- Email: [email protected]
Withholding advanced cardiac life support in out-of-hospital cardiac arrest: A prospective study
Resuscitation (2008) 76, 134—136
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/resuscitation
SHORT COMMUNICATION
Withholding advanced cardiac life support in out-of-hospital cardiac arrest: A prospective study夽 es Ricard-Hibon a, Franc ¸ois-Xavier Duchateau a,∗, Alexis Burnod a, Agn` Jean Mantz a, Philippe Juvin b a
Department of Anaesthesiology and Intensive Care, Beaujon University Hospital, 100 bd du G´ en´ eral Leclerc, 92110 Clichy, France b Emergency Department, Beaujon University Hospital, 100 bd du G´ en´ eral Leclerc, 92110 Clichy, France Received 18 May 2007; received in revised form 12 June 2007; accepted 21 June 2007
KEYWORDS Cardiac arrest; Out-of-hospital CPR; Ethics
Summary Aim of the study: To evaluate the decision criteria leading to refrain from starting cardiopulmonary resuscitation (CPR) in the prehospital setting. Materials and methods: We conducted a prospective, descriptive study, in a physician-staffed emergency medical service during a 12 month period. All patients presenting with a cardiac arrest were included. Patients were allocated to two groups: immediate decision to give CPR (R group) or withholding CPR (NR group). Characteristics of patients including previous health status, time intervals, therapies and outcomes, were collected. Data were compared between the two groups, * p < 0.05. Results: One hundred and fourteen patients (aged 61 ± 18 years) were enrolled in R group and 113 (73 ± 19 years*) in NR group. Patients of NR group more frequently presented with a deterioration of functional independence (51% versus 10%*), cognitive impairment (21% versus 8%*) and higher McCabe score and Knaus class (McCabe 2: 24% versus 2%*; Knaus class D: 23% versus 3%*). Presence of a bystander (75% versus 44%*) or basic life support (BLS) started by the bystander (40% versus 12%*) were more frequent in R than NR. Age (OR, 1.1; 95% CI, 1.0—1.1), McCabe score >0 (OR, 10.5; 95% CI, 1.4—79.0), lack of bystander BLS (OR, 11.2; 95% CI, 2.2—60.7) and ineffectiveness of BLS by EMTs (OR, 12.1; 95% CI, 2.0—72.8) were independent factors of withholding CPR. The physician conducted often the discussion alone (48%). Conclusion: Decision criteria leading to refrain from starting CPR in the prehospital setting are age, previous health status and initial BLS. Further thought should be allowed to ensure a share in the decision-making process in this particular practice. © 2007 Elsevier Ireland Ltd. All rights reserved.
夽
A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2007.06.018. ∗ Corresponding author. Tel.: +33 6 12 11 76 31; fax: +33 1 40 87 58 59. E-mail address: [email protected] (F.-X. Duchateau). 0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2007.06.018
Withholding advanced cardiac life support
135
Introduction When confronted with cardiac arrest, physicians of emergency medical service (EMS) have to decide immediately whether to resuscitate or not. In the prehospital critical medicine, particular aspects are the lack of complete information concerning the patient, isolation and a need for an immediate decision-making, reasons for not initiating cardiopulmonary resuscitation (CPR) were rarely evaluated. The aim of this study was to evaluate the decision criteria leading to refrain from starting CPR in prehospital critical care medicine.
Materials and methods The study is a prospective, descriptive study, which was conducted in a physician-staffed emergency medical service, covering an area with 290,172 inhabitants during a 12 months period. Emergency medical technicians (EMTs) staffed ambulances participate also in the EMS system and start basic life support (BLS) measures before the arrival of the medical team. All patients presenting with a cardiac arrest of any cause and managed by our EMS unit were included prospectively. Characteristics of patients including previous health status (McCabe and Knaus scoring system1,2 ), conditions of intervention, factors related with the event, time intervals, therapies and outcomes were collected during the intervention. The initial decision by the physician (whether to resuscitate or not) determined the allocation of the patients to one of the two groups: immediate decision to start CPR (R group) or withholding CPR (NR group).
