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

Perception of Personal Participation of the Nurses in Resuscitation Procedures: A Qualitative Study

Background and Objectives: Resuscitation is one of the most stressful tasks in emergency medicine. The participation of nurses in this procedure can have specific effects on them. In this research, we wanted to find out what these effects are. Materials and Methods: A qualitative approach by conducting semi-structured interviews was used, and a thematic data analysis of the recorded interviews was carried out. The collected data were transcribed verbatim, with no corrections to the audio recordings. The computer program ATLAS.ti 22 was used for the qualitative data analysis. Results: Eleven male registered nurses were interviewed, with an average of 18.5 years of experience working in a prehospital environment (max. 32/min. 9). A total of 404 min of recordings were analyzed, and 789 codes were found, which were combined into 36 patterns and 11 themes. As the most stressful situations, the interviewees pointed out the resuscitation of a child, familiar persons, conflicts with the environment, conflicts within the resuscitation team, nonfunctioning or insufficient equipment, complications during resuscitation, and resuscitating a person only for training. As positive effects, the interviewees cited successful resuscitations or their awareness that, despite an unsuccessful resuscitation, they did everything they could. Conclusions: Participation in these interventions has a specific positive or negative impact on the performers. The interviewees shared the opinion that they can cope effectively with the adverse or stressful effects of resuscitation. Yet, despite everything, they allow the possibility of subconscious influences of this intervention on themselves.

The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review

BACKGROUND

Cardiac arrest in hospital and out-of-hospital settings is associated with high mortality rates. Therefore, a bedside test that can predict resuscitation outcomes of cardiac arrest patients is of great value. Point-of-care ultrasound (POCUS) has the potential to be used as an effective diagnostic and prognostic tool during cardiac arrest, particularly in observing the presence or absence of cardiac activity. However, it is highly susceptible to "self-fulfilling prophecy" and is associated with prolonged cardiopulmonary resuscitation (CPR), which negatively impacts the survival rates of cardiac arrest patients. As a result, the current systematic review was created to assess the role of POCUS in predicting the clinical outcomes associated with out-of-hospital and in-hospital cardiac arrests.

METHODS

The search for scientific articles related to our study was done either through an electronic database search (i.e., PubMed, Medline, ScienceDirect, Embase, and Google Scholar) or manually going through the reference list of the relevant articles. A quality appraisal was also carried out with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2), and the prognostic test performance (sensitivity and sensitivity) was tabulated.

RESULTS

The search criteria yielded 3984 articles related to our topic, of which only 22 were eligible for inclusion. After reviewing the literature, we noticed a wide variation in the definition of cardiac activity, and the statistical heterogeneity was high; therefore, we could not carry out meta-analyses. The tabulated clinical outcomes based on initial cardiac rhythm and definitions of cardiac activity showed highly inconsistent results.

CONCLUSION

POCUS has the potential to provide valuable information on the management of cardiac arrest patients; however, it should not be used as the sole predictor for the termination of resuscitation efforts.

Nurses' experiences of ethical and legal issues in post-resuscitation care: A qualitative content analysis

BACKGROUND

Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care.

OBJECTIVE

To explore nurses' experiences of ethical and legal issues in post-resuscitation care.

RESEARCH DESIGN

This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were analyzed by conventional content analysis.

ETHICAL CONSIDERATIONS

The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected.

FINDINGS

Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care.

CONCLUSION

There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges.

Pre-arrest Prediction of Survival Following In-hospital Cardiac Arrest: A Systematic Review of Diagnostic Test Accuracy Studies

AIM

To evaluate the test accuracy of pre-arrest clinical decision tools for in-hospital cardiac arrest survival outcomes.

METHODS

We searched Medline, Embase, and Cochrane Library from inception through January 2022 for randomized and non-randomized studies. We used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We report sensitivity, specificity, positive predictive outcome, and negative predictive outcome for prediction of survival outcomes. PROSPERO CRD42021268005.

RESULTS

We searched 2517 studies and included 23 studies using 13 different scores: 12 studies investigating 8 different scores assessing survival outcomes and 11 studies using 5 different scores to predict neurological outcomes. All were historical cohorts/ case control designs including adults only. Test accuracy for each score varied greatly. Across the 12 studies investigating 8 different scores assessing survival to hospital discharge/ 30-day survival, the negative predictive values (NPVs) for the prediction of survival varied from 55.6% to 100%. The GO-FAR score was evaluated in 7 studies with NPVs for survival with cerebral performance category (CPC) 1 ranging from 95.0% to 99.2%. Two scores assessed survival with CPC ≤2 and these were not externally validated. Across all prediction scores, certainty of evidence was rated as very low.

