Withholding Resuscitation in Prehospital Care
Authors: Arthur Kellermann, Joanne Lynn
Journal: Annals of Internal Medicine (2006)

Editorials2 May 2006Withholding Resuscitation in Prehospital CareArthur Kellermann, MD and Joanne Lynn, MDArthur Kellermann, MDFrom Emory University, Atlanta, GA 30322, and RAND Corporation, Arlington, VA 22202. and Joanne Lynn, MDFrom Emory University, Atlanta, GA 30322, and RAND Corporation, Arlington, VA 22202.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-144-9-200605020-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Resuscitating people who will otherwise die defines a major mission for emergency medical services (EMS) (1). Having the technical capacity to resuscitate some patients, however, does not mandate attempting it nor ensure its success. As cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) became widespread, clinicians formulated guidelines and policymakers passed laws to direct their appropriate use (2-4).Clearly, we should not attempt resuscitation if the patient is obviously dead (5). Sometimes, however, we should not attempt resuscitation when it might succeed—when the patient is approaching death and does not want resuscitation (5, 6). For hospitalized patients, we have well-established routines for avoiding unwanted resuscitation: Physicians anticipate the situation, discuss matters with the patient or family, and write orders forgoing resuscitation.In community settings and hospital emergency departments, clinicians often do not know the patient's wishes, whether for lack of time to ask or lack of routines to ensure that someone asks. For this reason, the American Heart Association (AHA) has long maintained that "except in narrowly defined circumstances … professional first responders are expected to always attempt BLS [basic life support] and ACLS" (7). The AHA's most recent ethical guidelines reiterate this imperative: You must start CPR (6). Although this policy is ethically justifiable (6, 8), emergency medical personnel and bereaved families are often anguished when the circumstances mandate attempts at resuscitation on patients who cannot benefit from the intervention and probably do not want it.The most ethically justifiable way to reduce inappropriate resuscitation attempts is to encourage seriously ill and other at-risk persons to decide their preferences and document the decision in advance. At least 42 states have implemented various methods to authorize do-not-resuscitate (DNR) orders outside the hospital, using special forms, wristbands, and registries to document the patient's wishes (9). In a few states (10, 11), the use of standard forms, such as Physician Orders for Life-Sustaining Treatment (POLST), has become sufficiently widespread to be considered routine. In Oregon, 78.3% of decedents had a written advance directive (12).Unfortunately, other states lag behind. As a result, EMS providers and emergency physicians often encounter moribund patients, usually in the final stages of a chronic illness, who lack a legally valid advance directive (13). When one of these patients suddenly has cardiac arrest, what should an emergency responder or emergency physician do?A nationwide survey of more than 1200 emergency physicians revealed that 30% often or always honor unofficial DNR documents or a family member's report of the patient's wishes. However, most respondents, citing fear of criticism or legal liability, say that they would initiate resuscitation. More than half reported that they had, in the previous 3 years, attempted more than 10 resuscitations that they expected to be futile (14).Emergency medical services personnel have even less latitude than do emergency physicians. If standing orders require them to initiate resuscitation in the absence of an advance directive, that is exactly what they do—regardless of the family's wishes. Not surprisingly, such attempts almost never benefit the patient and often upset the patient's family and the EMS team.It doesn't have to be this way. In this issue, Feder and colleagues (15) describe what happened when King County, Washington, allowed EMS personnel to withhold resuscitation from terminally ill patients if a family member or caregiver at the scene verbally reported that the patient did not want resuscitation, even without a state-sanctioned DNR document. The guidelines do not require checking with a physician. Because the guidelines departed markedly from previous practice, local agencies could opt out of the change. About half did, which gave the authors an opportunity to learn from a natural before-and-after experiment with a control group.In the 16 local EMS agencies that adopted the guidelines, EMS personnel withheld resuscitation nearly twice as often, from 5.9% before using the guidelines to 11.8% after using them. In the 19 agencies that declined to adopt the guidelines, the proportion of withheld resuscitation attempts did not change (5.8% before vs. 4.2% after). In agencies that adopted the guidelines, nearly all of the increases in withholding CPR arose from honoring verbal requests. Most people who called EMS but later declined resuscitation "didn't know what else to do," sought someone to confirm death, or required immediate assistance for a frightening complication, such as dyspnea or coughing blood. These laypeople needed help, not someone to start CPR.Critics of the study will note that the groups were self-selected, that the study has limited generalizability, and that the number of withheld resuscitations was small. Widespread implementation certainly would require evaluating King County's guidelines in communities outside the northwestern United States, with its unusually strong history of empowering patients to control the circumstances of their deaths.Although we commend the authors for their humanity and diligence in conducting this evaluation, the guidelines do raise practical concerns. How can EMS providers decide if a physically wasted person has an undiagnosed but reversible condition or a "terminal" illness? If the home is orderly and prosperous, will EMS personnel give more deference to verbal requests given by family members? Would an EMS