Decision making in resuscitation from out of hospital cardiac arrest

Knowledge, Attitude and Decision-making of Nurses in the Resuscitation Team towards Terminating Resuscitation and Do-not-Resuscitate Order

Background

Making appropriate decisions for cardiopulmonary resuscitation (CPR) is very challenging for healthcare providers. This study aimed to evaluate knowledge, attitude, and decision making about do-not-resuscitate (DNR) and termination of resuscitation (ToR) among nurses in the resuscitation team.

Methods

This descriptive cross-sectional study was conducted in April-September 2020. Participants were 128 nurses from the CPR teams of two hospitals in Kermanshah and Hamedan, Iran. A valid and reliable researcher-made instrument was used for data collection. Data were analyzed using the Chi-square, Fisher's exact, and Mann-Whitney U tests, the Spearman's correlation analysis, and the logistic and rank regression analyses.

Results

Only 22.7% and 37.5% of participants had adequate knowledge about ToR and DNR. The significant predictor of DNR and ToR knowledge was educational level and the significant predictors of decision making for CPR were educational level, gender, and history of receiving CPR-related education (P<0.05). When facing a cardiac arrest and indication of DNR or ToR, 12.5% of participants reported that they would not start CPR, 21.5% of them reported that they would terminate CPR, and 14.8% of them reported that they would perform slow code. The DNR decision had significant relationship with educational level, DNR knowledge, and ToR knowledge (P< 0.05), while the ToR decision had significant relationship with educational level and ToR knowledge (P<0.05).

Conclusion

Nurses' limited DNR and ToR knowledge and physicians' conflicting orders and documentation can cause ethical challenges for nurses. Clear guidelines for DNR orders or TOR is necessary for nurses, in order to prevent any potential confusion, legal or psychosocial issues and concerns surrounding CPR and improve their involvement in CPR decision making process.

Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89-184.29), first monitored heart rhythm (3.07, 1.21-7.79 for PEA; 29.25, 1.93-442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87-0.97 per minute) and malignancy (0.22, 0.05-0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

Decision-making in cardiac arrest: physicians' and nurses' knowledge and views on terminating resuscitation

Introduction

Many cardiopulmonary resuscitation (CPR) attempts are unsuccessful and must be terminated. On the contrary, premature termination results in a self-fulfilling prophecy. This study aimed to investigate 1) physicians’ self-assessed competence in terminating CPR, 2) physicians’ and nurses’ knowledge of the European Resuscitation Council guidelines on termination, and 3) single factors leading to termination.

Methods

Questionnaires were distributed at advanced cardiac life support (ACLS) courses at a university hospital in Denmark. Participants included ACLS health care providers, ie, physicians and nurses from cardiac arrest teams, intensive care and anesthetic units or medical wards with a duty to provide ACLS. Physicians were divided into junior physicians (house officers) and experienced physicians (specialist registrars and consultants).

Results

Overall, 308 participants responded (104 physicians and 204 nurses, response rate: 98%). Among physicians, 37 (36%) did not feel competent to decide when to terminate CPR (junior physicians: n=16, 64%, compared with experienced physicians: n=21, 28%, P=0.002). Two (2%) physicians and one (0.5%) nurse were able to state the contents of termination guidelines. Several factors were reported to impact termination, including absence of a pupillary light reflex (physicians: 17%, nurses: 22%) and cardiac standstill on echocardiography (physicians: 18%, nurses: 20%). Moreover, nine (9%) physicians and 35 (17%) nurses would terminate prolonged CPR despite a shockable rhythm present.

Conclusion

One-third of all physicians did not feel competent to decide when to terminate CPR. Physicians’ and nurses’ knowledge of termination guidelines was poor, and both professions reported unvalidated or controversial factors as a single reason for terminating CPR.

Prehospital resuscitation practices: a survey of prehospital providers

Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.

Termination of resuscitation: the art of clinical decision making

Despite all of the progress in reanimating patients in cardiac arrest over the last half century, resuscitation attempts usually fail to restore spontaneous circulation. Thus, the most common of all resuscitation decisions after initiation remains the decision to stop. An entire library of research and guidelines for terminating resuscitative efforts has been developed in the past decade. However, this most central decision is often left open to chance, provider preference, family wishes, futility judgments, and resource concerns-a host of subjective considerations at the bedside and beyond. This article sheds light on these considerations, acknowledging the pivotal role that resuscitation science and guidelines can play in the multifactorial decision to discontinue resuscitative efforts.

Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital

OBJECTIVE

To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce 'life extinct' in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management.

DESIGN

Qualitative study involving semi structured interviews and a focus group.

SETTING

Accident & Emergency (A&E) departments in the Yorkshire region.

PARTICIPANTS

Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region.

RESULTS

Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues.

CONCLUSION

The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.

Resuscitation decision index: a new approach to decision-making in prehospital CPR

Retrospective and prospective studies have been undertaken to assess physicians' practice-patterns by studying cardiopulmonary resuscitation (CPR) case summaries. Most summaries reveal similar influences by the physician, patient and situation-related variables on the patterns of resuscitation. The initiation of resuscitation efforts is addressed frequently, but, very few studies discuss the topic of termination of resuscitation. Prehospital emergencies are addressed very rarely. The objective of this study was to introduce a new methodological approach towards initiation and termination of resuscitation efforts in prehospital situations. The subject studied were the physicians' decisions concerning initiation/withholding, termination/withdrawal and the resulting early survival rates. The result is termed the "Resuscitation decision index" (RDI). The "RDI" could be a tool allowing comparisons on a quantitative level, between different EMS systems or disciplines and giving an insight into the decision process. The "RDI" can enhance audit of resuscitation. The process of decision-making can be used to help future theoretical decision-making strategies.

Resuscitation in the A & E department: can concepts of death aid decision making?

The expectations of modern society may not recognize the limitations of technical medicine. This is particularly evident when considering the ethical problems faced by practitioners regarding the continuation or withdrawal of cardiopulmonary resuscitation within the Accident and Emergency department. This paper contends that concepts of death and our technical and cultural understanding of these must be more clearly defined and may then assist in the process of decision making. Clarifying our understanding of death, which is relevant to this clinical environment, provides us with a realistic goal for intervention. Heroic measures merely instill false hopes. A more precise delineation between cardiac arrest and death may then guide decision making, elaborate our clinical and moral perspectives on the situation and may ease the moral burdens of this complex and sensitive aspect of practice.