The reported chance of return to spontaneous circulation in small animals after cardiopulmonary arrest is between 35% and 45%; however, the reported rate of survival to hospital discharge for these patients is only 2% to 10%.1 Similarly in human medicine, the reported rate of survival to hospital discharge after CPR for an out-of-hospital cardiopulmonary arrest is 0% to 25%.2–4 Because of the high risk of death associated with cardiopulmonary arrest even when CPR is performed, a growing movement in human medicine has been not to focus solely on the patient, but to instead provide support for the family and to permit families to be present during resuscitative efforts (CPR and invasive procedures) for loved ones. This differs from the traditional discouragement or prohibition of families from witnessing resuscitative efforts in human health-care and veterinary medicine settings.
Although opinions on owner-witnessed CPR events in veterinary medicine may parallel those on FWR events in human medicine, there has been a lack of information about owner-witnessed CPR in the veterinary literature. The objectives of the study reported here were to determine opinions of veterinary emergency health-care providers on the topic of owner-witnessed CPR in small animal emergency veterinary medicine and to identify reasons for opposition or support of allowing owners to witness CPR of their pets. We anticipated that our findings would parallel findings on FWR in human health care.
Materials and Methods
Data collection
A cross-sectional, internet-based survey completed by ACVECC and ECVECC diplomates and ACVECC residents as well as other emergency-care veterinarians and technicians was used to collect data on 22 questions (multiple-choice and open-ended formats) regarding respondent demographics, CPR experience, and opinions about owner-witnessed CPR (Supplementary Appendix S1, available at avmajournals.avma.org/doi/suppl/10.2460/javma.253.8.1032). The survey was in English and had been formatted through an online survey toola that allowed all responses and data collection to remain anonymous. At the time of the survey, the authors of the report presented here understood that the ECVECC was newly established (2014), all diplomates of the ECVECC at that point were also diplomates of the ACVECC, and the ECVECC did not yet have residents; therefore, participation in the survey was solicited through email distribution lists of the ACVECC diplomates and residents and by posts on social media pages of the ACVECCb and veterinary ECC professionalsc between August 14, 2016, and September 14, 2016.
Eligibility criteria for veterinarian respondents and veterinary technician respondents included active or past engagement in practice and willingness to answer the survey. Respondents were categorized with the professional role as “other” if they described their role in another aspect of veterinary medicine, such as “veterinary technician and current practice manager.” There were no mandatory questions in the survey, and consent to participate was implied by completion of the survey. No remuneration or gifts were given for completing the survey. The study protocol was reviewed by the Tufts University Institutional Review Board Committee (protocol No. 12301).
Statistical analysis
Qualitative data analysis was performed to summarize the narrative survey results. In quantitative analyses, the χ2 likelihood ratio and Fisher exact tests were used to evaluate whether the frequency of responses differed among various groups of respondents for each question with a categorical response option. All analyses were performed with commercially available software,d and values of P < 0.05 were considered significant.
Results
Quantitative data analyses
Respondent demographics—A total of 359 surveys were completed; however, 1 was excluded from analyses because the respondent only answered demographic questions, but nothing further. Of the 358 remaining surveys, 203 (56.7%) were completed by veterinarians and 139 (38.8%) were completed by veterinary technicians (Table 1). Another 16 of the 358 (4.5%) respondents self-categorized their professional role as other, and from their comments were considered to have had combinations of jobs or multiple careers that involved ECC veterinary medicine and were therefore eligible for inclusion. Regarding gender, 287 of the 358 (80.2%) surveys were completed by females (female veterinarians, 146/358 [40.8%]; female technicians, 136/358 [38.0%]) and 67 (18.7%) surveys were completed by males (male veterinarians, 55/358 [15.4%]; male technicians, 21/358 [5.9%]). Four of the 358 (1.1%) respondents did not specify gender. Participants identified their ethnicity as White (n = 315 [88.0%]), Asian (14 [3.9%]), mixed (10 [2.8%]), Hispanic (9 [2.6%]), Black (2 [0.56%]), and other (2 [0.56%]). The remaining 6 of the 358 (1.7%) respondents selected the survey response to not report their ethnicity.
