Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions

2 May 2006 | Volume 144 Issue 9 | Pages 634-640

Background: Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order.

Objective: To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines.

Design: Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation.

Setting: King County, Washington.

Patients: 2770 patients with EMS-attended cardiac arrest.

Intervention: New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired.

Measurements: Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not.

Results: Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients).

Limitations: The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines.

Conclusions: Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.

Editors' Notes Context Emergency medical services (EMS) personnel attending out-of-hospital cardiac arrests sometimes attempt to resuscitate patients who do not want life-sustaining measures. Contribution This study involving 2770 patients with EMS-attended cardiac arrests assessed outcomes of guidelines that permitted personnel to withhold resuscitation in patients with terminal illnesses when the patients or caregivers indicated, in writing or verbally, that they did not want resuscitation. Sixteen of 35 EMS agencies in King County, Washington, implemented the guidelines. Implementation and control agencies withheld resuscitation in approximately 11.8% and 5.3% of cardiac arrests, respectively. The difference was primarily due to honoring verbal requests. Cautions In this observational study, self-selected agencies volunteered to implement guidelines. —The Editors

 

Author and Article Information

From King County Medic One and Kent Fire Department, Kent, Washington, and King County Emergency Medical Services and University of Washington, Seattle, Washington.

Acknowledgments: The authors thank Dr. Thomas Hearne, Dr. Mickey Eisenberg, Dr. Jack Murray, and John Jerin, King County Emergency Medical Services, for supporting the withholding resuscitation program; Ed Plumlee, King County Medic One, for advocating the program to the local fire chiefs; Linda Becker, King County Emergency Medical Service, for assistance with data acquisition; and Dr. Ned Feder for advice.

Grant Support: By the Medic One Foundation and King County Emergency Medical Services.

Potential Financial Conflicts of Interest: Grants: S. Feder, R.L. Matheny (Medic One Foundation).

Corresponding Author: Sylvia Feder, King County Medic One, 7064 South 220th Street, Kent, WA 98032; e-mail, sylvia_feder{at}kcfiremed.org.

Current Author Addresses: Ms. Feder and Mr. Matheny: King County Medic One, 7064 South 220th Street, Kent, WA 98032.

Dr. Loveless: Kent Fire Department, 24611 116 Avenue SE, Kent, WA 98030.

Dr. Rea: University of Washington/King County Emergency Medical Services, 999 3rd Avenue, Suite 700, Seattle, WA 98104.

Author Contributions: Conception and design: S. Feder, R.L. Matheny.

Analysis and interpretation of the data: S. Feder, R.S. Loveless Jr., T.D. Rea.

Drafting of the article: S. Feder.

Critical revision of the article for important intellectual content: S. Feder, R.L. Matheny, R.S. Loveless Jr., T.D. Rea.

Final approval of the article: S. Feder, R.L. Matheny, R.S. Loveless Jr., T.D. Rea.

Statistical expertise: R.S. Loveless Jr., T.D. Rea.

Obtaining of funding: S. Feder, R.L. Matheny.

Administrative, technical, or logistic support: R.L. Matheny.

Collection and assembly of data: S. Feder, R.L. Matheny, R.S. Loveless Jr.

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