From: Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review
Themes and subthemes | Non-medical factors influencing initiation/continuation of resuscitationa | Non-medical factors influencing withhold/termination of resuscitationa | Non-medical factors influencing decision-making non-specificallya | Non-medical factors explicitly mentioned as NOT influencing decision-makinga | ||
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Applying patient-related factors | ||||||
Patient characteristics | Age | QUAL | ||||
QUAN | 28.8% (n = 288) would almost always perform CPR on the young patient [42] | Perception of inappropriate CPR was significantly higher for cardiac arrests in patients older than 79 years of age (OR = 2.9 [95% CI 2.18–3.96]; P < .0001) [34] | Age in general [41] | |||
Social status | QUAL | Low social value if treated by a novice PRP (for practice purposes) [31] | Being aware of social status, but not being influenced [29] | |||
Ethical aspects | Perceived prognosis | QUAL | Expected low QoL after resuscitation [27, 30] Subjective assessed worn-out or morbid appearance [22] Perception of risk of post-resuscitation major impairment [5, 30] | |||
QUAN | 21.3% (n = 45) expressed concern for the patients (incl. quality of life) in a system, where EMTs were not allowed to terminate resuscitation [44] 2% (n = 8) mentioned expected low QoL after resuscitation in additional free-text answers [41] Perception of inappropriate CPR was significantly higher for cardiac arrests in patients whose first physical impression was rated “bad” to “poor” by the reporting clinician (OR = 3.7 [95% CI 2.78–4.94]; P < .0001 and OR = 3.5 [95% CI 2.36–5.05]; P < .0001, respectively) [34] | |||||
Dignity | QUAL | Allowing the patient to die “a natural death” or “die with dignity” [25, 29, 44] | ||||
QUAN | 21.3 (n = 45) expressed concern for the patients (incl. 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 [32] | Family members fearing permanent vegetative state [29] | Family wishes [22] Involving family as the patient proxy [29] | |
QUAN | 8% (n = 3) continued because family did not accept termination [37] | 59% (n = 138) would honour family wishes [45] 10.8% (n = 108) would honour family wishes [42] | Involving family as the patient proxy [41] | |||
Buying time for the family | QUAL | Giving the family time to realize the patient’s death/saying goodbye [5, 24] Showing the family that everything has been done [24] | Eliminating false hope [33] | |||
QUAN | Unnecessary emotional trauma [44] | |||||
Coping with the family’s emotions | QUAL | Avoiding dealing with family’s emotions [24, 29] Perception of better family support in-hospitally [32] | Continuation of CPR creates hope [24] | |||
QUAN | 0,4% (n = 1) stated cultural barriers lead to transportation [37] | 45.29% (n = 108) were comfortable with the termination of resuscitation when they knew that death was imminent [33] | 52% (n = 1200) were uncomfortable with terminating resuscitation [46] 69.1% (n = 165) were comfortable dealing with a family’s emotional response to death [33] | |||
Identifying with the family | QUAL | Continuation of futile CPR [24] | ||||
The presence of bystanders | Meeting expectations | QUAL | Expectations and perceptions of bystanders [8] | |||
QUAN | 70.1% (n = 180) stated bystanders’ reactions as a reason for prolonging CPR [36] | |||||
Respecting bystander efforts | QUAL | |||||
QUAN | 31.7% (n = 317) would initiate/continue obvious futile CPR to acknowledge bystander CPR [42] 26.6% (n = 266) would continue for teaching purposes [42] | |||||
Personal conditions have an impact | ||||||
Characteristics and experience of PRPs | PRPs’ age | QUAN | Younger PRPs were more inclined to initiate CPR [42] | Older clinician’s age was negatively associated with perceptions of appropriate CPR [34] | No association between age and paramedics’ attitudes toward withholding resuscitation attempts based on written or verbal ADs [45] | |
PRPs’ gender | QUAL | PRPs gender influence decision-making [31] | ||||
QUAN | Women were more inclined to initiate or continue CPR in patients with terminal illness [42] Men are more inclined to initiate or continue CPR for teaching purposes [42] | Male providers were significantly more likely to report believing that resuscitation ought to be terminated in case of advanced directives than female providers (42.8% vs. 25.3%) [36] | ||||
PRPs' level of education | QUAL | Level of education influences decision-making [23] | ||||
QUAN | Out-of-hospital nurses showed a greater tendency to perform CPR in situations of terminal illness or poor basal condition, and also to perform CPR even when not indicated [42] | Education on the appropriateness of CPR [34] | Paramedics were more likely to be troubled by terminating resuscitation than EMTs (P = .019) [38] | |||
Type of daily work | QUAL | A notable difference between their responses relating to the team they worked in and the type of work they encountered daily [23] | ||||
QUAN | Surgeons [40] | Surgeons [40] | No significant associations were found between the profession of the clinician and the perception of inappropriate CPR [34] | |||
Experience | QUAL | Level of experience, with experienced PRPs more inclined to terminate resuscitation [8, 22] | ||||
