concerns about the practicality of
such a policy have been raised [24].
10. Ethics and rights
Concern has been raised about the ethical ‘cor-
rectness’ of a witnessed resuscitation programme.
This has mainly focused on the potential breech of
patient confidentiality [25]. Currently this remains
a theoretical discussion as no complaint has as yet
been brought to any of the statutory bodies regu-
lating physician or nurses responsibilities to confi-
dentiality. In the absence of firm guidance such
organisations as the Resuscitation Council (UK)
advocate that humane considerations could out-
weigh potential ethical concerns [24]
The issue of relatives’ ‘rights’ must also be
considered. From a purely legal viewpoint, rela-
tives in the UK certainly, have no legal rights in
the care of adult patients [26]. Not withstanding
that, recent cultural trends towards increased pa-
tient autonomy have altered many patients and
relatives views towards acute care provision. The
Resuscitation Council now recommends that, if
possible, relatives should be offered the opportu-
nity to attend at resuscitation if properly sup-
ported. This would appear to be in line with recent
175
findings on relatives’ attitudes [17]. If health care
providers are to follow the public’s wishes, the
offer of inclusion at resuscitation attempts could
well become the norm, unless evidence to counter
this argument is firmly presented. In many ways
this rational is an extension of the fact that many
relatives have in fact been present during the
initial pre-hospital resuscitation attempts. In one
UK study 50% of relatives had been present dur-
ing the initial resuscitation phase prior to hospital
transfer [8]. Witnessed resuscitation is in many
instances a fact of circumstance. Only a well pre-
sented and supported argument will be enough to
actually remove a relative from a loved ones side.
11. Directions for the future?
The general public does on balance appear to
support the concept of witnessed resuscitation but
varying degrees of resistance exist amongst health
care staff. The future for such a policy would
appear to rest with three key processes. The first is
open debate and free discussion amongst both
providers and relatives upon the merits and forms
that witnessed resuscitation may take. The Resus-
citation Council has attempted to initiate this pro-
cess with its document ‘Relatives presence at
resuscitation’ [27]. This document must be com-
mended for its inclusion of both lay members and
a broad spectrum of health care providers
amongst its working party. The recommendation
that family members be offered the opportunity to
witness resuscitation was at the time of publica-
tion, based on little objective evidence of benefit to
relatives or minimal emotional cost to the staff
involved. In addition, the arguments against wit-
nessed resuscitation may not have been fully
weighted in the Council report [25]. Subsequent to
the report from the Resuscitation Council, the
Royal College of Nursing attempted to open the
debate to its members resulting in the rejection of
calls to provide witnessed resuscitation facilities in
Accident and Emergency departments [28]. This
polarity of views even amongst care providers does
emphasize the need for further open discussion of
these issues.
Secondly, the Resuscitation Council has firmly
recommended an increase in the amount of train-
ing for staff in the handling of relatives during
both witnessed resuscitation and bereavement in
176 R. Boyd / Resuscitation 43 (2000) 171–176
general. This follows surveys of Accident and
Emergency nursing staff showing considerable per-
ceived problems in this form of communication
[29]. The key to increased staff cooperation may
lie in their training and preparation.
Finally, the need for further quality research is
most apparent. To date the bulk of the survey
work has been retrospective with poor response
rates and poor control for survey biases. In addi-
tion there is only one randomised, controlled trial
within the field. In order to firmly convince uncer-
tain health care staff about the risks or benefits of
a witnessed resuscitation program we need trial by
evidence not trial by television. This is particularly
so in the fields of risk management and the psy-
chological stress amongst resuscitation staff.
12. Summary
Witnessed resuscitation though not as yet wide-
spread in practice is becoming established. Re-
search appears to show public support and a
desire for inclusion in the resuscitation process.
Further work would seem to show both satisfac-
tion and perhaps, psychological benefit for those
relatives enabled to witness. Limited work exists as
to the effects on health care providers and this
work at present shows no significant deleterious
effects. The quality of the initial witnessed resusci-
tation reports is however variable and there is a
great need for further work to validate the initial
findings before wholesale support could be given
to witnessed resuscitation as a ‘working’ policy.
The recommendations from the Resuscitation
Council in 1996 would seem to be increasingly
apposite.
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