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Waldemar, A. (2023). In-hospital family-witnessed adult resuscitation: Perspectives of patients, families and healthcare professionals. (Doctoral dissertation). Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>In-hospital family-witnessed adult resuscitation: Perspectives of patients, families and healthcare professionals
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]


Several international organizations recommend family-witnessed resuscitation (FWR) in hospitals, which means that the family should be offered to be present during resuscitation. These recommendations are based on research that shows that it is usually beneficial for the family to be present. The family can see that everything was done for the patient, they can say goodbye, they acknowledge that the patient passed away and the grieving process is facilitated. However, research has yet to examine how FWR affects the patient and family members who were present during the cardiac arrest and what it is like to live on with the shared experience.   

Healthcare professionals (HCPs) in general are sceptical of FWR, and current guidelines that recommend FWR have not made a significant im-pact in healthcare. HCPs believe that FWR could worsen the outcome for the patient and that the family could be psychologically damaged by being present during resuscitation.

HCPs also express uncertainty about how to act during FWR, because they have not received education or training about FWR. There is a need for research concerning the outcomes of FWR in hospitalized adult patients. Research on the experiences, attitudes, and self-confidence of HCPs in Sweden in relation to FWR, as well as the shared experiences of patients and families, is lacking. There is also lack of research exploring whether an educational intervention can have a positive impact on attitudes and self-confidence among HCPs.   

Overall Aim  

The overall aim of this thesis was to describe the prevalence, processes, and outcomes of FWR; explore experiences and attitudes towards FWR among patients, families, and HCPs; and to further develop and test an educational intervention addressing HCP.  


This thesis includes four studies, where the first study used a cross-sectional design (I), Study II was a retrospective observational cohort study, Study III was a qualitative study, and Study IV used a quasi-experimental design. The sample size ranged between 15-4846 participants across the studies. Data was collected through web surveys (I, IV), registers (II), and narrative face-to-face interviews (III). Descriptive and correlational statis-tics were used in the quantitative studies (I-II, IV) and interpretative phenomenological analysis (IPA) in the qualitative study (III). A 10-minute educational video was developed, pilot tested, and used as intervention in Study IV. The video was based on previous research covering the prevalence and outcome of FWR, attitudes among HCPs, patient and family experiences, and FWR guidelines.   


It was significantly more common that a family member was on site if the cardiac arrest occurred in acute settings such as emergency departments and intensive care units than in hospital wards (44% vs. 26%, p<0.001). In total, 395 patients (12 %) had family on site when the cardiac arrest occurred, in 186 of these cardiac arrests the family chose to witness resuscitation. (II). The mean time from initiation to termination of resuscitation was significantly longer if a family member was present (17.7 vs. 20.7 minutes, p=0.020) (II). There were no significant differences in survival rate between FWR and non-FWR, neither immediately after resuscitation (57% vs. 53%, p=0.291) nor in 30-day survival (35% vs. 29%, p=0.086) (II).  

HCPs reported a wide range of experiences regarding FWR (I, IV). More nurses (70%) than physicians (49%) expressed positive experiences in Study I, while in Study IV, the proportions were the opposite, with 52% of physicians and 33% of nurses reporting positive experiences.   

Regarding attitudes, the results from Study IV show a more positive attitude towards offering the family the opportunity to be with the patient during CPR compared to Study I. In Study IV, 77.1% of nurses and 58.1% of physicians reported a positive attitude towards FWR, while in Study I, 58.7% of nurses and 29.2% of physicians were positive.   

Performing defibrillation, administering drug therapies, and providing chest compressions during FWR were not considered to be a problem for either physicians or nurses. Nevertheless, being able to identify family members who demonstrate appropriate coping behaviours was more difficult, and 27% of nurses and 37% of physicians reported that they had no confidence in performing this task. Furthermore, 52.7% of nurses and 69.4% of physicians were not comfortable encouraging family members to talk to the patient during resuscitation (IV). In Study I, none of the included hospitals reported having local guidelines about FWR, while 18.6% reported that they had guidelines seven years later when Study IV was per-formed.  

The results suggest that the educational intervention had a positive influence on HCPs’ self-confidence during FWR (3.83±0.70 to 4.02±0.70, p<0.001) and their attitudes towards FWR (3.38±0.49 to 3.62±0.48, p<0.001) (IV).   

Patients and families describe powerlessness in the face of life's fragility, but also faith in life after experiencing and surviving a sudden cardiac arrest together. Even though the participants felt exposed and vulnerable in the care relationship and lacked a sense of control and continuity, they had hope and re-evaluated life, lived in the moment and saw the value in everyday life. The love they felt for people who were important to them and the gratitude for life increased after the cardiac arrest. The desire for freedom and independence also increased (III).  


Surviving as well as witnessing an in-hospital cardiac arrest is a critical event making patients and family members vulnerable. To meet their needs, HCPs should routinely invite the family to witness resuscitation if it is deemed to be safe. HCPs need to show compassion and evaluate how family members are coping during the process and provide support and in-formation during and after resuscitation. Processes and outcomes do not seem to be negatively affected by FWR, even though there is some resistance to FWR among HCPs. These obstacles must be considered when planning for the implementation of FWR in daily practice. A short online educational video can be a way to improve the self-confidence and attitudes towards FWR among HCPs. This will likely result in increased compliance with national and local guidelines that recommend FWR.  

