Factors that influence decisions about cardiopulmonary resuscitation: the views of doctors and medical students

Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests

Background

Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation.

Methods

This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.

Results

Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.

Conclusions

There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00654-y.

Factors influencing termination of resuscitation in children: a qualitative analysis

BACKGROUND

Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians.

METHODS

A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors.

RESULTS

Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept.

CONCLUSION

Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

A Cross-sectional Study Among Healthcare and Non-healthcare Students in Slovenia and Croatia About Do-not Resuscitate Decision-making

Objective

To survey university students on their views concerning the respect for autonomy of patients and the best interest of patients in relation to the withholding of resuscitation.

Methods

A cross-sectional survey among university students of medicine, nursing, philosophy, law and theology of the first and the final study years at the University of Ljubljana and the University of Zagreb was conducted during the academic year of 2016/2017. A questionnaire constructed by Janiver et al. presenting clinical case vignettes was used.

Results

The survey response rates for students in Ljubljana and Zagreb were 45.4% (512 students) and 37.9% (812 students), respectively. The results of our research show statistically significant differences in do-not resuscitate decisions in different cases between medical and non-medical students in both countries. Male and religious students in both countries have lower odds of respecting relatives’ wishes for the withholding of resuscitation (odds ratio 0.49–0.54; 95% confidence interval). All students agreed that they would first resuscitate children if they had to prioritize among patients.

Conclusions

Our study clearly shows that gender, religious beliefs, and type of study are important factors associated with the decisions pertaining to the respect for autonomy, patient’s best interest, and initiation or withholding of resuscitation.

Not quite a doctor, but should I help? A qualitative exploration of medical students' attitudes towards responding to medical emergencies that occur in the public domain

OBJECTIVE

To explore medical students' views on and experiences of responding to out-of-hospital medical emergencies.

SETTING

University College London (UCL).

PARTICIPANTS

11 UCL Medical School students.

STUDY DESIGN

Qualitative.

METHODS AND OUTCOME MEASURES

We carried out 11 one-to-one semistructured interviews, with participant validation and reflective work. The data were analysed using thematic analysis.

RESULTS

Three core themes were identified. (1) 'We Did Debate a Bit: Should We Go? Should We Not?'-Students' decisions to respond were based on the appearance of the casualty; the presence and actions of bystanders; witnessing the incident; self-perceived competence, confidence and knowledge; and personal experiences and feelings associated with medical emergencies. (2) 'It Would Represent the Medical Profession Well if We Did Step In and Help'-Students felt that they had an ethical and/or professional duty to help. (3) 'No One Should Die Because of a Lack of… Basic Life-Saving Techniques'-Students felt that medical school training alone had not sufficiently prepared them to respond to out-of-hospital medical emergencies. Improvements to training were suggested: integrating first aid/response training into the horizontal (systems-based) modules; teaching both common and less common medical emergencies and presentations; training that is led by experienced first responders and that increases students' exposure to out-of-hospital medical emergencies; and providing more revision training sessions.

CONCLUSIONS

Students felt that medical school training could be improved to better prepare them for responding to out-of-hospital medical emergencies, and wanted clarification on whether or not they have an ethical and/or professional duty to help. Further mixed-methods research using a larger sample needs to be carried out to confirm whether findings are transferable to other UK medical schools.

End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis

With population aging, “do not resuscitate” (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents “ageism.” We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that “do not attempt resuscitation” orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of “do not resuscitate” orders, but more research is needed to determine whether this represents “ageism.”

Does medical futility matter in 'do not attempt CPR' decision-making?

The current demographical trend towards an increasingly elderly population combined with advances in end of life care calls for a deeper understanding and common terminology about the concept of futility and additional influences on the resuscitation decision-making process. Such improved understanding of medical futility and other contributing factors when making DNACPR orders would help to ensure that clinicians make appropriate and thoughtful decisions on whether to recommend resuscitation in a patient. When estimating medical futility a physician should consider the chance of survival over different time periods and balance this against the chance of adverse outcomes. This information can then be offered to the patient (or the relatives) so that the patient's views about what is acceptable for the survival chance, length and type of survival can be factored into the eventual decision. Given the lack of evidence in this area and the poor level of patient knowledge and the emotive nature of the topic, it is not surprising that clinicians find such discussions hard.

