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Withholding Resuscitation

Keith Wesley, MD, FACEP | Wednesday, June 27, 2007

In this column, we ll review the current literature regarding all areas of prehospital medicine. These articles and papers represent the science of medicine as viewed by the researchers. How we interpret the results and what we do with those interpretations refine the care we provide on the street. I ll attempt to provide the most unbiased view of the science and translate that into what it means to those of us in the field.

Feder S, Matheny RL, Loveless RS Jr, et al: Withholding Resuscitation: A new approach to prehospital end-of-life decisions. Annals of Internal Medicine. 144(9):634 640, 2006.

The Science

King County, Wash., recently implemented guidelines that would allow EMS personnel to more liberally withhold resuscitation from patients in cardiac arrest who had a terminal condition and whose family or caregivers indicated in writing or verbally that no resuscitation was desired. Prior to this implementation, resuscitation was withheld only for those with a written Do Not Resuscitate order. After implementing the guidelines in 16 of 35 local EMS agencies, researchers tracked its effect on 2,770 EMS-attended cardiac arrests. Services using the new guidelines withheld resuscitation in 11.8 percent of patients compared with 5.3 percent in the services using the old guidelines. The reason for withholding resuscitation in the new guideline group was based on verbal requests alone 53 percent of the time.

The Street

Of course the biggest weakness of this paper is that the mere implementation of the new guideline and provision of education regarding end-of-life events is going to increase the number of field terminations. The agencies that did not adopt the new guidelines were not provided any additional education regarding this important topic, and, therefore, the marked increase in field termination in the study agencies may be due in large part to increased awareness. However, it s remarkable that verbal requests represented such a significant basis for withholding resuscitation. Although more liberal guidelines and education do increase field terminations, it s vital that any such program require on-line medical control authorization. Further studies should look at these cases and determine whether the decisions were appropriate.

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