Affiliations: Walter Reed Army Medical Center Washington, DC,
Fort Sam Houston, TX
Tripler Army Medical Center
Brooke Army Medical Center
Correspondence to: Kevin M. Creamer, MD, LTC, MC, Medical Director, Pediatric Intensive Care Unit, Walter Reed Army Medical Center, Department of Pediatrics (MCHL-KCC), 6900 Georgia Ave, NW, Washington, DC
To the Editor:
In their recent article in CHEST, McClenathan et al (December 2002)1
did a superb job of highlighting the issues surrounding family-witnessed resuscitation (FWR) from an adult medicine perspective. Although the American Heart Association recently recommended that family presence be strongly encouraged during resuscitative efforts, their survey clearly demonstrated that this practice is not universally embraced. Nevertheless, the practice of FWR is viewed favorably in the field of pediatrics.
The debate sparked by the parentally witnessed resuscitation event that was mentioned in the above article initially inspired the pediatricians involved to survey our own colleagues’ opinions of the practice. We found that pediatricians are more likely to be accepting of and to repeat FWR than their adult medicine counterparts.2
Roughly one third of the pediatricians surveyed would allow a family presence during cardiopulmonary resuscitation, and almost two thirds would repeat the practice. Pediatric inpatient-oriented specialists were far more accepting of family presence (57%) and were willing to repeat it (74%) than their adult counterparts in pulmonology (20%) and critical care medicine (40%).
The realities of pediatric training and practice make us more accepting of family presence. Early and repeated exposures to delivery room resuscitations help to prepare pediatricians for FWR. Deliveries, by their very nature, require at least one parent to be present, with the father usually toting a video camera. Additionally, we constantly interact with parents in their literal role as guardian. Parents are the decision makers, and they watch over their children even during calamity.
The comfort that pediatricians have with a parental presence may explain why family-centered care is embraced in pediatrics. In fact, the American Academy of Pediatrics and the American College of Emergency Physicians announced3–
that they are jointly working on documents regarding the application of family-centered care as it pertains to the death of a child in the emergency department. A recent review of peer-reviewed manuscripts4
shows a clear trend in favor of FWR, especially by families, followed by nurses and experienced physicians. This review pointed out the limitations in the published literature. Many FWR articles did not test a hypothesis, and broad conclusions were made from weak data. Clearly, more work is needed before FWR can be advocated wholesale.
In the mean time, increased discussion and study may enhance the opportunities for and acceptance of controlled FWR in many settings. When done correctly with appropriate staff liaisons, the practice of FWR can be very rewarding. Many parents have thanked my colleagues and me for allowing them to be present during their child’s precious last moments. They were present at the beginning of the child’s life. They should be allowed to be present at the end!
We thank Dr. Creamer for his interest in our article, and we acknowledge his expertise in pediatric intensive care and family- witnessed resuscitation (FWR) for pediatric patients. We agree with Dr. Creamer that pediatric medicine, by its very nature, requires a more family centered approach, in which there is continuous interaction between health professionals and parents functioning as guardians and decision makers.
In our original article, we stated that the results of opinions toward the pediatric patient should be interpreted with caution, as only 20 of the 494 physicians surveyed were trained in pediatric specialties. We warned that our pediatric resuscitation data might not reflect the opinions of the larger community of pediatric intensivists. In fact, Dr. Creamer’s published data show that he and many other pediatricians have embraced FWR with great success and satisfaction.
Our survey data did not show a statistically significant difference of opinion toward FWR of children when pediatric-trained health-care professionals were compared to adult health-care professionals (26.1% vs 14.2%, respectively; p = 0.138); however, the subgroup of 12 primary pediatricians was more likely to favor FWR for children compared to adult-trained health-care professionals (41.7% vs 14.2%, respectively; p = 0.022). While subgroup analysis supports Dr. Creamer’s position, we believe that the number of pediatricians we surveyed was too small to draw definitive conclusions.
In summary, we agree with Dr. Creamer that this area requires more research and discussion before FWR can be “advocated wholesale.” In the interim, hospital leaders should consider each patient and family situation individually and should ensure that physicians and nurses are trained to support FWR in appropriate circumstances.
Become a CHEST member and receive a FREE subscription as a benefit of membership.
Individuals can purchase this article on ScienceDirect.
Individuals can purchase a subscription to the journal.
Individuals can purchase a subscription to the journal or buy individual articles.
Learn more about membership or Purchase a Full Subscription.
Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited:
Customize your page view by dragging & repositioning the boxes below.
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.