Table 1
Data were compared between the two groups. Results are reported as mean ± S.D. for continuous variables and median for time intervals. Qualitative data are expressed as the percentage of patients. Statistical analysis was performed using an ANOVA or Mann—Whitney’s U-test for quantitative data and a 2 test for qualitative data. A multivariate analysis was also done. A p value of <0.05 was considered the threshold for significance. We used statistical package Stat-View 5® (Abacus Concept, Berkeley, CA, USA).
Results Two hundred and twenty-seven patients were included: 114 patients (aged 61 ± 18 years) in the R group and 113 in the NR group (aged 73 ± 19 years, p < 0.001). The proportion of patients undergoing CPR decreased with increasing age and was significantly lower for patients aged 80 or older when compared with patients aged under 60 (p < 0.001, Figure 1). Characteristics of patients and conditions of intervention are shown in the Table 1. Age (odds ratio (OR), 1.1; 95% confidence interval (CI), 1.0—1.1), McCabe > 0 (OR, 10.5; 95% CI, 1.4—79.0), lack of bystander BLS (OR, 11.2; 95% CI, 2.2—60.7) and ineffectiveness of BLS by EMTs (OR, 12.1; 95% CI, 2.0—72.8) were independent factors for withholding CPR. The physician conducted the discussion alone, without any consultation with the team in 48% of cases. Only five patients had expressed a wish previously concerning resuscitation (mostly do not attempt resuscitation) (four cases), and these orders were only verbal reports. The relatives expressed a request more often (15%) but this request rarely influenced the decision (four cases).
Characteristics of patients and conditions of intervention R group
NR group
p
n
%
n
%
McCabe score 0 1 and 2
84 22
79 21
60 46
57 43
<0.001
Knaus class A B C D
43 51 10 3
40 48 9 3
22 41 19 25
21 38 18 23
<0.001
Obvious deterioration of functional independence
11
10
51
53
<0.001
Obvious cognitive impairment
9
8
21
21
0.017
Factors related with the event Asystole Presence of a bystander Bystander BLS BLS by EMTs considered as effective
84 82 43 95
74 75 40 92
107 48 13 78
95 44 12 72
<0.001 <0.001 <0.001 <0.001
Time intervals Cardiac arrest—–EMTs arrival Cardiac arrest—–medical team arrival
8 [3—15] min 20 [10—30] min
12 [5—20] min 24 [15—39] min
0.050 0.013
Data are N (%) and median [interquartile range] for time intervals. Data compared with 2 test for qualitative data and Mann—Whitney’s U-test for quantitative data.
136
F.-X. Duchateau et al. factors which govern the decision to withhold prehospital CPR. In the face of an aging population,9 large prospective studies evaluating outcomes in relation with these criteria and designed to answer a the crucial question to start CPR or not, would be very valuable. Moreover, further thought should be allowed to ensure sharing in the decision-making process in this particular practice. Skills in withholding and withdrawal decisions should also be developed, as well as specific procedures and decision criteria in this particular field.
Conflicts of interest Figure 1 Proportion of patients undergoing CPR related to age. * p = 0.0003 when compared with patients aged <60. ** p = 0.0001 when compared with patients aged <60.
None.
Acknowledgments Discussion Decision criteria for not starting CPR are in accordance with previous studies.3,4 A long interval between collapse and CPR start reflects the chance of obtaining a good future quality of life.5 Despite its doubtful significance, age is still considered when deciding to initiate CPR or not.6 Underlying disease and previous general condition are also associated with presumed chance of survival and quality of life level.7 Our study suggests that McCabe score could help decision-making. The present study demonstrated also that decisions to withhold CPR are still often taken alone. We observed, that taking patient’s wish or family opinion into account is difficult in this particular setting. Events are sudden, and relatives most often unprepared for such discussions. Isolation is a specific aspect of the prehospital critical care medicine and emergency physicians are used to dealing with decisions relating to withholding and withdrawal of treatment.8 Nevertheless, withholding decisions cannot escape the necessity of a group decision-making process in such an essential question. Ethics require it and so does the law. Further thought should be given as to how to address this situation quickly in this particular setting. Encouragement to share the decision-making process inside the caregiver’s team could be the first step. In doubtful situations, we suggest starting CPR ‘in expectancy’ of further information. The usual treating physician could be called to request his point of view and get more information. We could also imagine the creation of a specific structure, available 24 h a day to help the physician to take the decision. Finally, the burden of such decisions for emergency physicians makes it necessary to encourage more frequent thought, discussions and competence in withholding and withdrawal decisions among prehospital caregivers.