Demographic characteristics of small animal emergency-care veterinarian and technician respondents (n = 358) to an online survey regarding owner-witnessed CPR in small animal emergency medicine.
| Characteristic | No. (%) of respondents |
|---|---|
| Age (y) | |
| 20–30 | 88 (24.6) |
| 31–40 | 174 (48.6) |
| 41–50 | 69 (19.3) |
| > 51 | 27 (7.5) |
| Gender | |
| Male | 67 (18.7) |
| Female | 287 (80.2) |
| Not specified | 4 (1.1) |
| Experience (y) | |
| < 1 | 2 (0.6) |
| 1–3 | 36 (10.1) |
| 4–5 | 52 (14.5) |
| 6–10 | 95 (26.5) |
| 11–20 | 118 (33.0) |
| > 20 | 51 (14.2) |
| Not specified | 4 (1.1) |
| Professional role | |
| Veterinarian, emergency practice | 15 (4.2) |
| Veterinarian, ACVECC diplomate, including diplomate members of the ECVECC | 129 (36.0) |
| Veterinarian, ACVECC resident | 59 (16.5) |
| Veterinary technician specialist, ECC | 29 (8.1) |
| Veterinary technician, ECC | 86 (24.0) |
| Veterinary technician in primary care practice | 24 (6.7) |
| Other* | 16 (4.5) |
Included respondents who self-reported more than 1 role (eg, veterinary technician specialist ECC and practice manager).
No respondent skipped questions on ethnicity or job title. No significant differences were detected between responses provided by veterinarians and those provided by technicians. There were also no significant differences in responses on the basis of gender or ethnicity, although most respondents self-reported as White females.
All 358 respondents answered the questions on age and years of experience in the veterinary profession, for which categories were provided. The age category with the highest proportion of selection by respondents (174/358 [48.6%]) was 31 to 40 years old (Table 1), and the most common category selected for experience was 11 to 20 years (118/358 [33.0%]).
There were no significant overall differences among age groups in positive or negative responses regarding their feelings toward owner-witnessed CPR.
Experience with CPR of pets—Although 3 respondents did not report whether their practice had successfully discharged a patient alive after cardiopulmonary arrest and CPR, 312 of the remaining 355 (87.9%; 95% CI, 84.5% to 91.3%) respondents reported that their practice had done so. When asked about allowing owners to witness CPR on their pet, 277 of 356 (77.8%) respondents indicated that they opposed owner-witnessed CPR, with 150 (42.1%; 95% CI, 37.0% to 47.2%) respondents indicating they would discourage but allow it, and 127 (35.7%; 95% CI, 30.7% to 40.7%) indicating they would not permit owners to witness the CPR at all. However, 74 of the 356 (20.8%; 95% CI, 16.6% to 25.0%) respondents indicated they would allow the owners to decide for themselves, and 5 (1.4%; 95% CI, 0.2% to 2.6%) indicated they would encourage the owners to be present. The proportion of respondents willing to have an owner present during CPR was significantly (P = 0.004) greater for respondents with > 10 years of experience than for those with less experience. When asked whether owners were typically present during CPR at the respondent's practice, 191 of 355 (53.8%; 95% CI, 48.6% to 59.0%) respondents reported that their practices did not typically allow pet owners to be present during CPR, whereas fewer reported that owners were rarely present (153 [43.1%]; 95% CI, 37.9% to 48.3%) or typically present (11 [3.1%]; 95% CI, 1.3% to 2.6%).
Potential impacts of owner presence on CPR of pets—When the 11 respondents who reported that owners were typically present during resuscitation were asked whether owner presence would negatively impact the performance of CPR, 9 responded. None reported that they thought that an owner's presence would negatively impact the performance of CPR; however, 4 of these 9 reported that they thought that an owner's presence would have a positive impact on the performance of CPR. In contrast, when the same question was posed to the 191 respondents from practices that did not allow owner presence during CPR, significantly (P < 0.001) more respondents (86/190 [45.3%]; 95% CI, 38.6% to 52.8%) indicated they thought that an owner's presence would have a negative impact on the performance of CPR, compared with only 10 (5.3%; 95% CI, 2.1% to 8.5%I) respondents who indicated that they thought that an owner's presence would have a positive effect on the performance of CPR. In addition, several respondents reported interference from pet owners present during resuscitation efforts, which they perceived as potentially upsetting to the clinical team.
