Background
The decision to terminate resuscitative efforts in pediatric cardiopulmonary arrest is complex [
1,
2] and may vary considerably among physicians and across institutions. Moreover, while guidelines for resuscitation like Pediatric Advanced Life Support (PALS) and Advanced Cardiac Life Support (ACLS) have been taught and followed by clinicians worldwide, the often subjective “non-medical” factors that could influence or guide a clinician’s decision to prolong or terminate cardiopulmonary resuscitation (CPR) are not considered. The International Liaison Committee on Resuscitation (ILCOR) has no position on non-medical factors.
Medical considerations for termination, such as initial cardiac rhythm, number of doses of epinephrine (adrenaline), and pupil response have been widely published [
3‐
7], while more subjective “non-medical” factors, including physicians’ attitudes and beliefs, have been discussed in very few publications. Larkin reviewed the complexity of the multifactorial decision to discontinue resuscitative efforts, including futility judgments and provider experience and comfort, especially when terminating efforts in children [
1]. Scribano et al. discussed medical factors influencing termination of resuscitative efforts in children and mentioned additional considerations such as child abuse, organ donation, and co-morbid conditions [
2]. Meanwhile, the European Resuscitation Council (ERC) acknowledges the responsibility of the physician to weigh and balance the risks, benefits, and costs resuscitative interventions have on the patient and their family, as well as the costs to the health care system and society as a whole [
8].
Variability surrounding the termination of resuscitation in children is highlighted in the Emergency Department (ED), where the duration of resuscitative efforts on pediatric patients in cardiac arrest involves significant uncertainty with vague and unclear end-points. This uncertainty may arise from such entities as having insufficient details surrounding the cardiopulmonary arrest, an unknown downtime, an unknown cause of the arrest, parental absence, or even parental interference [
9].
While some of the “non-medical” factors have been described previously in the literature, to our knowledge, there has been no effort undertaken to investigate the totality of “non-medical” factors and beliefs that physicians take into account, or are influenced by, when making resuscitative decisions in children. Thus, a clearer understanding of the uncertainty that exists around termination of resuscitation may help physicians to make more objective decisions in that same context. Among other mitigation effects, this may also serve to ameliorate some of the stress and anxiety surrounding critical events and high-stakes decisions. The aim of this study, therefore, was to identify and explore the phenomena of “non-medical” considerations surrounding the decision to terminate resuscitative efforts by Pediatric Emergency Medicine (PEM) physicians.
Discussion
Resuscitation education has, for years, focused on medical interventions taught to Emergency physicians through courses such as PALS and ACLS, but these guidelines make no mention of the “non-medical” considerations often involved in terminating resuscitative efforts. Few other decisions in medicine involve such complex and charged decisions as the irreversible decision to end life. As a result, it is essential that physicians be equipped with any information that could help them make well-conceived and thorough decisions during resuscitation. To aid in this process, we conceived the first study, to our knowledge, which conducted an in-depth exploration into the breadth of “non-medical” factors that physicians consider when making the decision to terminate resuscitative efforts in children.
In this study, physicians reported that a wide variety of considerations influence their decision to prolong or terminate resuscitation, which fell into the following categories: legal and financial factors, resuscitation-related factors, parent-related factors, patient-related factors, and physician-related factors. However, the relative weight and importance of each of the themes and factors varied between physicians.
A novel and interesting factor that emerged in this study was the idea that the patient reminded the physician of their own child or family. While the majority of physicians stated that this factor would only affect them emotionally and not cause them to prolong a resuscitation, it is conceivable that in a stressful and emotionally charged resuscitation, physicians may be swayed by their own emotions of sorrow for the family, distress over the loss of a child’s ability to experience life, or even fear of declaring death. This factor may be unique to resuscitating pediatric patients, as it is likely that the parental role is the nidus for these emotions and responses. Physicians’ emotions were another factor revealed in this study, described by participants as often causing them to prolong resuscitation. This underscores the significant influence non-medical factors have in medical decision-making and their role in contributing to variability in clinical practice. This variability is neither positive nor negative, but rather inevitable given each practitioner’s individual beliefs and experiences, and the uniqueness of each case.
Patient age was unanimously described in our study population as a factor not affecting decision-making during resuscitation. This may be due to the pediatric training obtained by all of the participants specializing in and actively practicing PEM, thereby increasing their comfort level. Patient age has been shown to be an important factor when making resuscitation decisions in adults, in that physicians may be less inclined to consider resuscitation in elderly patients [
30]. The converse has also been shown to be true, where pediatric resuscitations are longer than those on adult patients by non-PEM physicians [
31,
32]. It has also been shown that practitioners with pediatric training tend to have a shorter duration of resuscitation time than General Emergency Medicine (GEM) physicians, in that PEM physicians are twice as likely to terminate by 25 min if no return of spontaneous circulation is observed [
2].
