Resuscitation decision making by New Mexico emergency medical technicians

Resuscitation Decision Making by New Mexico Emergency Medical Technicians DAVID R. JOHNSON, The extent to which Emer9ency Medical Senlce personnel are placed in situations In which difficult cardiopulmonary resuscitation de&ions must be made has been poorly explored. Further, it is not known whether this kind of de&Ion making is troubling to emergency medlcal technicians. Atthouoh It is likely that amergency medical service systems handle withholding cardlopulmonaty rasuscitatlon in a variety of ways, the authors chose to examine a cross-section of New Mexico emergency medical technicians. Utinp a survey Instrument, emergency medical technicians of all tralninp levels, raprasentlno several emergency medlcal setvlce tyatems around the atate were asked how many times in their career they had been in a situation in which cardiopulmonary resuscitation had been withheld without a direct physiclan order. Of 310 individuals surveyed, 211 (66.6%) responded that this had occurred at least once. When asked whether they had been tmubled by one of these situations, 66 of 211 (41%) individuals responded “yes.” When a variety of demo9raphic factors were evaluated, only trainin to the paramedic level was Identified as belnp an Independent predictor of those who were troubled (P = .019). Emergency medical technician trainln9, protocols, and do not resuscitate proprams may need to be expanded to give further 9uldance to prehospltal personnel when making difficult resuscitation declslons. (Am J Emerg Mad 1993;11:139-142. Copyright 0 1993 by W.6. Saunders Company)

In New Mexico, emergency medical technicians (EMTs) are taught to initiate cardiopulmonary resuscitation (CPR) according to American Heart Association standards. They are generally taught to withhold CPR in only a few situations: decapitation, livor or rigor mortis, or tissue decomposition.’ Many other patients who present in cardiac arrest from major trauma or terminal illness have an equally bleak prognosis. Some have questioned the use of CPR in these patients. ‘y3 We believe that EMTs are often aware of this and hence speculated that there may be occasions when EMTs do not initiate CPR according to their teaching or protocols. Further, we were curious whether these situations troubled EMTs. If so, it may be reasonable to expand emergency medical service (EMS) teaching and protocols to provide better guidance when difficult resuscitation issues arise.

From the ‘Department of Emergency Medicine and the tNew Mexico Emergency Medical Services Academy, University of New Mexico, Albuquerque, NM. Manuscript received July 10, 1992; revision accepted October 9, 1992. Presented at the 1991 New Mexico American College of Emergency Physicians Emergency Medicine Symposium, Albuquerque, NM, May 1991. Address reprint requests to Dr Johnson, University of New Mexico School of Medicine Emergency Medical Services Academy, 620 Camino de Salud NE, Albuquerque, NM 67131. Key Words: Cardiopulmonary resuscitation, do not resuscitate,.emergency medical technician, prehospital ethics. Copyright 8 1993 by W.B. Saunders Company 0735-6757193111 OS-0009$5.00/O

MD,*t

W. ANN MAGGIORE,

JD, NREMT-P*

MATERIALSAND METHODS A survey instrument was used to collect the data during conferences and training sessions. These questionnaires were administered by one of the authors or a service director, and all were returned. The respondents represented EMTs from several EMS systems around New Mexico, each having separate medical directors and treatment protocols. A review of individual protocols and discussions with medical directors or service directors indicated that no system provided guidance regarding limiting resuscitation other than what had been taught in EMT classes. During the study period, all EMT training curricula were developed by the New Mexico EMS Academy in accordance with the National Department of Transportation standards. The questionnaires asked for demographic information including age, sex, and educational level. Educational level was given a rank of one through five, with one corresponding to high school graduate and five corresponding to a graduate degree. Professional data about each EMT included training level, years of EMS service, and whether the EMT was paid or volunteer. Those who reported being both paid and volunteer were ultimately classified as being paid. Information about each EMT’s primary service affiliation was also collected. This included type of community (urban, population greater than 30,000, or rural), and number of runs annually. The annual number of runs was given a ranking of one (5,000). The survey included the question: “How many times in your career as an EMT have you treated a patient in full cardiac arrest from any cause (medical or trauma), and CPR was not initiated for any reason?” Participants were asked to exclude times when a direct physician order to withhold CPR was elicited. Possible answers were never, once, two to five times, five to 10 times, and 10 times or more. Those who answered once or more were then asked: “Did this decision trouble you?” They were also given the opportunity to briefly state why or why not. Those who were troubled were then asked if they had discussed their concerns with their medical director. Multiple logistical regression was used to evaluate factors that might be predictive of EMTs being in a situation in which CPR was withheld and whether they would be troubled by this. All analysis was done using the EGRET statistical package (Statistics and Epidemiology Research Corp, Seattle, WA). An alpha of less than 0.05 was considered statistically significant. This study was reviewed by the University of New Mexico School of Medicine Human Research Review Committee.

