Family Witnessed Cardiopulmonary-Resuscitation - the Suitability and Impacts Towards Relatives in Malaysia

Family witnessed cardiopulmonary-resuscitation (CPR): The suitability and impacts towards relatives in Malaysia.

Being as an Assistant Medical Officer (AMO) whose engaged in the PHC services was full of excitement and challenging due to the roles as a first-provider in any emergency cases out-of-hospitals settings. Based on my vast experienced using the Gibbs’ reflective cycle (Appendix-C), I’ve always attended life-threatening cases of cardiac arrest which required the CPR-procedure. Normally, it has been a practice to excluding relatives from present during the procedure based on our clinical-guidance and traditional-believes that there will be more harm than benefits for them be involved. However in some cases, when the CPR attempt has failed to restored a client live, some of them have questioned my ability to conduct the procedure and intentionally causes a death, while some of them are preferred to be present with an intention to spend their last moments together. It is so unfortunate that despite of my intensity has left me with mixture feelings of disappointment, sadness, anger and incompetent in my role. Nonetheless, it has also highlighted a positive side of me to examine myself and the existing approach of the care.

For centuries, since Banner (1984) (Appendix-D) developed the skill acquisition theory, added by the usage of traditional-believes, intuition and guidelines (Parahoo, 2006 p.4), it has been a main guidance to support our clinical-practices. However, I was argued with the capability to be relied on those sources as it probably will harm the practitioners, endanger the clients and evoking dissatisfaction feelings among the relatives because they are occurred without any dependable basis and was not safely-effective based on the evidence-based practice (EBP) (Mantzoukas, 2007).

Despites abundance of definitions, Melynk et al. (2009) has nicely-described EBP as the substantial consolidation between the best available evidence of patient’s desire and values combined with well-designed research and scientific consideration of practice towards any clinical problem-solving. Based on my understandings with under-taken the common core in the published literatures, the philosophy of EBP was a process of thinking, questioning, searching, appraising, applying, evaluating and disseminating (Appendix-E) scientific evidence which comes from a well-designed and robust research as a guidance in any clinical-decision making with an aim to underpin the practice with the most suitable methods available.  

However with millions of accessible evidences, I was wondering which of those are prevails as the best scientific evidence. According to Booth (2010), stages of hierarchy pyramids which designed based on the methodological of studies (Appendix-F) will helps clinical-practitioners in sifting through a number of research and meet with the best available evidence. Commonly it is constructed with the most susceptible to eliminate bias at the top, followed by the most prone to have a bias at the bottom of the pyramid. Traditionally, randomised controlled trial (RCT) has been a “gold-standard” in clinical studies. It is a comparative, quantitative control experiment involving multiple groups who underwent an experiment to evaluate an intervention with a reliable outcome of results (Sackett et al., 1997).

Although it has not universally accepted in some countries, EBP has become a global-phenomenon in the healthcare-industries. Its extensive adoption is proven due to its strengths which are comprehensive for both of the clients and care givers (Cullen and Adams, 2010) as well as its efficiency in helping a country economic stability by promoting cost-effectiveness and reducing high rising costs of medical and health expenditures which has been one of the major concerns for the world leaders (Ke, Saksena and Holly, 2011).

Relatively with this essay, one of the significant strength of the implementations is the development of our capabilities to provide an effective, ethical and caring services based on the latest care available in accordance with our ethical obligation to respect over clients life in-terms of reducing mortality and contributing for a higher chances of survival as well as considering relatives admissibility in any clinical-decision making. Moreover, it will further increases our moral and confidence level as well as improving our flexibility, skills developments and critical thinking as a decision maker which allowed the maximisations of job satisfaction and reducing job retentions (Saba and McCormick, 2011). Meanwhile, as the clients are satisfied with the care provided, it wills slowly escalating their confidence-level towards the services which also helps to reduce in complaints and protecting us against any litigation.  

However, it has also some limitations to be implemented in my clinical-area. One of the major limitations identified is the dynamicity of times which is one of the most important parts in medical-emergency sciences in order to spontaneously specify the critical decision-making regarding a patient condition. Nonetheless, despites with the usage of electronic-gadgets such as smartphones will simplify the evidences searching via the internet, lack of skills required in EBP especially in focusing the clinical question, searching and critically appraising those evidence has also considered as time consuming  and perceived as one of the major limitations (Majid et al., 2011).

As I have cultivated a spirit of inquiry based on my experienced, the next step was to building-up a structured clinical-question based on the PICOT-elements. Emphasized by Schardt et al. (2007), the fundamental of implementing EBP was to asking well-develops questions through the PICOT-elements due to the advantages in avoiding any difficulties and time-consuming to develops a clinical-question. It is a simple abbreviation of “Population”, “Intervention”, “Comparison”, “Outcomes”, and “Time-frames” in-which the P, I, and O elements was essentials to be used in developing a clinical-question whilst, C and T elements are not necessarily present all over the time in-which it depends on the types of the questions (Stillwell et al., 2010). Thus, by having the keywords of relatives, adult CPR attempt, and the consequences which may arise due to the involvement, I have successfully develops the clinical-questions which structured as, “what are the consequences of relatives who’re presence during an adult CPR attempt?”.

In order to search the published literatures, I have been using the electronic databases of NORA, the library searching engines through the combination keywords of “family-present” and “cardiopulmonary-resuscitation”. The search was limited to English written scholarly publications including peer-reviewed journals articles specialising in research studies, CPR and cardiac arrest which published between 2011 until recently (Appendix-G). With a total of 65 literatures found, the titles of each article have been reviewed and have led to the rejection of 58 literatures which the titles of those article are not relevant with the topic discussed. Hence, with a balance of seven literatures (Appendix-H), the abstracts have been sifted based on inclusion-exclusion criteria (Appendix-I) to meet with the exact-studies which have an empirical data on relative attitudes regarding their involvements in out-hospitals adult resuscitation and were performed by the PHC services provider.