Emotional support for owners during CPR of their pets—When asked whether respondents would feel comfortable providing emotional support to owners witnessing CPR, 252 of 358 (70.4%; 95% CI, 65.7% to 75.1%) respondents indicated yes, 64 (17.9%; 95% CI, 13.9% to 21.9%) indicated no, and 42 (11.7%; 95% CI, 8.4% to 15.0%) indicated that they were unsure. Respondents from practices that typically allowed owners present during CPR were significantly (P = 0.018) more likely to report that they would feel comfortable providing such emotional support (n = 11/11), compared with respondents from practices that typically did not allow owners present (126/191 [66.0%]; 95% CI, 59.3% to 72.7%).
Potential impacts on pet owners—When asked how an owner's presence during CPR of their pet would affect the owner emotionally, 201 of 351 (57.3%; 95% CI, 52.1% to 62.5%) respondents reported that they thought it would be harmful; however, 118 (33.6%; 95% CI, 28.7% to 38.5%) reported uncertainty, 28 (8.0%; 95% CI, 5.2% to 10.8%) reported it would be beneficial, and 4 (1.1%; 95% CI, 0.0% to 2.0%) reported they did not think it would have any effect on the owner's emotions. Respondents from practices that typically had owners present during CPR were significantly (P = 0.001) more likely to answer that being present would benefit an owner's emotional status (n = 5/11 [45%]) than were respondents from practices that did not allow owners to be present (7/191 [3.7%]).
In contrast, when the respondents were asked whether they would like to be present for CPR efforts performed on their own pet, 162 of 355 (45.6%; 95% CI, 40.4% to 50.8%) respondents reported that it would depend on the situation, whereas 73 (20.6%; 95% CI, 16.4% to 24.8%) reported that they would like to be present, 65 (18.3%; 95% CI, 14.3% to 22.3%) reported that they would not resuscitate their pets, and 55 (15.5%; 95% CI, 11.7% to 19.3%) reported they would not like to be present. Three respondents skipped this question. When asked about their feelings regarding a professional colleague's presence during CPR efforts on the colleague's pet, 236 of 358 (65.9%; 95% CI, 61.0% to 70.8%) respondents indicated it was their colleague's choice, 73 (20.4%; 95% CI, 16.2% to 24.6%) indicated they would not mind their colleague being present but preferred them to not be present, 28 (7.8%; 95% CI, 5.0% to 10.6%) indicated they did not want their colleague present at all, and 21 (5.9%; 95% CI, 3.5% to 8.3%) indicated that they would like their colleague present.
Qualitative data analysis
Respondents' comments revealed that the presence of many owners during CPR resulted from the pet arresting in their presence or from owners' insistence on being present. In addition, responses to open-ended questions in the survey conveyed various impressions, positive and negative, of the 49 respondents who provided written responses regarding their experiences during owner-witnessed CPR. Illustrative quotations from respondents were compiled (Table 2). Common themes included concerns about the performance of CPR and the emotional effects on owners and staff. Comments included concerns that the owners' last visions or memory of their pets would be of them undergoing CPR, which could be difficult to watch, and respondents questioned whether owners would be psychologically prepared for the situation or what CPR actually entails. A few respondents suggested that owners should be allowed to be present only after intubation and catheterization had been achieved. Other, yet fewer, responses described more favorable outcomes with owner-witnessed CPR.
