Public Perceptions of Family Presence During Resuscitation: A Cross-Sectional Survey in Slovenia

Cardiopulmonary resuscitation (CPR) is a challenging and emotional situation for healthcare teams, requiring quick thinking and responsiveness. Traditionally, family members have been kept away from the resuscitation area, but research conducted internationally, notably in England and the United States, supports the presence of family members during resuscitation (1–4). It is noteworthy that approximately 70% of relatives prefer to be present during health-related procedures, including resuscitation (5). Studies have indicated diverse implications of family-witnessed resuscitation. The existing international literature suggests that the presence of family members has a positive impact, particularly in terms of establishing trust between family members and the medical staff resuscitating the patient, creating a more humane atmosphere that facilitates farewell and provides solace during grief in the event of a potential fatal outcome (6–8). These benefits are not limited to patients and their families, but also apply to clinicians (9). However, opponents of this viewpoint raise the possibility of psychological trauma (stress, anxiety) caused by being present during resuscitation, and express concerns that family members might interfere with and disrupt the resuscitation process. These studies also mention ethical dilemmas regarding inviting family members into the resuscitation room, as well as the potential for legal disputes (10, 11).

A broad consensus among international medical associations, including the American Heart Association (AHA), the European Resuscitation Council (ERC) and the European Federation of Critical Care Nursing Associations, supports the presence of relatives during CPR (12–14). However, despite the existing perspectives on this topic, there is still an ongoing debate in many countries, including Slovenia, regarding the involvement of the patient’s family members during resuscitation. The latest research on this topic highlights the evolving standard of care and the importance of introducing institutional policies to support family presence during resuscitation (FPDR) (15–17). Studies emphasise the need for a patient-centred approach that balances safety, family autonomy and interprofessional teamwork skills, and involves a designated family facilitator such as an on-call chaplain (18).

The adoption of policies allowing FPDR into clinical practice presents a number of challenges, including legal, ethical and procedural considerations (15). From a personnel perspective, a major barrier to adopting these policies is the lack of written instructions (8). However, there is a paucity of data on the attitudes of patients and their families towards FPDR (7, 8, 19). Moreover, Toronto and LaRocco (7) highlight the limited literature available on the viewpoints of families from Eastern countries, indicating the need for further research on this topic to understand potential cultural variations in the perceptions of FPDR. In Slovenia, the topic of FPDR is under-researched, particularly with regard to the perspectives of relatives themselves. The main objectives of this exploratory study were: i) to assess current public perceptions of FPDR in Slovenia and ii) to investigate whether demographic characteristics are associated with the general population’s perceptions of this topic.

Of the 1,120 people who clicked on the survey link, 799 started the survey and 618 completed it. As participation in the study was voluntary, the overall response rate was 51%. The average age of respondents was 42.8 years (SD=13.8; range: 18-82 years). Participants’ demographic and other characteristics are listed in Table 1. In addition, 60.9% of participants stated that they had a relative who had been treated in an intensive care unit, and 27.5% had either attended or experienced CPR.

The internal consistency reliability of individual subscales and the overall scale of the translated instrument was assessed using Cronbach’s alpha. The Cronbach’s alpha for the total scale was 0.913, and the coefficients for the subscales ranged from 0.916 (Insight-Building Benefits) to 0.848 (Personal Risks). These values indicate a high degree of internal consistency. The mean, standard deviation, actual and possible score range of the instrument with the respective median values are presented in Table 2. Of the two benefits scales, subscale 1 obtained a mean value of 24.2 (SD=7.5) and was also the subscale that was rated highest by respondents, while subscale 3 obtained a mean value of 17.0 (SD=5.9). Of the two risks scales, subscale 2 obtained a mean value of 20.3 (SD=6.6) and subscale 4 obtained a mean value of 8.6 (SD=3.2). Subscale 1 (InsightBuilding Benefits) showed a negative skewness (-0.368), while the other subscales displayed a positive skewness as follows: 0.170, 0.114 and 0.232. Overall, respondents were moderately favourably disposed towards FPDR (mean=70.1; SD=17.1). A total of 50.5% of respondents attained a score of 70 points or above on the total score scale.

