To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study

Abstract

Background: If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene.Purpose: To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene.Methods: Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene.Results: In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization. Conclusion:In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.

Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review

“…The included papers contained data from 25 unique studies. Of these papers, 12 were qualitative studies [ 5 , 8 , 22 – 31 ], two mixed-method studies [ 32 , 33 ], and 13 quantitative studies [ 34 – 46 ]. The papers were published between 1993 and 2021.…”

“…allowing the patient to “die with dignity”) in a system, where EMTs were not allowed to terminate resuscitation [ 44 ] Patient’s wishes QUAL Lack of DNACPR [ 28 ] Presence of DNACPR [ 23 ] The patient’s wishes were absent from many participants decision-making processes [ 22 ] QUAN 95% (n = 223) of paramedics believed “strongly” or “somewhat” that prehospital providers should honour written ADs in the field [ 45 ] About 74.5% (n = 320) would not resuscitate a dying patient who has an advance directive or DNACPR order, were they given legal certainty. [ 39 ] 73.7% (n = 176) felt confident when there was a DNACPR order, and they did not initiate resuscitation [ 33 ] 48.8% (n = 481) would not start CPR in the presence of DNACPR orders as presented by the family [ 42 ] 43% (n = 99) of PRPs would perform CPR instead of wasting time to locate a DNACPR [ 43 ] 1% (n = 4) mentioned the availability of a living-will declaration or the presumed will to live in additional free-text answers [ 41 ] Patient’s best interests QUAL Giving the patient “the benefit of the doubt” [ 23 ] Perceiving termination to be “the patient’s best interests” [ 30 ] Evaluating the patient’s best interests [ 22 ] Involving of and involvement by bystanders and family members Family wishes and emotions Family wishes QUAL Begging and pleading for continuation [ 24 , 29 ] Family religion dictating continuation [ ...…”

“…(P = 0.06), "Would you resuscitate a patient who holds an advanced directive that clearly states he/she does not want to be resuscitated?" (P = 0.64) [ 39 ] No association between perception of appropriate CPR and religiosity (p = 0.61) [ 34 ] Fear of consequences QUAL Fear of legal issues or criticism [ 23 , 29 , 32 ] Official complaints [ 27 ] Fear of working outside practice guidelines [ 28 ] QUAN Fear of legal issues or criticism [ 39 ] Fear of legal issues or criticism [ 44 ] Team interaction Team interaction QUAL When team members had conflicting opinions, the opinion to transport generally prevailed over the opinion to terminate on-scene [ 5 , 32 ] Consulting with a superior [ 27 ] Getting advice from others [ 22 ] Team agreement may influence decision-making [ 26 ] Consulting with a superior [ 23 , 30 , 32 ] Crew composition [ 23 ] Being influenced by external factors EMS work environment Emergency Medical System QUAL The reputation of the EMS system [ 31 ] System-related pressure to save lives no matter what [ 30 ] Organizational support [ ...…”

“…Patient age formed a part of the decision-making [ 41 ]. In younger patients, some providers would almost always perform resuscitation [ 42 ] and continue resuscitation for longer [ 8 , 27 , 29 , 31 , 32 ]. Old age in itself was not described as a reason to cease treatment, but young age was reported to be a reason to initiate resuscitation [ 29 ] and treat the patient more aggressively [ 31 ].…”

“…The patient’s family and their wishes, emotions, and/or expectations could pressure providers to the initiation, continuation [ 24 , 29 , 30 , 32 ], and termination [ 29 ] of resuscitation. Some providers mentioned that the family’s religion could lead to pressure to continue obviously futile resuscitation when according to the religious beliefs, everything possible had to be done including transportation to the hospital [ 32 ]. In cases where the family wished for termination, the providers described the family as expressing fear of suffering or a permanent vegetative state for the patient [ 29 ].…”