RESULTS All 326 questionnaires that were administered were returned. Sixteen questionnaires were excluded because important information was missing, leaving 310 for analysis. Table 1 shows the demographic information of the study population. Respondents were evenly split according to training level. A majority of them were male with a similar percentage being paid. A total of 211 (68%) of the respondents indicated that on one or more occasions they had been 139

AMERICAN JOURNAL OF EMERGENCY MEDICINE I Volume 11, Number 2 I March 1993

140

TABLE1.

TABLE3. Independent Predictors of Having Withheld Resuscitation One or More Times

Demographics (N = 310) Mean + SD

Age Years of EMS experience

33.7 -t 8.2 yr 7.3 2 7.2 yr

Training level EMT-B

1.ooo

Count (%) EMT-I Training level EMT-basic EMT-intermediate EMT-paramedic Sex Male Female Pay status Paid Volunteer Community type Rural (population <30,000) Urban (population r30,OOO) Service runs per year Less than 100 100 to 500 500 to 1,000 1000 to 5,000 Over 5,000 NA Education High school/GED Some college Bachelor’s degree Graduate work or degree NA ABBREVIATIONS:

107 (34.5%) 84 (27.1%) 119 (38.4%) 235 (75.8%) 75 (24.2%) 217 (70.0%) 93 (30.0%) 141 (45.5%) 189 (54.5%) 68 (22.2%) 35 (11.4%) 13 (4.2%) 71 (23.1%) 120 (39.1%) 3 (1.0%) 77 (24.9%) 179 (57.9%) 30 (9.7%) 23 (7.5%) 1 (
NA, no answer; GED, general equivalancy de-

gree.

in a situation in which resuscitation was withheld (Table 2). A total of 75 (24%) of the respondents indicated that they had been in the situation 10 or more times. Of the 211 EMTs who had been in the situation described, 81 (41%) indicated that they had felt troubled by the experience. Of those who reported feeling troubled, 47% reported that they had spoken to their medical director about the situation(s). The factors that were independently predictive of having withheld resuscitation were training level, years of service, and call volume (Table 3). Training level, however, was the only independent predictor of those EMTs who were troubled by the decision to withhold resuscitation (Table 4). Paramedics were more likely to be troubled by this decision than the combined group of intermediate and basic EMTs (P = .019). The questionnaires also left space for participants to briefly describe why they were troubled or not by the decision to withhold resuscitation. While these comments TABLE2. Emergency Medical Technicians of All Training Levels Who Had Withheld Resuscitation One or more times (N = 310) Ten or more times (N = 310) Troubled (N = 211)

211 (68%) 75 (24%) 81 (41%)

