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Family presence during Cardiopulmonary Resuscitation in the Covid-19 Era

      Family presence during adult resuscitation (FPDR) has been empirically shown to be beneficial for patients, families and healthcare workers,
      • Jabre P.
      • Tazarourte K.
      • Azoulay E.
      • et al.
      Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment.
      and the bioethics literature normatively supports it.
      • Lederman Z.
      • Baird G.
      • Dong C.
      • Leong B.S.H.
      • Pal R.Y.
      Attitudes of Singapore Emergency Department staff towards family presence during cardiopulmonary resuscitation.
      • Lederman Z.
      Family for life and death: family presence during cardiopulmonary resuscitation.
      • Lederman Z.
      Family presence during cardiopulmonary resuscitation.
      • Lederman Z.
      • Garasic M.
      • Piperberg M.
      Family presence during cardiopulmonary resuscitation: who should decide?.
      • Lederman Z.
      Family presence during resuscitation-evidence based guidelines?.
      • Vincent C.
      • Lederman Z.
      Family presence during resuscitation: extending ethical norms from paediatrics to adults.
      But what about FPDR for patients sick with Covid-19?
      The main two arguments supporting FPDR are the patients’ autonomy and beneficence toward patients and relatives. Social media is replete with reports of persons lamenting that they could not be with their loved ones in their last moments. Similarly, authors have emphasized the importance of palliative care during the outbreak,
      • Wakam G.K.
      • Montgomery J.R.
      • Biesterveld B.E.
      • Brown C.S.
      Not dying alone — modern compassionate care in the covid-19 pandemic.
      and FPDR could be seen as palliative care in the ED
      • Lederman Z.
      • Baird G.
      • Dong C.
      • Leong B.S.H.
      • Pal R.Y.
      Attitudes of Singapore Emergency Department staff towards family presence during cardiopulmonary resuscitation.
      and other departments.
      One common argument against FPDR is the risk to families, as witnessing CPR may be emotionally traumatic. This argument has scarce empirical support.
      • Compton S.
      • Grace H.
      • Madgy A.
      • Swor R.A.
      Post-traumatic stress disorder symptomology associated with witnessing unsuccessful out-of-hospital cardiopulmonary resuscitation.
      However, FPDR for patients sick with Covid-19 necessarily pose a greater risk to relatives, as they may become infected as well. Further, FPDR for patients with Covid-19 may pose an increase risk to public health, as relatives may become contagious and/or require additional public resources thus increasing the burden on healthcare systems.
      How can we then balance the risks and benefits associated with FPDR in the era of Covid-19?
      First, smart phones and mobile computers could substitute human touch. This would allow some companion for the dying patient and some closure for relatives, while not exposing them to risk. This solution is obviously the easiest to justify and implement, requiring only the staff's collaboration and access to technology.
      A second solution may be to allow relatives to be present in the same room, and even to touch their loved ones. This is more likely to optimize the beneficial aspects of FPDR for both families and patients. Conversely, this will clearly increase the risk for relatives who are not already immune to the virus as well for the public health. A policy could however be put in place to mitigate these risks. Until vaccines become available, relatives may be asked to self-quarantine as a condition be present during CPR. This would at least reduce the risk to public health. With a reduced risk and thus burden on public, relatives could then make a value judgment that they alone can and should make- do the potential benefits of accompanying their loved ones during the last moments of their lives justify the risk to their own health?
      A third solution for loneliness at deathbed could be having the patients’ pets to accompany the dying. Other than a few cases of Covid-19 infection in felines and canines in Hong Kong, Belgium and New York City, pet dogs and cats seem to be immune to the virus and to not shed it further. Unless we come to learn otherwise, they may provide the last warm touch for patients dying of Covid-19. Pets provide solace for loneliness among the living,
      • Powell L.
      • Edwards K.M.
      • McGreevy P.
      • et al.
      Companion dog acquisition and mental well-being: a community-based three-arm controlled study.
      and there is no reason why they should not do so among the dying. These animals could be closely monitored and not be allowed to come in contact with other patients in case of any health concerns.

      Conflicts of interest

      The author declares no conflicts of interest.

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