Conclusions Associated with age, evaluation of previous health status using McCabe score and existence of bystander BLS are the
Franc ¸ois-Xavier Duchateau, MD, Philippe Juvin, MDPhD, and Alexis Burnod, MD, designed and supervised the study and analyzed and interpreted the data. Agn` es Ricard-Hibon, MD, did the data analysis. Jean Mantz, MDPhD, interpreted the data. Franc ¸ois-Xavier Duchateau and Philippe Juvin wrote the paper. No financial support.
References 1. McCabe WR, Jackson GG. Gram negative bacteremia: etiology and ecology. Arch Intern Med 1962;29:2132—9. 2. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9:591—7. 3. Horsted TI, Rasmussen LS, Lippert FK, et al. Outcome of out-ofhospital cardiac arrest—–why do physicians withhold resuscitation attempts? Resuscitation 2004;63:287—93. 4. Meyer W, Balck F. Resuscitation decision index: a new approach to decision-making in prehospital CPR. Resuscitation 2001;48:255—63. 5. Herlitz J, Enqdahl J, Svensson L, Anqquist KA, Young M, Holmberg S. Factors associated with increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in an national perspective in Sweden. Am Heart J 2005;149: 61—6. 6. Bunch TJ, White RD, Khan AH, Packer DL. Impact of age on longterm survival and quality of life following out-of-hospital cardiac arrest. Crit Care Med 2004;32:963—7. 7. Baskett PJF, Steen PA, Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005. Section 8. The ethics of resuscitation and end-of-life decisions. Resuscitation 2005;67S1:S171—80. 8. Ferrand E, Marty J. French LATASAMU Group: prehospital withholding and withdrawal of life-sustaining treatments. The French LATASAMU survey. Intensive Care Med 2006;32:1498— 505. 9. Libow LS. Geriatrics in the United States—–baby boomers’ boon? N Engl J Med 2005;352:750—2.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/resuscitation
SHORT COMMUNICATION
Withholding advanced cardiac life support in out-of-hospital cardiac arrest: A prospective study夽 es Ricard-Hibon a, Franc ¸ois-Xavier Duchateau a,∗, Alexis Burnod a, Agn` Jean Mantz a, Philippe Juvin b a
Department of Anaesthesiology and Intensive Care, Beaujon University Hospital, 100 bd du G´ en´ eral Leclerc, 92110 Clichy, France b Emergency Department, Beaujon University Hospital, 100 bd du G´ en´ eral Leclerc, 92110 Clichy, France Received 18 May 2007; received in revised form 12 June 2007; accepted 21 June 2007
KEYWORDS Cardiac arrest; Out-of-hospital CPR; Ethics
Summary Aim of the study: To evaluate the decision criteria leading to refrain from starting cardiopulmonary resuscitation (CPR) in the prehospital setting. Materials and methods: We conducted a prospective, descriptive study, in a physician-staffed emergency medical service during a 12 month period. All patients presenting with a cardiac arrest were included. Patients were allocated to two groups: immediate decision to give CPR (R group) or withholding CPR (NR group). Characteristics of patients including previous health status, time intervals, therapies and outcomes, were collected. Data were compared between the two groups, * p < 0.05. Results: One hundred and fourteen patients (aged 61 ± 18 years) were enrolled in R group and 113 (73 ± 19 years*) in NR group. Patients of NR group more frequently presented with a deterioration of functional independence (51% versus 10%*), cognitive impairment (21% versus 8%*) and higher McCabe score and Knaus class (McCabe 2: 24% versus 2%*; Knaus class D: 23% versus 3%*). Presence of a bystander (75% versus 44%*) or basic life support (BLS) started by the bystander (40% versus 12%*) were more frequent in R than NR. Age (OR, 1.1; 95% CI, 1.0—1.1), McCabe score >0 (OR, 10.5; 95% CI, 1.4—79.0), lack of bystander BLS (OR, 11.2; 95% CI, 2.2—60.7) and ineffectiveness of BLS by EMTs (OR, 12.1; 95% CI, 2.0—72.8) were independent factors of withholding CPR. The physician conducted often the discussion alone (48%). Conclusion: Decision criteria leading to refrain from starting CPR in the prehospital setting are age, previous health status and initial BLS. Further thought should be allowed to ensure a share in the decision-making process in this particular practice. © 2007 Elsevier Ireland Ltd. All rights reserved.
