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Milling L, Kjær J, Binderup LG, de Muckadell CS, Havshøj U, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S, Nielsen D. Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review. Scand J Trauma Resusc Emerg Med 2022; 30:24. [PMID: 35346307 PMCID: PMC8962561 DOI: 10.1186/s13049-022-01004-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/25/2022] [Indexed: 11/10/2022] Open
Abstract
Aim This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest. Methods We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings. Results We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.
Conclusions Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01004-6.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Jeannett Kjær
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | - Ulrik Havshøj
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark.,Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Nielsen
- Department of Infectious Diseases, Sub-Department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
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2
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Wirpsa MJ, Carabini LM, Neely KJ, Kroll C, Wocial LD. Mitigating ethical conflict and moral distress in the care of patients on ECMO: impact of an automatic ethics consultation protocol. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106881. [PMID: 33441301 DOI: 10.1136/medethics-2020-106881] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/09/2020] [Accepted: 11/29/2020] [Indexed: 06/12/2023]
Abstract
AIMS This study evaluates a protocol for early, routine ethics consultation (EC) for patients on extracorporeal membrane oxygenation (ECMO) to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress. METHODS We conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019 (n=68). Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers' perceptions of the impact of the early intervention protocol. RESULTS Limited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a 'bridge to nowhere', EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy. CONCLUSION Data from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC-at least while this medical technology is in its nascent stages.
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Affiliation(s)
- M Jeanne Wirpsa
- Medical Ethics Program, Northwestern Medicine, Central Region, Chicago, Illinois, USA
- Spiritual Care and Education, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Louanne M Carabini
- Anesthesiology, Northwestern Medicine, Chicago, Illinois, USA
- Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kathy Johnson Neely
- Medical Ethics, Northwestern Medicine, Central Region, Chicago, Illinois, USA
- Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Camille Kroll
- Center for Bioethics and Medical Humanities, Northwestern University, Chicago, Illinois, USA
| | - Lucia D Wocial
- School of Nursing, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana, USA
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Enumah ZO, Carrese J, Choi CW. The Ethics of Extracorporeal Membrane Oxygenation: Revisiting the Principles of Clinical Bioethics. Ann Thorac Surg 2020; 112:61-66. [PMID: 34159900 DOI: 10.1016/j.athoracsur.2020.08.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/27/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Extracorporeal life support has become accepted as a rescue therapy for cardiopulmonary shock, and there have been over 100,000 extracorporeal membrane oxygenation (ECMO) cases since 1987. Rapid growth has presented ethical challenges and concerns. Here, we discuss core principles of bioethics in an attempt to more thoroughly appreciate the ethical concerns and considerations raised by use of this technology. METHODS An extensive literature review was performed on current papers on ECMO and ethics. In this paper, we utilized 3 case studies to highlight 4 major tenets of bioethics as they relate to use of ECMO: autonomy, beneficence, nonmaleficence, and justice. RESULTS Case studies presented involved unique perspectives on utilization of ECMO and a careful balance of benefits and harms as they relate to autonomy, beneficence, nonmaleficence and justice. We present nuanced interpretations of autonomy (eg, physician autonomy) and justice (eg, various providers interpret and offer ECMO differently). An additional challenge includes contending with potentially prolonged clinical courses and/or complications that either result directly from cannulation for ECMO or indirectly from being subject to ensuing extreme conditions and prolongation of life that medical science has yet to fully understand. CONCLUSIONS ECMO programs continue to grow in number and capacity. A deep appreciation of the bioethical dimensions of this technology and its application must be pursued, understood and applied to individual patient scenarios.
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Affiliation(s)
| | - Joseph Carrese
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
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Kobata H, Tucker A, Sarapuddin G, Negoro T, Kawakami M. Continuous amplitude-integrated electroencephalography for prognostication of cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation with targeted temperature management. Resuscitation 2020; 156:107-113. [PMID: 32918986 DOI: 10.1016/j.resuscitation.2020.08.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has been increasingly used for adult cardiac arrest (CA) patients refractory to conventional CPR. However, data on early prognosticators of neurological outcome are lacking. METHODS CA patients undergoing ECPR were prospectively monitored via amplitude-integrated EEG (aEEG). Targeted temperature management (TTM) was induced using an extracorporeal membrane oxygenation system. aEEG background patterns were classified into continuous normal voltage (CNV), discontinuous normal voltage (DNV), low voltage (LV), flat trace (FT), burst suppression (BS), and status epilepticus (SE). The Cerebral Performance Category (CPC) scale scores at hospital discharge and at 6 months after discharge were assessed, as was wakefulness after TTM. Good neurological outcome was defined as a CPC score of 1 or 2. RESULTS Twenty-two patients were studied. Six patients who showed CNV within 24 hours after arrival, including one with initial FT and two with initial LV, regained consciousness and had good neurological outcome except for one who died of haemorrhagic complication. Patients with persistent FT or BS at any time did not regain consciousness. Regarding 19 patients in whom aEEG data were obtained within 24 hours, CNV background predicted good outcome at 6 months with 100% sensitivity, 93% specificity, 83% positive predictive values, and 100% negative predictive values. All these indices were 100% concerning wakefulness after TTM. CONCLUSION aEEG monitoring was feasible and practical in adult CA patients undergoing ECPR and TTM. Evolution of aEEG background within 24 hours provides early accurate information for neurological prognostication.