Table 3 shows the descriptive statistics of the sample population’s demographic characteristics with respect to the four FPDR-BRS subscales. To establish statistically significant differences among demographic groups, independent sample T-tests and one-way ANOVA were performed. Statistically significant differences in responses were observed in the following three demographic variables: age group, work sector and previous experience with cardiopulmonary resuscitation. Across all four subscales, the younger population (aged between 18 and 39) expressed less favourable views towards the practice of FPDR compared to the other age groups. Post-hoc tests revealed statistically significant differences in the four subscales only between the 18–39 age group and the other two groups (p<0.001). In addition, respondents not affiliated with the healthcare sector showed a more positive perception of FPDR in the first three subscales (Insight-Building Benefits, Personnel Risk, and Connection-Forming Benefits). Respondents with previous CPR experience scored higher on subscale 4, indicating less concern that the practice of FPDR could cause psychological trauma to family members.

The results also reveal differences among individual groups in relation to the overall FPDR-BRS. Older individuals (age group 60–82) and respondents who were not affiliated with the healthcare sector scored higher on the total FPDR-BRS, indicating a more positive perception of FPDR among family members.

In our study, factors such as marital status, educational level, religious affiliation and prior exposure to a loved one’s treatment in an intensive care unit showed no significant association with the general population’s perceptions of FPDR. No statistically significant differences were observed in the subscales or the overall FPDR-BRS scores pertaining to these variables.

FPDR represents a multifaceted and emotionally charged subject within the context of healthcare. The aim of this study was twofold: firstly, to assess the prevailing perceptions of the Slovenian public regarding FPDR, and secondly, to identify potential associations between demographic characteristics and attitudes towards this practice.

The results from the present study show that over 50% of respondents tend to be in favour of FPDR practice. This is consistent with the findings of a recent study in which family members were interviewed and stated that they would like to have the option to be present if their family member underwent CPR (22). However, a recent study in Poland indicates that both patients and their family members have insufficient knowledge regarding their permission to be present during CPR interventions (19). Hence, to effectively address this issue, it is imperative to establish unambiguous guidelines that endorse FPDR as an option within a patient-centred approach, rather than making it mandatory (7).

Attitudes towards FPDR vary considerably between different groups (Table 3), with individuals aged 1839 being less favourably disposed towards FPDR. This discrepancy could be due to different views on the role of family members in medical emergencies. Younger people may place more emphasis on the efficiency of the resuscitation process and be more concerned about possible distractions or interference from family members (23). Another possible explanation for this discrepancy could be that younger people have too little experience with critical care scenarios, which could lead to a sense of unease at the prospect of witnessing a resuscitation procedure (23). Another factor that could play a role is the influence of media portrayals of resuscitation procedures. These are often characterised by over-dramatisation, which can trigger feelings of anxiety (24). However, this area is still largely unexplored, and further research, taking into account different values, life expectations and the influence of social media, would provide a better insight into this phenomenon. Conversely, older individuals may possess a more nuanced understanding of the emotional needs of family members during such critical situations. In fact, individuals over the age of 60 had a more positive overall perception of FPDR. This suggests that age may influence attitudes towards the presence of family members in resuscitation scenarios. These findings may indicate a generational shift in attitudes, with older people placing more importance on the traditional role of family presence and support at critical moments than their younger counterparts (22).

In our study, respondents who were not affiliated with the healthcare work environment tended to have a more positive attitude towards FPDR. Healthcare professionals, particularly physicians, often express reluctance towards the presence of family members during invasive procedures, indicating a lower degree of willingness to allow FPDR (16). On the other hand, patients’ family members have been reported to have significantly more positive attitudes towards FPDR compared to healthcare professionals, with family members believing that it may be beneficial for the relatives’ grieving process (7). These findings suggest that healthcare professionals may have a more pragmatic view of FPDR and focus more on the potential challenges and risks that FPDR may pose during resuscitation efforts. In contrast, the general public may emphasise the emotional support and closure that FPDR can provide (25). Non-healthcare individuals may also be more open to recognising the potential emotional and psychological benefits of FPDR without being influenced by professional concerns about procedural risks and clinical effectiveness (26).

Despite some reluctance among healthcare professionals to accept FPDR, training in this practice combined with advanced resuscitation instruction significantly increases its acceptance. This emphasises the importance of education and training in this area (27,28). As demonstrated by Chapman et al. (29), enhanced familiarity with FPDR practices could encourage support, and repeated exposure could raise clinicians’ awareness of the benefits rather than of the potential drawbacks of these practices. Research suggests several strategies for training healthcare professionals in FPDR, including simulations with standardised patients, role-playing, case studies, asynchronous online modules and traditional face-to-face lectures (7, 30, 31).