Probability Value

Odds Ratio

EMT-P Years of experience <5 yrs 5 to 10 yrs >lO yrs Service runs per year
I

<.OOl

1

<.OOl

>

<.OOl

1

.002

>

,712

1

,173

1

,014

1

,009

4.139 6.033 1.ooo 3.460 3.372 1.000

100 to 500

0.8258

500 to 1,000

3.391

1,000 to 5,000

5.633

Over 5,000

6.278

yielded interesting information, they could not be quantitatively analyzed (see Discussion). DISCUSSION Ethical decision making regarding resuscitation has been widely discussed for the hospital setting.4 In recent years this has also become a major issue in prehospital care.5 Much of the prehospital literature on this topic has centered around do not resuscitate (DNR) orders and advance directives.6-8 Situations in which advance directives or prehospital DNR protocols do not exist, and resuscitation is unlikely to benefit the patient, have recently received some attention.’ EMTs are exposed to a wide variety of resuscitation scenarios. Our survey indicated that EMTs are not initiating resuscitation on every patient who is found pulseless and apneic. It should be noted that when these data were collected there were no formal state or local prehospital DNR programs in existence in New Mexico. lo In addition, reviews of individual system protocols or discussions with medical or service directors indicated that no EMS system had addressed limiting resuscitation in specific circumstances other than what was taught at the New Mexico EMS Academy. During the study period, the EMS Academy curricula at all training levels regarding resuscitation was the same: in the absence of a direct physician order, EMTs are to initiate resuscitation on all patients unless decapitation, decomposition, or liver/rigor mortis exist. One potential problem in this study is that the question asked of these EMTs did not specifically exclude these conditions. However, the vast majority of “troubled” EMTs commented on the reasons for their distress. Their comments indicated that these clearly irreversible conditions were not the source of problems in prehospital resuscitation decision making. In addition, there were no comments that

JOHNSON

AND MAGGIORE

n RESUSCITATION

TABLE 4. Independent Predictors Withholding Resuscitation

of Being “Troubled”

MAKING

by

Probability Value

Odds Ratio Training level EMT-B

DECISION

1.000

EMT-I

1.010

EMT-P EMT-B and EMT-l

1.958 1.000

EMT-P

1.947

I

,980

1

,076

1

,019

indicated that the visual impact of decapitation or decomposition was the source of distress. Rather, they cited issues such as inadequate training, terminal illness, legal concerns, unknown “down time,” and concerns for family members. Unfortunately, a complete listing of all of the comments received would be impossible. This study is also somewhat limited by the fact that we made no attempt to determine the medical or ethical appropriateness of withholding resuscitation. We sought only to get an estimate of how frequently EMTs are faced with this issue and whether they are comfortable with this level of decision making. These data support the conclusions that withholding resuscitation in the prehospital setting is common and that it is a source of distress for many EMTs. It appears from our data that the factors associated with being in situations in which resuscitation is withheld are call volume, level of training, and years of service. It seems reasonable to conclude from this that most EMTs who remain active for a long period of time will be placed in this situation at least once, if not many times. We also attempted to evaluate which EMTs were the most troubled by this kind of decision making. Our statistical analysis isolated training level from other factors. Individuals trained to the paramedic level were significantly more likely to be troubled by resuscitation decision making when compared with the combined group of basic and intermediate EMTs. Factors such as age, sex, educational level, and other demographic variables did not seem to be important in this small sample. It should be noted, however, that this sample may not be truly representative of EMTs across the state. The numbers of EMTs of each of the three training levels was similar in this study despite the fact that in New Mexico basic EMTs outnumber intermediates and paramedics by approximately seven to one. It is also quite possible that paramedics, in general, have been exposed to many more resuscitations and, as a result, are more likely to have faced a difficult situation. It is also possible that paramedics have received sufficient training to realize that resuscitation is not a simple issue. Some of the comments we received from paramedics who were troubled by resuscitation decisions bear out this possibility. One paramedic said: “I don’t like to see people die. However, there are times when there is very little hope for survival. I believe that patients should be allowed to die with dignity.” Another paramedic stated: “I knew it was against the bounds of licensure, but 1 wanted the situation to be as comfortable as

