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

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Finally, the most relevant article with the most powerful study designs of RCT entitled as, “offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment” has been found. It is written by Jabre et al. (2014) (Appendix-J) and has been published in the Intensive Care Medicine Journal on May-14, volume 40 issue 7, from pages 981 to 987. This was a sequence of improvements from their first study (Jabre et al., 2013) which studied multiple psychological criterions towards relatives, patients and the PHC provider in a short-period times of three months. With the same methodological of studies, the selected article is only focussing the psychological impacts of relatives in a one-year periods. Therefore, apart from critically reading the selected article, I will also using their first trials as a guidance to acquire more information regarding their trials study.

Although the selected article has fulfilled all the requirements and criteria needed, I have realize that even with the use of RCT which considered as the “gold-standard” in conducting a research, it still has some flaws and imperfections (Walker, 2005). Thus, it is a necessity for readers to critically appraise all types of research-evidence to ensure the degree of quality, value and constancy on a certain parts of the study (Cullum, 2000). Despite numerous numbers of appraisal-tools guidance, I will be using the Critical Appraisal Skills Program (CASP) tools of RCT (Appendix-K) which consists 11-types of questionnaire. The selection was made due to the design of the questionnaires which developed specifically to evaluate the validity, reliability and generalizability to be implemented in my clinical practice. Furthermore, the concepts of the framework are much easier to use and to be understood especially for a beginner in the appraising techniques.

As been stated in the title and study-abstract, the authors was searching for an answer regarding the psychological-consequences which may arise among relatives as a result of offering them to be participates in the out-of-hospital CPR involving their loved-ones comparing with a normal practice of family management while the on-going procedure. Using multiple numbers of questionnaires, they will be assessed in a period of one-year after the treatment. Thus, by adopting five-elements of PICOT, they have successfully addressed all the focus issue in the trials.

Randomization is one of the important elements to be focussed in research due its capability to eliminate biases and it allows the usage of probability theory to articulate any possibilities as an origin for the dissimilarity of an end outcome (Suresh, 2011). Therefore, to acquire the valid outcomes of the treatments, all the populations-studied have been randomly allocated using a simple random sample techniques based on their equal chances to be selected in either of the treatments. It has been conducted by 15 Pre-Hospital emergency-medical services (SAMU) units which has randomly allocated in either of the groups at the early stages of the trials.

Nevertheless, it has not yet indicates the successfulness of a randomization process. According to Altman et al. (2001), the successfulness of a randomization is relied on two important sections of the unpredictable allocation arrangement and allocation concealment arrangement until the assignment appears. At this level, although it has proven that treatments to populations-studied have been randomized, it has also indicates that the allocation concealment was not attained because the SAMU team-members were aware on which groups of populations would be randomised to. From my opinions, this failure cannot be indicates as the main key for the unsuccessfulness of the trials because the SAMU team-members were only allowed to select participants based on their group allocations. Furthermore, as the authors has underlined the inclusion and exclusion criteria to guiding the selection of the population-studied has perceived as one of the techniques used by the authors to accommodates the flaws and minimizing selection and accidental biases.

In contrast, the authors have implicitly stated that they are using a single-blinded study in the trial. It is one of the blinding techniques where only one of either researchers or subject-studied have a knowledge of the group allocations (Schulz and Grimes, 2002). It was based on the descriptions which stated that in a one year period after the procedure, a trained psychologist who was uninformed to the group allocation will be collecting the outcomes of the study by interviewing all the participants in both of the groups using a number of structured-questionnaires through a phone call. Those who are not picking-up the call after 15 times of trial will be classified as unreachable. The adoption of the techniques is considered as one of the main strength of the trial because as the assessors are unaware of the group allocation, it helps to reduce an interviewer bias while the data collection. Simultaneously, it has also shown that each of the subject-studied in both groups has been treated in a same manner by the assessors. Therefore, the authors has successfully eliminates the experimenter bias and enhanced the validity of the study.

Theoretically, all the subjects-studied in the RCT-design was aiming to accomplish the assignment trials so they can be analysed based on the group allocations. However, it has always being affected by refusal and absents which primarily causes by their failure to adapt with the treatments received and decided to withdraw while the on-going process (Gupta, 2011). As happened in the trial, a risk of attrition bias has been identified when a total of 56.4% from both intervention-group (25.5%) and control-group (30.9%) did not complete the assessments according as plans. Accordingly, it will causes an imbalance in the randomize groups and it might generates either overestimation or underestimations of both benefits and weakness of the outcomes.

Nevertheless, as they are using an intention-to-treat analysis (ITT), it has proven that each of the subject-studied has been analysed based on their original allocations. These analysis will assures that the strength of randomization are preserved by analysing the subject-studied based on their original group allocation although in the middle of the trials they have either changing the intervention received or completely withdrawal from the trials. It is proven in the “figure 1” when they have stating the “N =” at the top of the diagram which indicates their compliance with their ITT plans.

At the end of the trials, it is found that all the results have reflected the primary and secondary variable outcomes without any shenanigan activity have been detected.