Experience with CPR appears to have a significant impact on attitudes, particularly regarding concerns about the psychological trauma experienced by family members. Respondents who had experienced CPR were less concerned about potential psychological harm, possibly because first-hand experience tends to demystify the process and its effects. This finding is consistent with the literature that suggests that familiarity with medical procedures can reduce anxiety and increase understanding in laypersons (2, 8).

Contrary to expectations, no significant association was found between factors such as marital status, educational level, religious affiliation and previous exposure to intensive care unit treatment and perceptions of FPDR. This suggests that these variables may not be relevant to shaping attitudes towards family presence during resuscitation. Previous studies have reported conflicting results regarding the effects of these variables on the perceptions of FPDR (23, 25). This may suggest that attitudes towards FPDR are influenced more by personal and experiential factors rather than broader demographic characteristics.

Findings from the present study have important implications for both the adoption of FPDR policies and their practical implementation in healthcare settings. It is important to acknowledge that the perceptions of FPDR are not homogeneous across demographic groups. This understanding can help tailor communication and education efforts to the specific needs of different groups. For example, education programmes aimed at younger people could focus on demystifying the resuscitation process and addressing their specific concerns. Consequently, working with healthcare professionals to address their concerns and provide evidence-based guidance on how to perform FPDR is recommended. This would help to allay fears and increase acceptance of the practice.

Overall, this study contributes to the ongoing debate on FPDR by highlighting the complexities of public perceptions and the potential influence of demographic factors on attitudes towards the inclusion of family members in resuscitation scenarios. In the context of healthcare systems striving to provide compassionate and patient-centred care, understanding and addressing the public’s concerns and preferences regarding FPDR will be of utmost importance. This will be crucial in shaping future policies and practices. Furthermore, future research could investigate the influence of cultural and social norms on perceptions of FPDR. This could provide further insight into the promotion of patient-centred care in resuscitation settings. A comparison of different cultural contexts could also shed light on the way different societies manage the tension between medical effectiveness and emotional support during medical crises.

Even though the study provides an insight into public opinion on FPDR in Slovenia, certain limitations need to be taken into account. One of the most important limitations is the possibility of sample bias. One of the most important limitations is the potential for sample bias. The survey was based on a convenience sample. Therefore, the sample may not fully represent the general population. Furthermore, the participants were invited to complete the questionnaire through different communication channels (e.g., social media, friends, work colleagues’ invitations). This recruitment method represents a potential bias, as participants may share similar perspectives or attitudes toward FPDR. In fact, in our sample a considerably high percentage of healthcare workers participated in our study. Although the study attempted to capture the perceptions of all demographic categories, certain subgroups may be underrepresented, for example people from rural areas, people from poorer socio-economic backgrounds and people with limited access to digital technology. In fact, the older population is underrepresented in our sample (Table 1). Further investigations should focus on this group’s perceptions of FPDR, as they are more likely to require resuscitation, and family members are often present during such events. Moreover, as this was a cross-sectional study, it captured public perceptions at a single point in time. Due to the design of the study, causality cannot be inferred from the results and any observed associations should be interpreted with caution. This approach did not take into account the potential change in the perceptions of FPDR over time, particularly in light of increasing public awareness and changing healthcare regulations and practices. Longitudinal studies would be needed to observe changes in perceptions over time. To adequately evaluate the results of the study, these limitations should be fully acknowledged. Future studies could overcome these limitations by using more representative sampling methods, incorporating qualitative data, and examining long-term changes in public perceptions. Despite these limitations, the study provides an important foundation for understanding public perceptions of FPDR in Slovenia and suggests avenues for future research.

In conclusion, this study provides valuable insights into public perceptions of FPDR. The results show that the public is generally positively disposed towards FPDR. Certain demographic groups, such as older adults aged 60-82 and those not employed in healthcare, tend to have a more favourable attitude towards FPDR. Interestingly, respondents with prior experience with CPR were less concerned that FPDR could lead to psychological trauma in family members.

The results suggest that FPDR is gaining acceptance, particularly among certain demographic groups and people with relevant experience. However, there is still room for improvement when it comes to increasing overall positive attitudes and reducing concerns about the emotional impact of this practice on families. As FPDR becomes more widely accepted, it will be important for healthcare providers to prioritise education, training and support in order to achieve the best possible outcomes for patients and their families.