Examples of written-in answers provided by 49 respondents of Table 1 for their experiences with the presence of owners during CPR on pets.
| Positive | Negative |
|---|---|
| Oddly, the few owners who are present at the time of CPR are the most thankful to the staff for all that they do and understand how hard it is on them. | The few times I have been in this situation, it was very traumatic for the owner. |
| I have had only good experiences with this. Owners rarely interrupt/intervene and feel more comfortable watching the team work and knowing that they are in their pet's presence. I strongly urge people to consider this, as they have done in human medicine. | I have experienced owners being present for CPR more than a handful of times. It is distracting for the team, and the owners tend to want to touch the patient, which means we don't have complete access to the patient. It's also distracting to the doctor to work the code when the client is asking questions during the process |
| All owners who have been present during CPR know that we and they did everything that they could. | In the rare experiences when my [patients'] owners were present during CPR, I think it pushed them toward stopping CPR, as they perceived the efforts as invasive without response from their pet. The few times when an owner has been present at the time of arrest, their presence during CPR affected how the team communicated (eg, less verbalizing, more facial expressions and eye contact, and lower volume), and the owners typically are very distressed and require an additional team member, who could otherwise assist, to deal with them. |
| Owners who have been present seem to accept the death better and feel like they should be a part of their pets' final moments. They seem to appreciate being there and can know what happened and their imagination doesn't have to fill in the blanks. | I hate for clients to have this as a lasting memory of their pet. |
| Chest compressions can appear to be very violent, and I feel that is difficult for a client to watch. | |
| It [watching CPR] would leave the owner with a bad last memory. | |
| I don't think they're psychologically prepared for the true drama of the situation. | |
| Most owners are not prepared or educated regarding what CPR actually entails, and I think many would be traumatized by the reality of it. |
Discussion
Family-witnessed resuscitation and its positive impacts on human health care were, to the authors' knowledge, first described in results of a hospital survey5,6 administered to attending staff and family members after 2 families demanded and were allowed to be present during resuscitation efforts performed on their family members in 1982. Since then, organizations (eg, the American Heart Association and American College of Critical Care Medicine) have published statements3,5,7 in favor of FWR, but the topic has remained controversial.
Results of the present study indicated that most respondents were opposed to owner-witnessed CPR, a finding that paralleled opinions of human health-care providers on the topic of FWR.8 In addition, many concerns about FWR raised in human health-care studies8–14 are similar to those identified by respondents in the present study for owner-witnessed CPR, especially that owners could interrupt CPR, cause it to be performed less effectively, and distract the resuscitation team.
Opposition to FWR in human health care has involved concerns that interference or outburst from family members could negatively influence resuscitation effort outcomes,8–10 that FWR could increase the number of complaints and lawsuits,8,11 and that FWR could increase emotional and psychological trauma to the attending family members.8,9,11 In contrast, multiple studies have shown that FWR causes no delay in treatment,10,15,16 has a low to no incidence of family interference,8 is associated with < 1% of attending family members engaged in aggressive behavior with the medical team, and has resulted in no reported lawsuits.17 Further, when compared with family members who had been absent during CPR efforts, family members who had been present were better able to cope with the death,17,18 had fewer symptoms of posttraumatic stress disorder and anxiety,17 and seemed more satisfied with their experience and the commitment to their loved ones by the health-care team.19
Although several respondents in the present study reported interference from pet owners present during CPR efforts, the true incidence was unknown. In addition, recall bias may have contributed to respondents' negative perceptions because it was likely that a particularly dramatic event could have remained in a clinician's memory for a longer period than a peaceful experience. Observational studies are needed to assess the likelihood of interference from pet owners during owner-witnessed CPR.
Another finding of the present study was the concern that owner-witnessed CPR may cause psychological trauma to owners. This concern has been reported8,17 in human health care too. Comments from respondents regarding owner-witnessed CPR suggested that some reluctance to have owners present could have reflected respondents' fears of how CPR could appear to or be perceived by laypersons. This perception that owner-witnessed CPR could cause psychological trauma to owners was contrary to findings17,19 in human health care, although those findings were based on evaluations of family members only 3 to 6 months after the event. In a study20 on the impact of human health care FWR ≤ 1 year after the resuscitation event, posttraumatic stress symptoms, depression, and traumatic grief were less likely in people who participated in FWR than in those who did not.20 Future research should assess whether these findings are similar for pet owners who participate in owner-witnessed CPR of their pets.
