Background
Methods
Description of study context
Study design
Data analysis
Descriptive analysis and statistical methods
Legislative approval of the study
Results
Resuscitative efforts initiated | Dead without treatment | Test | Level of significance | |
---|---|---|---|---|
n | 642 | 633 | ||
Sex F/M | 212/430 | 288/345 | Chi2
| <0.0001 |
Age (Median, Quartiles) | 68 years (57, 78) | 77 years (65, 85) | Kruskal-Wallis | <0.0001 |
Presence of bystanders | Chi2
(2 × 6 table) | <0.0001 | ||
None (n (% 95% CI)) | 47 (7.3% (5.4–9.1%)) | 53 (8.4% (6.3–10.8%)) | ||
Next of kin (n (% 95% CI)) | 277 (43.1% (39.3–47.1%)) | 252 (39.8% (36.0–43.7%)) | ||
Caregivers (n (% 95% CI)) | 70 (10.9% (8.6–13.6%)) | 210 (33.2% (29.5–37.0%)) | ||
Health care workers (n (% 95% CI)) | 75 (11.7% (9.3–14.4%)) | 23 (3.6% (2.3–5.4%)) | ||
Others (n (% 95% CI)) | 133 (20.7% (17.6–24.1%)) | 51 (8.1% (6.1–10.5%)) | ||
No information available (n (% 95% CI)) | 40 (6.2% (4.5–8.4%)) | 44 (7.0% (5.1–9.2%)) | ||
Place of incident | Chi2
(2 × 5 table) | <0.0001 | ||
Home (n (% 95% CI)) | 409 (63.7% (59.9–67.4%)) | 421 (66.5% (62.7–70.2%)) | ||
Nursing home (n (% 95% CI)) | 49 (7.6% (5.7–10.0%)) | 142 (22.4% (19.2–25.9%)) | ||
Public place (n (% 95% CI)) | 144 (22.4% (19.3–25.9%)) | 44 (7.0% (5.1–9.2%)) | ||
Other (n (% 95% CI)) | 20 (3.1% (1.9–4.8%)) | 11 (1.7% (0.9–3.1%)) | ||
No information available (n (% 95% CI)) | 20 (3.1% (1.9–4.8%)) | 15 (2.4% (1.3–3.9%)) | ||
Prehospital physician informed of pre-existing illness | Chi2
(2 × 7 table) | <0.0001 | ||
No known illness (n (% 95% CI)) | 335 (52.2% (48.2–56.1%)) | 291 (46.0% (42.0–49.9%)) | ||
Malignancy (n (% 95% CI)) | 23 (3.6% (2.3–5.3%)) | 79 (12.5% (10.0–15.3%)) | ||
Cardiac disease (n (% 95% CI)) | 114 (17.8% (14.9–20.9%)) | 60 (9.5% (7.3–12.0%)) | ||
Neurological disease (n (% 95% CI)) | 31 (4.8% (3.3–6.8%)) | 38 (6.0% (4.3–8.1%)) | ||
Chronic Obstructive Pulmonary Disease (n (% 95% CI)) | 50 (7.8% (5.8–10.1%)) | 58 (9.1% (7.0–11.7%)) | ||
Substance abuse (n (% 95% CI)) | 32 (5.0% (3.4–7.0%)) | 20 (3.2% (1.9–4.8%)) | ||
Other (n (% 95% CI)) | 57 (8.9% (6.8–11.4%)) | 87 (13.7% (11.2–16.7%)) |
Principal findings
Ethical considerations | Total number | |
---|---|---|
1. Patient | Do-not-resuscitate order or note from doctor | 38 |
Reported wishes and outlook regarding resuscitation | 3 | |
Life expectancy | 17 | |
Quality of life | 21 | |
2. Relatives | Emotional states of relatives | 2 |
Wishes and outlooks regarding resuscitation | 4 | |
3. Future patients, medical staff or general public | 0 | |
Total number of ethical considerations | 85 |
Do-not-resuscitate order
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In 21 of patients (3.3% (2.1–5.0%)) in whom natural death was allowed, the main consideration influencing the physician to not initiate treatment was the patients’ expected quality of life after the incident.
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In 17 patients (2.9% (1.6–4.3%)), the physician’s reason to refrain from treatment was the patient’s estimated life expectancy following a hypothetically successful resuscitation attempt.
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In a total of six patients (0.9% (0.3–2.1%)), the reasons for not initiating any resuscitation attempts but to allow natural death to happen was the knowledge of end-of-life wishes or the expectations of the patients or the relatives.
Discussion
An overall evaluation of the documentation can be summed up in five findings
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Firstly, when resuscitative efforts are withheld from the patient, the patient usually dies. Accordingly, the decision to withhold resuscitative therapy is almost always a self-fulfilling prophecy when based on the assumption that a patient cannot be resuscitated. Hence, no evidence of less than optimal decisions is likely to emerge in medical records, i.e., cases where a patient survives despite the absence of resuscitation and has significant benefit from it. This calls for alternative ways of quality-assuring the decisions.
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Secondly, it should be taken into account that there is no easy solution to the potential ethical problems. Merely recommending resuscitation when in doubt in an attempt to always err on the side of caution is not a viable option. Not only can this approach result in patients left with severe handicaps following resuscitation attempts that should never have been initiated, other missions may be left unattended while the MECU is preoccupied with this procedure. Furthermore, emergency transportation of patients undergoing resuscitative attempts, poses a hazard to the MECU crew as well as other people in the streets [14].
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Thirdly, within the hospital, the decision to terminate or to refrain from resuscitative therapy is usually made by a group of physicians and other caretakers following plenary-type consultations, often taking into consideration the expectations and end-of-life wishes of patient and relatives. This in itself is clearly a practice that tends to enhance and assure the quality of the ethical decisions made. The requirement of an explicit formulation of the ethical considerations that comes with the public nature of plenary-type consultation arguably has a positive influence on the quality of the decision-making [15, 16]. This presumed quality-enhancing effect of decision-making is absent in the pre-hospital setting. In some cases, nursing home staff or relatives are at the scene, but more often only one physician and one to three EMTs are present. Formally and legally, however, the authority to decide to either withhold or to terminate resuscitative measures rests with the physician present. A DNR-order can in some cases aid the decision process, but due to the nature of most prehospital deaths, it is exceedingly rare to encounter DNR- orders at the prehospital scene. Thus, the decision to resuscitate or not lies solely with the physician at the scene and must be made based on considerations taking only into account the available limited patient-related information.
Strengths and limitations
Conclusion and Recommendations
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◦ A systematic recording of persons involved in the deliberations (e.g., relatives, nursing staff, or a note from the patient’s doctor).
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◦ Notes on ethical considerations, including for instance:
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◦ Information about the patient’s end-of-life wishes (e.g., a DNR-order or more informal information)
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◦ Estimations of quality of life before and after the incident
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◦ A summary of other ethical concerns taken into account such as the integrity of the patient and frame of mind of relatives
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