夽
A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2007.06.018. ∗ Corresponding author. Tel.: +33 6 12 11 76 31; fax: +33 1 40 87 58 59. E-mail address: [email protected] (F.-X. Duchateau). 0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2007.06.018
Withholding advanced cardiac life support
135
Introduction When confronted with cardiac arrest, physicians of emergency medical service (EMS) have to decide immediately whether to resuscitate or not. In the prehospital critical medicine, particular aspects are the lack of complete information concerning the patient, isolation and a need for an immediate decision-making, reasons for not initiating cardiopulmonary resuscitation (CPR) were rarely evaluated. The aim of this study was to evaluate the decision criteria leading to refrain from starting CPR in prehospital critical care medicine.
Materials and methods The study is a prospective, descriptive study, which was conducted in a physician-staffed emergency medical service, covering an area with 290,172 inhabitants during a 12 months period. Emergency medical technicians (EMTs) staffed ambulances participate also in the EMS system and start basic life support (BLS) measures before the arrival of the medical team. All patients presenting with a cardiac arrest of any cause and managed by our EMS unit were included prospectively. Characteristics of patients including previous health status (McCabe and Knaus scoring system1,2 ), conditions of intervention, factors related with the event, time intervals, therapies and outcomes were collected during the intervention. The initial decision by the physician (whether to resuscitate or not) determined the allocation of the patients to one of the two groups: immediate decision to start CPR (R group) or withholding CPR (NR group).
Table 1
Data were compared between the two groups. Results are reported as mean ± S.D. for continuous variables and median for time intervals. Qualitative data are expressed as the percentage of patients. Statistical analysis was performed using an ANOVA or Mann—Whitney’s U-test for quantitative data and a 2 test for qualitative data. A multivariate analysis was also done. A p value of <0.05 was considered the threshold for significance. We used statistical package Stat-View 5® (Abacus Concept, Berkeley, CA, USA).
Results Two hundred and twenty-seven patients were included: 114 patients (aged 61 ± 18 years) in the R group and 113 in the NR group (aged 73 ± 19 years, p < 0.001). The proportion of patients undergoing CPR decreased with increasing age and was significantly lower for patients aged 80 or older when compared with patients aged under 60 (p < 0.001, Figure 1). Characteristics of patients and conditions of intervention are shown in the Table 1. Age (odds ratio (OR), 1.1; 95% confidence interval (CI), 1.0—1.1), McCabe > 0 (OR, 10.5; 95% CI, 1.4—79.0), lack of bystander BLS (OR, 11.2; 95% CI, 2.2—60.7) and ineffectiveness of BLS by EMTs (OR, 12.1; 95% CI, 2.0—72.8) were independent factors for withholding CPR. The physician conducted the discussion alone, without any consultation with the team in 48% of cases. Only five patients had expressed a wish previously concerning resuscitation (mostly do not attempt resuscitation) (four cases), and these orders were only verbal reports. The relatives expressed a request more often (15%) but this request rarely influenced the decision (four cases).
Characteristics of patients and conditions of intervention R group
NR group
p
n
%
n
%
McCabe score 0 1 and 2
84 22
79 21
60 46
57 43
<0.001
Knaus class A B C D
43 51 10 3
40 48 9 3
22 41 19 25
21 38 18 23
<0.001
Obvious deterioration of functional independence
11
10
51
53
<0.001
Obvious cognitive impairment
9
8
21
21
0.017
Factors related with the event Asystole Presence of a bystander Bystander BLS BLS by EMTs considered as effective
84 82 43 95
74 75 40 92
107 48 13 78
95 44 12 72
<0.001 <0.001 <0.001 <0.001
Time intervals Cardiac arrest—–EMTs arrival Cardiac arrest—–medical team arrival
8 [3—15] min 20 [10—30] min
12 [5—20] min 24 [15—39] min
0.050 0.013
Data are N (%) and median [interquartile range] for time intervals. Data compared with 2 test for qualitative data and Mann—Whitney’s U-test for quantitative data.