Resuscitation decisions for patients dying in the community: a qualitative interview study of general practitioner perspectives

BACKGROUND

Most patients dying at home do not have a Do Not Attempt Cardiopulmonary Resuscitation decision and may have inappropriate attempts at resuscitation made when they die.

AIM

To investigate how general practitioners think and feel about making and communicating Do Not Attempt Cardiopulmonary Resuscitation decisions for patients dying in the community.

DESIGN

Qualitative study using semi-structured interviews with general practitioners. The interviews were recorded and analysed using interpretative phenomenological analysis.

SETTING/PARTICIPANTS

Purposive sampling was used to recruit 10 general practitioners from urban and rural practices in Southern England and of various ages and experience. Interviews were carried out either in their home or in their practice.

RESULTS

General practitioners often wait until the patient has clearly deteriorated to communicate and document the Do Not Attempt Cardiopulmonary Resuscitation decision. They consider the chance of success of a resuscitation attempt, quality of life, dignity and the patient's and family's wishes. General practitioners feel they should discuss the decision with the patient but have anxieties about this. They vary widely in how much they guide patients and families in decision-making. Timing and the avoidance of conflict are important. Teamwork provides support in decision-making.

CONCLUSION

Resuscitation decisions are important in facilitating a peaceful death, but can be difficult for general practitioners to discuss. General practitioners might benefit from clearer guidance on when an attempt at resuscitation is unlikely to be successful, especially in non-malignant disease. Team discussions including Gold Standards Framework meetings can give confidence and support in making difficult end-of-life decisions.

Clinical model for ethical cardiopulmonary resuscitation decision-making

BACKGROUND

Decisions to withhold cardiopulmonary resuscitation (CPR) for future cardiac arrest continue to be problematic, with a lack of consistency in how doctors approach this decision.

AIMS

To develop a clinical model that can be used in education to improve consistency in CPR decision-making.

METHODS

A qualitative study, using semistructured interviews with a total of 33 senior doctors, junior doctors and nurses from two Melbourne hospitals explored how decisions to withhold CPR are made. Interviews explored: issues arising; how doctors learn to make these decisions; how they deal with disagreement and their experiences of performing CPR. The transcripts were coded and analysed thematically.

RESULTS

Three major themes were identified: CPR as a life-and-death decision; good and bad dying; and trust. The research also defined the two elements to a CPR decision: (i) technical and (ii) ethical.

CONCLUSIONS

Applying ethical principles commonly used in medicine, a model for ethical CPR decision-making has been developed that identifies four patient groups, each with a different discussion aim. This approach simplifies the complexities of the CPR decision, providing a structured way to teach CPR decision-making to doctors and thereby achieve greater consistency in the decisions made.

In-hospital cardiopulmonary resuscitation: Trainees' worst and most memorable experiences

BACKGROUND

To examine the personal experiences of higher specialist trainees in Geriatric Medicine (GM) with regard to cardiopulmonary resuscitation (CPR) and do not attempt resuscitation (DNAR) decision making.

SETTING

UK.

PARTICIPANTS

Two hundred and thirty-five higher trainee members of the British Geriatrics Society (BGS) at the Specialist Registrar (SpR) level.

DESIGN

Postal questionnaire survey.

METHODS

We distributed a questionnaire examining the various issues around DNAR decision making among the trainee members of the BGS in November 2003. In one of the questions, we asked the participants, 'Briefly describe your worst or most memorable experience of DNAR'. Responses to this question were analysed by thematic schema and are presented.

RESULTS

Overall the response rate was 62% (251/408) after second mailing and 235 of these were at SpR grade. One hundred and ninety-eight participants provided an answer to the above question, providing diverse and often detailed accounts, most of which were negative experiences and which appeared to have had a powerful influence on their ongoing clinical practice. The emerging themes demonstrated areas of conflict between trainees and other doctors as well as patients and relatives.

CONCLUSION

SpR grade geriatricians are exposed to extreme and varied experiences of DNAR decision making in the UK. Efforts to improve support and training in this area should embrace the complexity of the subject.