Another factor noted in the literature is whether or not the parents’ attendance at the bedside is beneficial or disruptive and, more specifically, whether it impacts resuscitation timing or efforts [
9,
22,
32]. Medical societies, including the ERC, have recommended parents be at the bedside, stating that that their presence is neither disruptive nor stressful to the staff. Their proximity helps the parents to gain a more realistic understanding of the resuscitation and allows them to better grieve and adjust after their child’s death [
3]. Despite these recommendations, Tripon et al. found that the majority of Emergency physicians and nurses surveyed in their study were reluctant to have parents present due to psychological trauma for the parents, risk of interference with medical management, care team stress, and, above all, a personal attitude espousing medical paternalism. Our study found that while physicians felt that parental presence was important for numerous reasons, including parental acceptance of death, most participants identified parental presence as a factor not affecting their decision to prolong or terminate a resuscitation. Moreover, the majority of physicians stated that they would prolong resuscitation in the instance of parental absence at the bedside in order to allow time for the parent to arrive to the Emergency Department.
Rules or guidelines for the non-medical considerations for terminating resuscitation in the pediatric population are sparse. The ERC suggests that the resuscitation team leader should consider terminating a resuscitation after 20 min. In addition, they outline other relevant considerations including age, cause of arrest, pre-existing medical conditions, duration of untreated cardiopulmonary arrest, and medical factors such as number of doses of epinephrine (adrenaline), the end-tidal CO
2 value, and the presence of a shockable rhythm [
3‐
6,
33]. In our study, there was no consensus as to how long a resuscitation should continue in the ED before termination and which principal factor(s) should be considered. One reason for variability in resuscitation duration and the occurrence of prolonged resuscitations may be that physicians are struggling with the numerous and highly subjective non-medical considerations elucidated in this study without a proper framework in which to address them.
PEM, EM, and non-EM physicians would perhaps benefit from this delineation of the non-medical factors often considered when terminating resuscitation in children. As discussed by Engebretse et al., simply following protocols and standards restricts imagination, reflective thinking, and critical judgment, which are all essential for objective clinical decision making. In contrast, knowledge of uncertainty lends itself to creative thinking and objective knowledge [
34]. Thus, a clearer understanding of the uncertainty that exists around termination of resuscitation may help physicians to make more thoughtful and objective decisions in the unique moment when they are charged with declaring the death of a pediatric patient.
Furthermore, it has been well documented that the ED is a uniquely stressful environment and that acuity and critical events contribute toward burnout among EM physicians [
35‐
37]. A meta-analysis by de Boer et al. discusses how work-related critical events are positively related to anxiety, depression, and even post-traumatic stress disorder (PTSD) in hospital-based health care providers [
38]. Additional education about resuscitation, expanded to include the non-medical factors described here, could potentially help decrease variability and/or normalize the experiences of providers, and possibly mitigate some of the stress they experience. Likewise, these factors could provide a scaffold for self-assessment post-resuscitation and might contribute to improved mental health outcomes among physicians. Given the degree of burnout and mental health illness currently seen in the medical field [
39,
40], any attempt that can be made to mitigate the contributing factors and improve the long-term health and well being of physicians would be significant.
Limitations
As with other qualitative studies with requisite small sample sizes, the generalizability of these results is limited. PEM physicians at other hospitals may have varying perspectives due to their own clinical experiences, training, and personal beliefs and values. EM physicians who experience pediatric, adult, and geriatric arrests may have different views that were not addressed within our sample population. Furthermore, it was essential that the PI perform the interviews with participants due to the lack of an available alternative, but the familiarity between the subjects and their interviewer may have influenced participant responses in some cases.
There was a discrepancy between the number of resuscitations reported by study participants and the average number of true resuscitations that occur in the ED annually. This could be because resuscitations are memorable and impactful, leading physicians to inflate the occurrences. Another possible explanation is that participants joined another physician’s resuscitation as a co-attending and reported that resuscitation as their own, thereby increasing the number.
Conclusion
Evidence from this study demonstrates that a variety of “non-medical” factors are considered by physicians when deciding whether to prolong or terminate resuscitation in children. Most physicians, to a certain degree, considered length of the arrest, acuity, and reversibility of the medical condition, the patient’s likely neurological outcome, parental absence at the bedside, the physician’s years of clinical experience, and the physician’s own moral and ethical perspective.
On the other hand, the data demonstrated factors less likely to be considered by the physician, which included legal and financial considerations, cultural or religious preferences of the family, whether or not the cause of arrest was non-accidental trauma, and the age of the patient.
An increased understanding of the nuanced nature of decisions regarding termination of resuscitation may help physicians in making objective clinical decisions in pediatric cardiopulmonary arrests.
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