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Table 4 Non-medical factors and their influence on decision-making

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

Applying patient-related factors

     

Patient characteristics

Age

QUAL

Young age [27, 29, 31, 32]

 

Age in general [5, 23]

 
  

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]

Perceived wishes of continuation [24, 29]

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

CPR for “show” [24, 27]

Presence of bystanders/relatives [29, 32]

 

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

Acknowledging bystander CPR [5, 29]

   
  

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

Inexperience [22, 32]

Experiences with successful resuscitation [29, 32]

Level of experience, with experienced PRPs more inclined to terminate resuscitation [8, 22]

Experience may influence decision-making [23, 30, 31]

Experience from previous cases [5, 29]

 
  

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]

Uncertainty [8, 22]

Starting CPR immediately to save time [29]

Requiring verifiable information [8]

 

Uncertainty [24, 31]

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

Training purposes [29, 31]

   
  

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

Crew safety [8, 29, 32]

   
  

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]

 
  1. QUAL, Qualitative; QUAN, Quantitative; QoL, quality of life; DNACPR, do not attempt CPR; HEMS, Helicopter Emergency Medical Service; EMS, Emergency Medical System; PRP: Professional Resuscitation Provider
  2. aIn studies where the percentage of participants in a given group was provided, the number of participants (n) was calculated by hand. Some quantitative studies did not provide specific percentages nor the number of patients, and in these cases, only the corresponding narrative theme has been provided