International Termination of Resuscitation Practices - a Worldwide Survey
Conditions: Out-Of-Hospital Cardiac Arrest
Sponsor: University of Southern Denmark

International Initiation and Termination of Resuscitation Practices  
- 
Protocol of a cross-sectional survey 
 
Ulrik Havshøj1,2,3,*,, Ida-Marie Dreijer Juhl2,4,, Louise Milling1,3, Jeannett Kjær Jørgensen1, Helle Collatz 
Christensen5, Freddy Lippert 5, Laurie J. Morrison 1,6, Søren Mikkelsen1,3, Anne Craveiro Brøchner1,2,3 
 
1 The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Denmark 
2: Department of Anesthesiology and Intensive Care Medicine, University Hospital Kolding, Kolding, Denmark 
3: Department of Regional Health Research, Region of Southern Denmark, Odense, Denmark 
4: Department of Clinical Research, University of Southern Denmark, Odense, Denmark 
5: Copenhagen Emergency Medical Services & Danish Clinical Quality Program (RKKP), National Clinical Registries & Department of 
Clinical Medicine, University of Copenhagen, Copenhagen, Denmark 
6: Division of Emergency Medicine, Department of Medicine, University of Toronto,   
Emergency Services, Sunnybrook Health Sciences Center, Toronto, Canada 
 
*: Corresponding author: mail: Ulrik.havshoj2@rsyd.dk 
 
 
 
Date 06.04.22 
 
 
 
 
 
 

 
Background 
Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the World (1-4). Substantial 
international differences in survival to hospital discharge have been reported (4,5); ranging from 0% 
to 18% in Europe (6,7), 0,5% to 8,5% in Asia (8), 9% to 17% in Australia and New Zealand (9), and 
from 1.1% to 8.4% in North America (10). Regional differences of up to a fivefold increase in survival 
have also been reported in multiple settings and geographic locations (11-15). 
Neither the international nor the national variation is fully understood but may be attributed to 
multiple factors such as organization of the Emergency Medical Service (EMS) system (16,17), the 
response time of the EMS (16), bystander cardiopulmonary resuscitation (CPR)(4,18), and the use of 
Automatic External Defibrillators (AED’s) (4,16,19-20). However, Dyson et al (21) found that the 
Utstein core factors accounted for only 51% of the global variation in survival to hospital discharge. 
Supplemental factors accounting for the global variation in survival following OHCA may be 
variations in the population that are sought resuscitated in each emergency medical system. 
Transportation rates may vary and the number of patients with OHCA that have their treatment 
terminated prehospitally may influence the survival. If an EMS initiates resuscitation in all patients 
with cardiac arrest – even patients with obvious signs of death, different considerations of who to 
include in the calculations may skew the survival rate. Similarly, local regulations or guidelines 
concerning the withholding and termination of resuscitation may influence the survival rate when 
comparing outcomes between different EMS systems (22, 23).  
The European Resuscitation Council (ERC) stated in their 2021 guidelines that the EMS systems 
should define and implement criteria for the withholding and termination of CPR in OHCA, taking 
into consideration the specific local legal, organizational, and cultural context (24).  
Validating Termination-of-Resuscitation guidelines locally could be challenging both ethically and 
epidemiologically. This would ultimately require a prospective study with a transportation rate of 
100%, which would put an immense amount of pressure on the limited sources of the EMS systems.  
In this survey, we want to describe the international and national variations in the initiation, the 
termination of resuscitation, and the refraining from resuscitation of adult patients (>18 years of 
age) suffering from non-traumatic OHCA. Specifically, we want to describe differences in initiation-, 

termination-, and practices of refraining from resuscitation in OHCA and the guidance documents 
or legislation that govern these practices.  
Method  
Study design 
We have developed an online cross-sectional mixed-methods explanatory design survey through 
feedback from members of the European Prehospital Research Alliance (EUPHOREA), a review of 
published literature, and following consensus among the authors. The survey is designed in 
accordance with the CROSS checklist (25) and will be conducted from May 2022 until June 2022. 
Population 
Members of the EUPHOREA, the International Liaison Committee of Resuscitation (ILCOR), the 
European Resuscitation Council, and the Resuscitation Academy are invited to participate. In total, 
more than 35 countries will be invited. Each invited country will have to identify at least two 
national experts with special expertise in prehospital resuscitation practices. We exclude countries 
with less than two respondents.  
Survey 
We plan to perform a pilot test of the questionnaire in five countries with divergent EMS systems. 
This pilot study will enable us to improve the questionnaire. The questionnaire will be modulated 
following feedback received during the pilot test. If there are major changes, the questionnaire will 
be tested again in all settings. To maximize data quality, participants will be contacted in case of 
missing data or major discrepancies in the answers from the same country.  
Data 
The database will consist of both qualitative and quantitative data. REDCap, an online questionnaire 
tool, will be used to share the questionnaire with the participants and to record the data. The 
survey is conducted using an approved server provided by Odense Patient data Explorative Network 
(OPEN), at Odense University Hospital and the University of Southern Denmark. Analyses will be 
conducted using STATA (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: 
StataCorp LLC) and NVivo (qualitative data analysis software; QSR International Pty Ltd. Version 12, 
2018). The answers will be anonymized when eligible for analysis.  

Analysis 
Prior to the initiation of the study, the questionnaire will be tested among experts, and an 
agreement regarding the content of the questionnaire is made. If none or only one participant 
responds on behalf of a country or region, that particular country/region will be ineligible for 
analysis. Quantitative data will be presented as frequencies and proportions. Qualitative data will 
be analyzed using content analysis (26).  
This study is registered with ClinicalTrials.gov (NCT05029180). 
 
Perspective  
This survey could be of importance in understanding the multiple factors leading to the substantial 
variation in survival found following OHCA. Understanding both international and regional 
differences in resuscitation practices and the outcome will help improve EMS system characteristics 
(4, 11, 27). Using these data and analyses, different countries, regions, and systems may be able to 
benchmark themselves. Furthermore, the interpretation of future studies on OHCA from different 
settings may be improved to further increase survival following OHCA.  
Strengths and limitations  
The objectiveness in the questions, a reflective stage, and the need for providing evidence when 
answering, decreases the possibility of perception bias and recall bias. We further consider that it 
will reduce the risk of any Hawthorne effect and availability bias. Since the questionnaire is only 
available in English and the provided evidence from respondents may be in their native language, 
there is a risk of language bias. As the number of respondents is limited, not all the regional 
differences may be described.  
Ethics  
The Danish Health and Medicines Authority has approved the study (Ref. No. 3-3013-3088/1). All 
regulations of data security will be complied with and are approved by the Region of Southern 
Denmark (Ref. No. 21/23002). Since this survey regards organizational differences, no formal 
contact with patients is established. 
 

Publication 
This study will be part of a PhD thesis “Termination of Resuscitation in a physician-manned 
Emergency Medical System” and published in a peer-reviewed journal with the PhD student as the 
first author and other authors included according to the Vancouver rules for authorship. The 
participants of the questionnaire are listed as collaborators in any publications related to this study.  
Conflicts of interest and financial disclosure 
The authors have no conflicts of interest and there are no financial relationships related to this 
study.  
Funding 
This study is part of a PhD program supported with grants from the Laerdal Foundation and The 
Danish Helicopter Emergency Medical Service Research Foundation.  
 

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