In the present study, veterinary professionals with > 10 years of experience were more likely than those with less experience to allow owner-witnessed CPR. This could have been attributed to an increased level of confidence in handling owners and resuscitation efforts concurrently or to more experience with owner-witnessed CPR. Similarly, physicians who have had previous experience with FWR are reportedly more in favor of FWR15,21 than are physicians without such previous experience.22
Interestingly, results of the present study indicated that when the pet owner involved was a colleague, 65.9% of respondents reported that they felt it was a colleague's choice to be present for resuscitative efforts, compared with only 20.8% who favored owner's choice when the owner was not a colleague. In addition, only 7.8% of respondents would not allow a colleague to be present for CPR on their pet, compared with 35.7% who would not allow a noncolleague to be present for CPR on their pet. This difference could have been attributed to respondents' perception that veterinary professionals have more education on and awareness of the reality and outcomes of CPR. Education on FWR has been shown to increase support of FWR,23 and hospitals that have successfully implemented FWR programs have included education on FWR as part of staff training.15
Another key role in the success of FWR has been use of a designated family-support person, an individual dedicated to and accompanying the attending family members the entire time during a CPR event.7,12 The individual in this role explains and prepares the attending family members for what they are about to see. Then, when the support person leads the family to the treatment room, the support person helps answer any questions the attending family members may have and explains why and what is being done during the CPR event. This role could be filled by individuals with formal training in human emotional cues and behaviors (eg, a social worker or psychologist) or a designated staff member. Because of limited staffing in many veterinary practice settings, it could be difficult for practices to have a dedicated owner-support person, and that responsibility likely could fall to the veterinarian or technician managing the resuscitation efforts.
Results of the present study indicated that 87.9 % of respondents worked at a practice that had successfully discharged a patient alive after CPR, which supported that CPR was not always futile. On the basis of respondents' comments, the frequency of discharges following CPR appeared low. Such low numbers in this regard were consistent with prior reports in the veterinary literature.1
There were several limitations to the present study. First, a survey response rate could not be calculated because of the distribution method used. Therefore, skewing of data was possible because only responders with strong opinions for or against owner-witnessed CPR may have taken the time to complete the survey. The distribution method also limited our ability to obtain information on this topic from general practitioners. Although general practitioners could perform CPR, we believed that general practitioners would have had less experience with owner-witnessed CPR than would ECC veterinarians.
Second, no data about the geographic location of respondents were collected, whereas a study8 of human health-care providers showed a regional difference in support of FWR in the United States. Human health-care providers in the Midwest are more likely to support FWR, whereas those in the Northeast are more likely to oppose it.11,22 Regional differences could therefore be expected to exist in veterinary medicine.
Third, respondents in the present study were asked to recall any experience over the course of their career; therefore, recall bias may have influenced results. The validity of the results of the present study could change with future observational studies and with veterinary practice implementation of programs for owner-witnessed CPR, including identified owner-support persons.
In conclusion, results of the present study indicated that most emergency veterinary health-care providers surveyed were opposed to owner-witnessed CPR. These respondents appeared to have had concerns similar to those of human health-care providers regarding FWR, especially regarding the emotional and psychological effects on owners witnessing resuscitation. However, emotional benefits from FWR in human health care have been reported, and emotional impacts of owner-witnessed CPR could be an area of research in veterinary medicine. Investigation is needed to obtain more information about pet owner wishes regarding witnessing the performance of CPR on their pets.
Acknowledgments
No third-party funding or support was received in connection with this study or the writing or publication of the manuscript. The authors declare that there were no conflicts of interest.
ABBREVIATIONS
| ACVECC | American College of Veterinary Emergency and Critical Care |
| CI | Confidence interval |
| ECC | Emergency and critical care |
| ECVECC | European College of Veterinary Emergency and Critical Care |
| FWR | Family-witnessed resuscitation |
Footnotes
SurveyMonkey, San Mateo, Calif.
ACVECC Facebook page. Available at: www.facebook.com/pg/ACVECC/community/. Accessed Apr 7, 2016.
ER VET Tech Rounds. Available at: www.facebook.com/groups/ERVetTechRounds/. Accessed Apr 7, 2016.
SPSS Statistics, version 22.0, IBM Corp, Armonk, NY.
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