136
F.-X. Duchateau et al. factors which govern the decision to withhold prehospital CPR. In the face of an aging population,9 large prospective studies evaluating outcomes in relation with these criteria and designed to answer a the crucial question to start CPR or not, would be very valuable. Moreover, further thought should be allowed to ensure sharing in the decision-making process in this particular practice. Skills in withholding and withdrawal decisions should also be developed, as well as specific procedures and decision criteria in this particular field.
Conflicts of interest Figure 1 Proportion of patients undergoing CPR related to age. * p = 0.0003 when compared with patients aged <60. ** p = 0.0001 when compared with patients aged <60.
None.
Acknowledgments Discussion Decision criteria for not starting CPR are in accordance with previous studies.3,4 A long interval between collapse and CPR start reflects the chance of obtaining a good future quality of life.5 Despite its doubtful significance, age is still considered when deciding to initiate CPR or not.6 Underlying disease and previous general condition are also associated with presumed chance of survival and quality of life level.7 Our study suggests that McCabe score could help decision-making. The present study demonstrated also that decisions to withhold CPR are still often taken alone. We observed, that taking patient’s wish or family opinion into account is difficult in this particular setting. Events are sudden, and relatives most often unprepared for such discussions. Isolation is a specific aspect of the prehospital critical care medicine and emergency physicians are used to dealing with decisions relating to withholding and withdrawal of treatment.8 Nevertheless, withholding decisions cannot escape the necessity of a group decision-making process in such an essential question. Ethics require it and so does the law. Further thought should be given as to how to address this situation quickly in this particular setting. Encouragement to share the decision-making process inside the caregiver’s team could be the first step. In doubtful situations, we suggest starting CPR ‘in expectancy’ of further information. The usual treating physician could be called to request his point of view and get more information. We could also imagine the creation of a specific structure, available 24 h a day to help the physician to take the decision. Finally, the burden of such decisions for emergency physicians makes it necessary to encourage more frequent thought, discussions and competence in withholding and withdrawal decisions among prehospital caregivers.
Conclusions Associated with age, evaluation of previous health status using McCabe score and existence of bystander BLS are the
Franc ¸ois-Xavier Duchateau, MD, Philippe Juvin, MDPhD, and Alexis Burnod, MD, designed and supervised the study and analyzed and interpreted the data. Agn` es Ricard-Hibon, MD, did the data analysis. Jean Mantz, MDPhD, interpreted the data. Franc ¸ois-Xavier Duchateau and Philippe Juvin wrote the paper. No financial support.
References 1. McCabe WR, Jackson GG. Gram negative bacteremia: etiology and ecology. Arch Intern Med 1962;29:2132—9. 2. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9:591—7. 3. Horsted TI, Rasmussen LS, Lippert FK, et al. Outcome of out-ofhospital cardiac arrest—–why do physicians withhold resuscitation attempts? Resuscitation 2004;63:287—93. 4. Meyer W, Balck F. Resuscitation decision index: a new approach to decision-making in prehospital CPR. Resuscitation 2001;48:255—63. 5. Herlitz J, Enqdahl J, Svensson L, Anqquist KA, Young M, Holmberg S. Factors associated with increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in an national perspective in Sweden. Am Heart J 2005;149: 61—6. 6. Bunch TJ, White RD, Khan AH, Packer DL. Impact of age on longterm survival and quality of life following out-of-hospital cardiac arrest. Crit Care Med 2004;32:963—7. 7. Baskett PJF, Steen PA, Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005. Section 8. The ethics of resuscitation and end-of-life decisions. Resuscitation 2005;67S1:S171—80. 8. Ferrand E, Marty J. French LATASAMU Group: prehospital withholding and withdrawal of life-sustaining treatments. The French LATASAMU survey. Intensive Care Med 2006;32:1498— 505. 9. Libow LS. Geriatrics in the United States—–baby boomers’ boon? N Engl J Med 2005;352:750—2.