QUAN | Inexperienced [42] | Association between experience and believing “death is a part of life" (P = 0.032), “withholding resuscitation is resuscitation ethical" (P = 0.048) and that one should "not resuscitate a patient who holds a DNAR order" (P = 0.002) [39] EMS professionals who had more than 16 years of experience were more comfortable honouring the MOLST (83%) than those with 6 years or less (55%, P < .007) [43] | Experience [38] | There was no association between years of EMT-D service and willingness to honour a DNACPR order (p = 0.47) [44] No association between years of experience, or personal EOL decision-making experience and paramedics’ attitudes toward withholding resuscitation attempts based on DNACPRs [45] Results showed tendencies of PRPs with a higher level of experience may shorten the duration of unsuccessful resuscitative efforts, but this was not significant [41] | ||
Emotions and personal values | Uncertainty | QUAL | Making sure nothing is missed [22] Starting CPR immediately to save time [29] Requiring verifiable information [8] | Clinical uncertainty [28] | ||
QUAN | 33% (n = 762) feared terminating the resuscitation too early [46] | |||||
Personal values | QUAL | PRP’s religion [32] Heroic value [31] Responsibility [29] | Termination of resuscitation of a patient who might face a quality of life they would consider unacceptable for themselves [8] | Interpersonal factors influence the application of formal guidelines [24] | ||
QUAN | There was no significant association between religiosity and the following questions: "Is death a part of life?" (P = 0.07), "Is every human life worth living, no matter the circumstances?" (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 [23] The reputation of the EMS system [29] | ||
QUAN | Concerns about inappropriate resource utilization if all patients are sought resuscitated [44] | |||||
Training purposes | QUAL | |||||
QUAN | 26.6% (n = 266) indicated to initiate or continue resuscitation for training purposes “sometimes”, “often” or “almost always” [42] | |||||
Provider fatigue | QUAL | Provider fatigue at the end of a shift [23] | ||||
Crew safety | QUAL | |||||
QUAN | 86% (n = 1985) indicated scene safety as a barrier to terminate resuscitation [46] | Feeling threatened by family in case of termination [46] | Scene safety was not cited as an issue [38] | |||
Area of service | QUAN | Rural areas [36] | ||||
Legislation | Formal guidance | QUAL | Uncertainty about legislation [23] | Some PRPs were guided by the law [25] Some PRPs felt conflict about withholding resuscitation and lacked confidence in decision making about TOR [33] | ||
QUAN | 6.6% (n = 36) CPR attempts were undertaken despite the presence of a known written do not attempt resuscitation (DNAR) decision. Of these, 38.9% (n = 14) clinicians considered the CPR appropriate, 25.0% (n = 9) were uncertain about its appropriateness, and 36.1% (n = 13) considered this inappropriate [34] | 28.9% (n = 69) felt conflicted about what to do when there was a DNACPR, and the family called 911, and 41.4% (n = 99) felt conflicted when there was no DNACPR and the family asked them not to resuscitate [33] | Some PRPs were guided by the law [39] Only 9.8% (n = 42) think that they are competent to handle advanced directives [39] | |||
The arrest setting | Location of arrest | QUAL | Settings that were associated with high mortality and morbidity [22] | |||
QUAN | Location of arrest [37] | |||||
The environment | QUAL | Weather conditions [32] | Environmental conditions [8] | |||
QUAN | Weather conditions [37] | |||||
Logistics | QUAL | Logistical limitations [8] Long distances [32] | ||||
Navigating conflicts in the area of tension between key factors | ||||||
Conflicts with the law and guidelines | Legal and guidelines | QUAL | Moral decisions were overridden by protocol [28] | Deviation from the guidelines to respect the patient’s dignity [26] | Balancing patient’s wishes and legislation [23] | |
QUAN | 76.6% (n = 328) of the paramedics stated that they had no legal latitude in withholding resuscitation in a dying and terminally ill patient [39] 63% (n = 148) would disregard the DNACPR order and initiate resuscitation [44] | |||||
Conflicting values | Family wishes | QUAL | In case of disagreement between family members regarding the DNACPR status of the patient, the resuscitation was continued [32] | Family wishes vs. patient’s rights [23, 25, 26] Family wishes vs. resuscitations providers personal values [29] | ||
QUAN | 24.4% (n = 58) experienced conflicts between patient and family [33] | |||||
The duty to save lives | QUAL | The conflict between own moral beliefs and system expectations [30] | Balancing duty and values [24] | |||
Team interaction | QUAL | Conflicting values in the resuscitation team [8] Conflicting interpersonal factors [23] | HEMS personnel believed ambulance nurses not initiating resuscitation in patients where they felt this would have been appropriate [5] | Conflicting values in the resuscitation team [31] | ||
Lack of information | QUAL | PRPs would start resuscitation regardless of this in almost all situations and rather collect additional information during resuscitation to support further decision making [5] | Incomplete or conflicting information [8] |