CONCLUSIONS

We identified very low certainty evidence across 23 studies for 13 different pre-arrest prediction scores to outcome following IHCA. No score was sufficiently reliable to support its use in clinical practice. We identified no evidence for children.

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation

BACKGROUND

In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores.

METHODS

The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades.

RESULTS

Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047).

CONCLUSIONS

In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.

High-performance work systems, multiple commitments, and knowledge exchange and combination among Chinese public hospital nurses

AIM

This research explores and examines the differentiated mediation roles of multi-foci commitment in the relationship between HPWS and knowledge exchange and combination among Chinese hospital nurses.

DESIGN

This study employs a quantitative research approach and survey design.

METHODS

Individual-level time-lagged data were collected from 845 nurses in public hospitals in China using online questionnaires. Aside from personal information, the items in the questionnaires were adopted from mature scales in previous research.

RESULTS

The results of multiple regression analysis demonstrate that nurses' professional and affective commitments partially mediate the relationship between HPWS and KEC. Nurses' continuance commitment does not play a mediation role in HPWS-KEC relationship, although HPWS positively influences nurse continuance commitment, which then weakly and positively impacts KEC.

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.

[Ad hoc ethical decision-making in clinical acute and emergency medicine : Position paper of the Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]

Decisions with considerable medical and ethical implications are made in emergency departments every day. Despite time pressure and high workloads, they have to be arrived at in an expert manner in all dimensions. For immediate ethical decisions, structuring the decision-making process in the form of standard procedures can be helpful, provided that they are trained and practiced in an interdisciplinary and interprofessional manner. The support for ad hoc ethical decisions presented here recommends an "ethical team time out" for the evaluation of treatment choices, in a framework where the patient's will and medical indication are examined and completed in a structured manner. Further experts (ideally, an ad hoc clinical ethics consultation) should be consulted if the treatment measure is of questionable medical benefit and/or of questionable patient consent.

Exploring the Feelings of Nurses during Resuscitation—A Cross-Sectional Study

Cardiopulmonary resuscitation (CPR) is one of the most stressful situations in emergency medicine. Nurses involved in performing basic and advanced resuscitation procedures are therefore exposed to a certain amount of stress. The purpose of this study was to determine the stressors and the level of stress experienced by nurses during resuscitation. A cross-sectional quantitative study was done. The sample consisted of 457 nurses who worked in emergency units. First demographic data were collected, followed by a questionnaire regarding the effect of different situations that occur during and after resuscitation on nurses including Post-Code Stress Scale questionnaire. The most disturbing situations for respondents were resuscitation of young person (MV = 3.7, SD = 1.4), when they fail to establish an intravenous pathway (MV = 3.5, SD = 1.4), chaotic situation during resuscitation (MV = 3.4, SD = 1.4) and making decision about termination of resuscitation (MV = 3.1, SD = 1.5). Research has shown that nurses are exposed to a certain amount of stress during resuscitation, but most of them manage to compensate for stress effectively.

What are the care needs of families experiencing cardiac arrest?: A survivor and family led scoping review

AIM

The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, "What are the needs of families experiencing cardiac arrest?" from the moment of collapse until the outcome is known.

METHODS

This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information.

RESULTS

We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest.

CONCLUSION

Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Analyzing the operational conditions of crash carts in clinical and surgical hospitalization units

OBJECTIVE

To evaluate the operational conditions of crash carts in all clinical and surgical hospitalization units of public hospitals in a region in Southern Brazil.

METHOD

Quantitative, cross-sectional study to evaluate crash carts in adult clinical and surgical hospitalization units. The data were collected through a checklist containing 16 continuous variables.

RESULTS

Nineteen crash carts in nineteen units were evaluated. Analysis shows that the most frequent problems were excess of equipment and its lack of organization, medication in incorrect compartments and/or with no identification, and inappropriate environment for transportation.

CONCLUSION

The most relevant factors that possibly interfere with the operational conditions of crash carts are directly related to the organization and management of material resources, which may lead to the reduction of its functionality during patient care. Such problem may be solved by readjusting items and performing frequent verification.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Clinical decision rules for termination of resuscitation during in-hospital cardiac arrest: A systematic review of diagnostic test accuracy studies

AIM

To assess whether any clinical decision rule for patients sustaining an in-hospital cardiac arrest (IHCA) can predict mortality or survival with poor neurological outcome.