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Affiliation(s)
- Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan.
| | - Adam Tucker
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan; Department of Neurosurgery, Japanese Red Cross Kitami Hospital, Kitami, Japan
| | - Gemmalynn Sarapuddin
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan; Neurology Department, Institute of Neurosciences, The Medical City, Pasig, Philippines
| | | | - Makiko Kawakami
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
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Siao FY, Chiu CW, Chiu CC, Chang YJ, Chen YC, Chen YL, Hsieh YK, Chou CC, Yen HH. Can we predict patient outcome before extracorporeal membrane oxygenation for refractory cardiac arrest? Scand J Trauma Resusc Emerg Med 2020; 28:58. [PMID: 32576294 PMCID: PMC7310513 DOI: 10.1186/s13049-020-00753-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 06/08/2020] [Indexed: 11/10/2022] Open
Abstract
Background Refractory cardiac arrest resistant to conventional cardiopulmonary resuscitation (C-CPR) has a poor outcome. Although previous reports showed that extracorporeal cardiopulmonary resuscitation (E-CPR) can improve the clinical outcome, there are no clinically applicable predictors of patient outcome that can be used prior to the implementation of E-CPR. We aimed to evaluate the use of clinical factors in patients with refractory cardiac arrest undergoing E-CPR to predict patient outcome in our institution. Methods This is a single-center retrospective study. We report 112 patients presenting with refractory cardiac arrest resistant to C-CPR between January 2012 and November 2017. All patients received E-CPR for continued life support when a cardiogenic etiology was presumed. Clinical factors associated with patient outcome were analyzed. Significant pre-ECMO clinical factors were extracted to build a patient outcome risk prediction model. Results The overall survival rate at discharge was 40.2, and 30.4% of patients were discharged with good neurologic function. The six-month survival rate after hospital discharge was 36.6, and 25.9% of patients had good neurologic function 6 months after discharge. We stratified the patients into low-risk (n = 38), medium-risk (n = 47), and high-risk groups (n = 27) according to the TLR score (low-flow Time, cardiac arrest Location, and initial cardiac arrest Rhythm) that we derived from pre-ECMO clinical parameters. Compared with the medium-risk and high-risk groups, the low-risk group had better survival at discharge (65.8% vs. 42.6% vs. 0%, p < 0.0001) and at 6 months (60.5% vs. 38.3% vs. 0%, p = 0.0001). The low-risk group also had a better neurologic outcome at discharge (50% vs. 31.9% vs. 0%, p = 0.0001) and 6 months after discharge (44.7% vs. 25.5% vs. 0%, p = 0.0003) than the medium-risk and high-risk groups. Conclusions Patients with refractory cardiac arrest receiving E-CPR can be stratified by pre-ECMO clinical factors to predict the clinical outcome. Larger-scale studies are required to validate our observations.
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Affiliation(s)
- Fu-Yuan Siao
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Department of Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Department of Mechanical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan
| | - Chun-Wen Chiu
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Chieh Chiu
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ying-Chen Chen
- Department of Cardiovascular Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Li Chen
- Department of Cardiovascular Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yung-Kun Hsieh
- Department of Cardiovascular Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chu-Chung Chou
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsu-Hen Yen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan. .,College of Medicine, Chung-Shan Medical University, Taichung, Taiwan.
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Ramanathan K. Ethical challenges of adult ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:303-308. [PMID: 33967451 DOI: 10.1007/s12055-020-00922-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 01/10/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) is expanding rapidly, and as more centres streamline their management policies, the bioethics literature on ECMO has been highlighting the ethical challenges of using an expensive, resource-intensive technology including its eligibility, duration of support, cost-effectiveness and societal repercussions. The absence of high-quality studies on long-term outcomes of ECMO survivors leads to multiple ethical problems involving patient autonomy, beneficence and clinical wisdom pertaining to its initiation, maintenance and termination. This article reviews some of the ethical challenges that affect decision-making during ECMO therapy and suggests an ethical framework that may help the treating team deal with such conundrums, when the patient does not recover despite being on ECMO.
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Affiliation(s)
- Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.,Bond University, Gold Coast, Australia
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Bell SM, Kovach C, Kataruka A, Brown J, Hira RS. Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:146. [PMID: 31758275 DOI: 10.1007/s11886-019-1249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF THE REVIEW Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient. RECENT FINDINGS Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.
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Affiliation(s)
- Sean M Bell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Kovach
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Akash Kataruka
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Josiah Brown
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ravi S Hira
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA. .,Cardiac Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA, USA.
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