Termination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene

Abstract

BackgroundDiscussions on ethical aspects of life-and-death decisions within the hospital are often made in plenary. The prehospital physician, however, may be faced with ethical dilemmas in life-and-death decisions when time-critical decisions to initiate or refrain from resuscitative efforts need to be taken without the possibility to discuss matters with colleagues. Little is known whether these considerations regarding ethical issues in crucial life-and-death decisions are documented prehospitally. This is a review of the ethical considerations documented in the prehospital medical records of patients in a Danish prehospital setting for whom the decision to resuscitate or not was made at the scene.MethodsThe study is based on discharge summaries of all patients subjected to crucial life-and-death decisions by the Mobile Emergency Care Unit in Odense in the years 2010 to 2014. The medical records with possible documentation of ethical issues were independently reviewed by two philosophers in order to identify explicit ethical or philosophical considerations pertaining to the decision to resuscitate or not.ResultsIn total, 1275 patients were either declared dead at the scene without exhibiting layman’s reliable signs of death or admitted to hospital following resuscitation.In a total of 62 patients, 85 specific ethical issues related to resuscitation were documented. The expressions of the ethical considerations were generally vague or unclear and almost exclusively concerned the interests of the patient and not the relatives. In the vast majority of cases where an ethical content was identified, the ethical considerations led to a decision to terminate treatment.ConclusionsA strengthened practice of documenting ethical considerations in prehospital life-and-death decision-making in the patient’s medical records is required. We suggest that a template be implemented in the prehospital medical records describing the basis for any ethical decisions. This template should contain information regarding the persons involved in the deliberations and notes on ethical considerations. The documentation should include considerations concerning the patient’s end-of-life wishes, the estimations of the quality of life before and after the incident, and a summary of other ethical concerns taken into account, such as the integrity of the patient and frame of mind of relatives.

External validation of multimodal termination of resuscitation rules for out-of-hospital cardiac arrest patients in the COVID-19 era

“…As of September 2020, more than 20,000 people have been con rmed to have COVID-19 in South Korea, and 385 of these patients have died. In addition, more than 50% of these cases were in Daegu, the area of interest in this study, and its neighboring area Gyeongbuk [10]. Further, more than 130 healthcare workers and medical staff have been infected.…”

“…Accordingly, recent cardiopulmonary resuscitation (CPR) guidelines were changed to recommend that all healthcare providers assess the safety of the scene and wear higher levels of PPE for protection against infectious airborne droplets and detailing the criteria for the basic life support termination of resuscitation (BLS-TOR) rule. These guidelines stipulate that before terminating resuscitative efforts, the healthcare workers must check that (1) the arrest was not witnessed by emergency medical service (EMS) personnel or a rst responder, (2) ROSC was not observed prior to the patient being transported to the emergency medical center (EMC), and (3) no electrical shocks were delivered [7][8][9][10][11][12][13][14].…”

Clinical Investigations External Validation of Multimodal Termination of Resuscitation Rules for Out-of-hospital Cardiac Arrest Patients in the Covid-19 Era

“…Gyeongbuk, the neighboring area [10].More than 130 cases of infected healthcare workers and medical staff have been reported.One physician died while treating two con rmed patients.…”

“…Fortunately, recent cardiopulmonary resuscitation (CPR) guidelineswere changed, recommendingthat all healthcare providers assess the safety of the scene and wear higher levels of PPE for protection against infectious airborne dropletsand detailing the criteria for the basic life support termination of resuscitation (BLS-TOR) rule. These guidelines stated that before terminating resuscitative efforts, the healthcare workers must check that 1) the arrest was not witnessed byemergency medical service (EMS) personnel or a rst responder,2)ROSC was not observed prior to the patient being transported to the emergency medical centre (EMC), and 3) no electrical shocks were delivered [7][8][9][10][11][12][13][14].…”

Quantitative pupillometry and neuron-specific enolase independently predict return of spontaneous circulation following cardiogenic out-of-hospital cardiac arrest: a prospective pilot study

“…In this context, the TOR decision for patients with OHCA remains a major challenge 12 because of the related medical, legal, and ethical issues. Recent guidelines have provided recommendations and frameworks for guiding the TOR decision, with the National Association of EMS Physicians suggesting that resuscitative efforts could be terminated for patients who have not responded after 20 min of Advanced Cardiac Life Support (ACLS) 13 .…”