METHODS

We searched online databases from inception through July 2020 for randomized controlled trials and non-randomized studies. Two reviewers assessed studies for inclusion. We followed PRISMA guidelines for Diagnostic Test Accuracy Studies, used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We assessed predictive values for no return of spontaneous circulation (ROSC), death before hospital discharge, and survival with unfavorable neurological outcome.

RESULTS

Out of 6436 studies, 92 studies were selected for full-text screening. We included 3 observational studies describing the derivation and external validation for the UN10 rule (Unwitnessed arrest; Nonshockable rhythm; 10 min of resuscitation without ROSC) amongst patients suffering from IHCA. No studies were identified for clinical implementation. Positive Predicted Values (PPV) for death before hospital discharge for the three studies were 100% (95% CI: 97.1%-100%), 98.9% (95% CI: 96.5%-99.7%), and 93.7% (95% CI: 93.3%-94.0%). One study reported a PPV for prediction of survival with unfavorable neurological outcome, 95.2% (95% CI: 94.9%-95.6%). The level of evidence was rated as very low certainty.

CONCLUSIONS

We identified very low certainty evidence for one clinical decision rule (the UN-10 rule) that was unable to reliably predict mortality or survival with unfavorable neurological outcome for adults suffering from IHCA. We identified no evidence for children. PROSPERO CRD42020164091.

Factors associated with prolonged cardiopulmonary resuscitation attempts in out-of-hospital cardiac arrest patients presenting to the emergency department

BACKGROUND

There is high variability among clinicians' decision of appropriate cardiopulmonary resuscitation (CPR) duration before deciding for termination of resuscitation. This study attempted to investigate factors associated with the decision to prolong resuscitation attempts in cardiac arrest patients treated in an emergencydepartment (ED).

METHODS

A retrospective study that evaluated two years of mortality registry starting in 2015 was conducted in the ED of University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia. Adult out-hospital cardiac arrest (OHCA) patients treated in the ED were included. Multivariate logistic regression analysis was utilized for the exploration of factors associated with prolonged CPR attempts (> 30min).

RESULTS

The median CPR duration was 24min (range 2-68min). Four variables were independently associated with prolonged CPR attempts: younger age (OR, 0.97; 95% CI, 0.95-0.99; p<0.001), pre-existing heart disease (OR, 1.97; 95% CI, 1.07-3.65; p=0.031), occurrence of transient return of spontaneous circulation (ROSC) (OR, 2.38; 95% CI, 1.05-5.36; p=0.037), and access to the ED by nonemergency medical services (EMS) transport (OR, 1.92; 95% CI, 1.09-3.37; p=0.024).

CONCLUSION

Patient-related and access-related factors were associated with prolonged CPR attempts among OHCA patients resuscitated in the ED.

Identifying out-of-hospital cardiac arrest patients with no chance of survival: An independent validation of prediction rules

BACKGROUND

The Basic life support (BLS) and Advanced life support (ALS) are known prediction rules for termination of resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA). Recently, a new rule was developed by Jabre et al. We aimed to independently validate and compare the predictive accuracy of these rules.

METHODS

OHCA cases in Iceland from 2008 to 2017 from a population-based, prospectively registered database. Primary outcome was survival to discharge among patients that met all conditions of abovementioned rules: BLS (not witnessed by EMS personnel, no defibrillation nor ROSC before transport), ALS (BLS criteria plus not witnessed nor CPR by bystander) and Jabre (not witnessed by EMS personnel, initial rhythm non-shockable, no sustainable ROSC before third dose of adrenaline).

RESULTS

Overall, 568 OHCA patients were included in validation of TOR rules. Mean age 67, males 74%, witnessed by EMS 11%, by bystander 66% that attempted CPR in 50%, transported to hospital 60%, overall survival 20%. All rules had high specificity for mortality, 99.6-100% (95%CI 95-100). The Jabre and BLS rules had similar sensitivity 47% (43-52) vs. 44% (40-49), respectively, the sensitivity of ALS was lower, 8% (5-11). Combined use of positive BLS and Jabre rules performed the best, identifying 88/226 (39%) of futile cases transported to hospital, specificity 100% (97-100) and sensitivity 59% (55-64).

CONCLUSIONS

The accuracy of the BLS and Jabre TOR rules to predict mortality after OHCA is very good and their combined use may be superior to the use of either one.