141

possible for the family.” Attitudes such as these may reflect a deep sense of caring, but also raise serious legal concerns. While the morally correct decision may have been made, what is the potential liability for EMS systems and medical directors? Advanced age, terminal illness, and estimated “down time” were frequently cited as reasons for withholding resuscitation. Some investigators have questioned the value of initiating resuscitation in unwitnessed arrests with symptoms of more than 15 minutes’ duration and asystole as a presenting rhythm.’ We are aware of no EMS services in New Mexico that use these criteria in prehospital proto~01s.‘~ This was summed up by another paramedic, who wrote: “I did not always agree with the decision. 1 felt that this situation was not adequately covered by protocols.” Traumatic arrests were also cited as an area of concern. The comments received indicated that many EMTs understood that traumatic arrest has a poor prognosis and that CPR is probably not beneficial in these cases.3 This fact, however, may not be adequately reflected in their training or protocols. It seems reasonable that the poor prognosis of traumatic cardiac arrest should be reflected in prehospital protocols. A number of EMTs also commented that they were troubled that the decision not to resuscitate was often made by someone else. Some individuals reported being denied access to patients by law enforcement personnel. One paramedic noted that he had not been allowed to resuscitate patients “on several occasions” in order that crime scenes be protected. All of these comments seemed to indicate that police are sometimes more interested in investigating crimes than in allowing EMTs to perform their jobs. Scene safety, however, was not cited as an issue. Regardless of the variety of reasons for not initiating resuscitation, the simple fact that these situations occur relatively frequently in New Mexico is a significant concern. Resuscitation decision making is often complex and should be guided by physician medical directors. We do not know whether the medical directors in this state are aware of the potential liability in these decisions. Less than half of the “troubled” EMTs reported discussing these cases with their medical directors. There appear to be four categories of patients who present to prehospital providers in cardiopulmonary arrest. One category includes those patients who have left advance directives or who have been placed on DNR status by physicians. A second category includes patients without advance directives but who are clearly expected to die. This group is perhaps one source of stress experienced by EMTs in our study. A third category of patients is those who die unexpectedly, but who have a very poor prognosis for resuscitation. This group includes prehospital trauma arrests and arrests with prolonged down times or cardiovascular unresponsiveness. The final group includes those patients who experience sudden death but are potentially salvageable. It is for this group that emergency medical services with advanced life support capability were developed. It is, however, frequently difficult to identify and separate this group from the other three. We do not know whether EMTs are making medically sound, legally defensible, or ethically correct resuscitation

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AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 11, Number 2 n March 1993

decisions. We do know, however, that EMTs are making these decisions. Training, prehospital protocols, DNR programs, and physician involvement should be expanded to address complex resuscitation issues. CONCLUSION EMTs are often in situations in which resuscitation of patients in cardiopulmonary arrest is not initiated. Many EMTs reported being troubled by the decision to not attempt resuscitation. Paramedics were more likely to be troubled by these decisions than basic and intermediate EMTs. This study may indicate a need for prehospital DNR programs as well as expansion of training and protocols to address resuscitation issues. We would like to thank Dr Dorothy Pathak for her assistance in the statistical analysis. Professors Rob Schwartz and Joan Gibson of the UNM School of Law also provided valuable assistance and encouragement.

2. Blackhall LJ: Must we always use CPR? N Engl J Med 1987;317:1281-1285 (editorial) 3. Mattox KL, Feleciano DV: Role of external cardiac compression in truncal trauma. J Trauma 1982;22:934-936 4. AMA Council on Ethical and Judicial Affairs: Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991; 2651868-1871 5. Stratton SJ: Withholding CPR in the prehospital setting. Prehospital Disaster Med 1990;5:45-46 6. Miles SH, Crimmins TJ: Orders to limit emergency treatment for an ambulance service in a large metropolitan area. JAMA 1985;254:525-527 7. American College of Emergency Physicians Guidelines for ‘do not resuscitate’ orders in the prehospital setting. Ann Emerg Med 1988;17:1106-1108 8. lserson KV: Foregoing prehospital care: Should ambulance staff always resuscitate? J Med Ethics 1991;17:19-24

REFERENCES

9. Aprahamian C, Thompson BM, Gruehow HW, et al: Decision making in prehospital cardiac arrest. Ann Emerg Med 1986; 15 1445-449

1. American Heart Association: Instructor’s Manual for Basic Life Support. Dallas, TX, American Heart Association, 1987, p 165

10. Sachs GA, Miles SH, Levin RA: Limiting resuscitation: Emerging policy in the emergency medical system. Ann Intern Med 1991;114:151-154