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. p. 119
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1871
Family witnessed resuscitation, Cardiac arrest, In-hospital, Attitudes, Self-confidence
National Category
urn:nbn:se:liu:diva-198794 (URN)10.3384/9789180753340 (DOI)9789180753333 (ISBN)9789180753340 (ISBN)
Public defence
2023-12-01, Hasselqvistsalen, building 511, Campus US, Linköping, 09:00 (Swedish)

2023-10-30: The thesis was first published online. The online published version reflects the printed version. 

2024-01-19: The thesis was updated with an errata list which is also downloadable from the DOI landing page. Before this date the PDF has been downloaded 409 times.

Available from: 2023-10-30 Created: 2023-10-30 Last updated: 2024-01-19Bibliographically approved
Waldemar, A., Bremer, A., Holm, A., Strömberg, A. & Thylén, I. (2021). In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: A retrospective observational cohort study. Resuscitation, 165, 23-30
Open this publication in new window or tab >>In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: A retrospective observational cohort study
Show others...
2021 (English)In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 165, p. 23-30Article in journal (Refereed) Published
Abstract [en]

Aim: International and national guidelines support in-hospital, family-witnessed resuscitation, provided that patients are not negatively affected. Empirical evidence regarding whether family presence interferes with resuscitation procedures is still scarce. The aim was to describe the prevalence and processes of family-witnessed resuscitation in hospitalised adult patients, and to investigate associations between family-witnessed resuscitation and the outcomes of resuscitation. Methods: Nationwide observational cohort study based on data from the Swedish Registry of Cardiopulmonary Resuscitation. Results: In all, 3257 patients with sudden, in-hospital cardiac arrests were included. Of those, 395 had family on site (12%), of whom 186 (6%) remained at the scene. It was more common to offer family the option to stay during resuscitation if the cardiac arrest occurred in emergency departments, intensive-care units or cardiac-care units, compared to hospital wards (44% vs. 26%, p &lt; 0.001). It was also more common for a staff member to be assigned to take care of family in acute settings (68% vs. 56%, p = 0.017). Mean time from cardiac arrest to termination of resuscitation was longer in the presence of family (20.67 min vs. 17.49 min, p = 0.020), also when controlling for different patient and contextual covariates in a regression model (Stand (b) 0.039, p = 0.027). No differences were found between family-witnessed and non-family-witnessed resuscitation in survival immediately after resuscitation (57% vs. 53%, p = 0.291) or after 30 days (35% vs. 29%, p = 0.086). Conclusions: In-hospital, family-witnessed resuscitation is uncommon, but the processes and outcomes do not seem to be negatively affected, suggesting that staff should routinely invite family to witness resuscitation.

Place, publisher, year, edition, pages
In-hospital cardiac arrest; Cardiopulmonary resuscitation; Family-witnessed resuscitation; Family presence during resuscitation; Registry study
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
urn:nbn:se:liu:diva-178541 (URN)10.1016/j.resuscitation.2021.05.031 (DOI)000678542100007 ()34107335 (PubMedID)

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS); ALF Grants Region ostergotland; Region ostergotland; Astrid Janzon Foundation

Available from: 2021-08-24 Created: 2021-08-24 Last updated: 2023-10-30
Waldemar, A. & Thylén, I. (2019). Healthcare professionals experiences and attitudes towards family-witnessed resuscitation: A cross-sectional study. International Emergency Nursing, 42, 36-43
Open this publication in new window or tab >>Healthcare professionals experiences and attitudes towards family-witnessed resuscitation: A cross-sectional study
2019 (English)In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 42, p. 36-43Article in journal (Refereed) Published
Abstract [en]

Background: Family-witnessed resuscitation (FWR) offers the option for family to be present during a cardiac arrest, which has been proven to help them in their grieving process. International guidelines highlight the importance of FWR, but this has not yet been widely implemented in clinical practice in Europe. Aim: Explore nurses and physicians experiences and attitudes toward FWR in cardiac care units. Methods: Cross-sectional web-based multicentre survey study including the seven university hospitals in Sweden, with 189 participants. Results: The most common concern was that the resuscitation team may say things that are upsetting to the family member during resuscitation, with 68% agreeing with this statement. Physicians opposed FWR more strongly than nurses (3.22 vs. 2.93, p amp;lt; .001). Twenty-five percent stated that family should not be present during resuscitation, as it would be far too painful for them, while 23% of the nurses and 11% of the physicians considered that FWR is beneficial to the patient, p amp;lt; 0.001. There was strong agreement that there should always be a healthcare professional dedicated to take care of family (92%). None of the hospitals had local guidelines regarding FWR. Conclusion: Many concerns still exist in relation to FWR, suggesting that those barriers must be taken into consideration when planning for implementation of FWR in everyday practice.

Place, publisher, year, edition, pages
Attitudes; Cardiopulmonary resuscitation; Experiences; Family presence; Family-witnessed resuscitation; Healthcare professionals
National Category
urn:nbn:se:liu:diva-154328 (URN)10.1016/j.ienj.2018.05.009 (DOI)000455920300008 ()29887282 (PubMedID)

Funding Agencies|Linkoping University Hospital Research Fund

Available from: 2019-02-04 Created: 2019-02-04 Last updated: 2023-10-30

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