crew decide differently if they knew the family had a history of elder neglect, legal problems, or substance abuse? The overwhelming majority of interactions will probably be honest and loving, but a single case involving a duplicitous family member or an absent relative who later objects might stir enough outcry to scuttle the policy. Evaluations of the improved policies, such as the one reported here, will be important evidence for communities to weigh before reacting strongly.Anyone who has felt obliged to initiate CPR against his or her better judgment knows how distressing it is to feel aging ribs crack while ignoring the entreaties of a frantic spouse. Although 78% of emergency physicians who were surveyed about withholding resuscitation reported that fear of legal reprisal should not influence their decisions, 94% admitted that it does (14). If communities decide to allow on-the-spot judgments, they must provide a reasonable degree of legal protection, much as Good Samaritan laws protect physicians who respond to emergencies.Perhaps the success of Oregon and other states in encouraging patients with serious chronic illnesses to make plans in advance will inspire nationwide acceptance of a version of POLST (11). No one with a chronic disease that will probably lead to his or her death should leave the doctor's office or hospital without a discussion and documentation of his or her preferences for life-sustaining treatment, including resuscitation. Our care system should reliably make these decisions available when needed, using electronic records, bracelet or necklace indicators, POLST forms in the home, and other strategies.Still, no matter how widespread advance directives become, EMS and emergency department personnel will still confront difficult late-night decisions to initiate or withhold resuscitation. The King County guidelines offer a welcome alternative to the AHA's approach. The imperative to "always resuscitate" offers clarity but can have substantial emotional, moral, and financial costs. Health professionals have long been taught to "never say never." It may be equally wise to teach "never say always."References1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112 24 Suppl IV1-203. [PMID: 16314375] MedlineGoogle Scholar2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Landmark article July 9, 1960: Closed-chest cardiac massage. By W. B. Kouwenhoven, James R. Jude, and G. Guy Knickerbocker. JAMA. 1984;251:3133-6. [PMID: 6374176] CrossrefMedlineGoogle Scholar3. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med. 1976;295:364-6. [PMID: 934225] CrossrefMedlineGoogle Scholar4. Optimum care for hopelessly ill patients. A report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med. 1976;295:362-4. [PMID: 934224] CrossrefMedlineGoogle Scholar5. Kellermann AL. Criteria for dead-on-arrivals, prehospital termination of CPR, and do-not-resuscitate orders. Ann Emerg Med. 1993;22:47-51. [PMID: 8424615] CrossrefMedlineGoogle Scholar6. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 2: Ethical Issues. Circulation. 2005;112 24 SUPPL IV6- IV11. [PMID: 16314374] MedlineGoogle Scholar7. Cummins RO, eds. Ethical Aspects of CPR and ECC. Textbook of Advanced Cardiac Life Support. Dallas: American Heart Association; 1994. Google Scholar8. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment: Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: U.S. Government Printing Office; 1983:240-4. Google Scholar9. Sabatino CP. Survey of state EMS-DNR laws and protocols. J Law Med Ethics. 1999;27:297-315, 294. [PMID: 11067612] CrossrefMedlineGoogle Scholar10. Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc. 1998;46:1097-102. [PMID: 9736102] CrossrefMedlineGoogle Scholar11. Physician Orders for Life-Sustaining Treatment. Accessed at www.polst.org on 19 March 2006. Google Scholar12. Tilden VP, Tolle SW, Drach LL, Perrin NA. Out-of-hospital death: advance care planning, decedent symptoms, and caregiver burden. J Am Geriatr Soc. 2004;52:532-9. [PMID: 15066067] CrossrefMedlineGoogle Scholar13. Lynn J, Goldstein NE. Advance care planning for fatal chronic illness: avoiding commonplace errors and unwarranted suffering. Ann Intern Med. 2003;138:812-8. [PMID: 12755553] LinkGoogle Scholar14. Marco CA, Bessman ES, Schoenfeld CN, Kelen GD. Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians. Acad Emerg Med. 1997;4:898-904. [PMID: 9305432] CrossrefMedlineGoogle Scholar15. Feder S, Matheny RL, Loveless RS, Rea TD. Withholding resuscitation: a new approach to prehospital end-of-life decisions. Ann Intern Med. 2006;144:634-40. LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Emory University, Atlanta, GA 30322, and RAND Corporation, Arlington, VA 22202.Grant Support: None.Disclosures: None disclosed.Corresponding Author: Arthur Kellermann, MD, MPH, Department of Emergency Medicine, School of Medicine, Emory University, 531 Asbury Circle Annex, Suite N340, Atlanta, GA 30322; e-mail, [email protected]edu.Current Author Addresses: Dr. Kellermann: Department of Emergency Medicine, School of Medicine, Emory University, 531 Asbury Circle Annex, Suite N340, Atlanta, GA 30322.Dr. Lynn: RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoWithholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions Sylvia Feder , Roger L. Matheny , Robert S. Loveless Jr , and Thomas D. Rea Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions Stuart Farber , Jim Shaw , Jeff Mero , and W. Hugh Maloney Metrics Cited ByTermination of resuscitation in the out-of-hospital settingPart 1: Executive SummaryPart 3: EthicsÉtica de las decisiones en resucitación cardiopulmonarAn Intensive Care Unit Taking Off!End of LifeParamedic Knowledge, Attitudes, and Training in End-of-Life CareTRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care?The POLST (Physician Orders for Life-Sustaining Treatment) Paradigm to Improve End-of-Life Care: Potential State Legal Barriers to Implementation 2 May 2006Volume 144, Issue 9Page: 692-693KeywordsCaregiversEmergency medicineFearHeartResuscitation ePublished: 2 May 2006 Issue Published: 2 May 2006 CopyrightCopyright © 2006 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...