Grey areas: New Zealand ambulance personnel’s experiences of challenging resuscitation decision-making

Highlights

• Highly-experienced participants still characterised decision-making as challenging.

• A lack of information or mixed prognostic factors increased uncertainty.

• Exceptional or unfamiliar contexts were more challenging.

• Environmental conditions, logistics and bystander behaviour impacted on decisions.

• Awareness of personal values and stressors may facilitate certainty and coping.

Abstract

Introduction

When faced with a patient in cardiac arrest, ambulance personnel must rapidly make complex decisions with limited information. Much of the research examining decisions to commence, continue, withhold or terminate resuscitation has used retrospective audits of registry data and clinical documentation. This study offers a provider-perspective which characterises uncertainty and highlights clinical, cognitive, emotional and physical demands associated with decision-making in the cardiac arrest context.

Method

Semi-structured interviews with a purposive sample of sixteen demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles across New Zealand.

Results

All participants readily identified clinical, cognitive, emotional and ethical challenges associated with resuscitation decision-making. Four main themes were identified: grey areas; exceptional cases; scene challenges; and personal responses. A lack of information or a mix of favourable and unfavourable prognostic factors created decision-making uncertainty or “grey areas”. Exceptional cases such as first-encounters also increased uncertainty and presented emotional, ethical and clinical challenges. Cardiac arrest scenes were often challenging, and participants described managing bystander expectations and responses and logistical limitations including adverse environmental conditions, fatigue and task-overload, and crew resource management.

Conclusion

This unique research presents a provider-perspective on the challenges faced by ambulance personnel deciding to commence, continue, withhold or terminate resuscitation efforts. Knowledge of personal values and strategies for managing personal responses appear to be central to certainty and coping. Simulated training should move beyond resuscitation task performance, to incorporate challenging elements and encourage ambulance personnel to explore their personal values, stressors and coping strategies.

Introduction

For the majority of out of hospital cardiac arrest patients, the event heralds imminent death [1]. For those with a reversible cause, prompt initiation of the aptly-named chain of survival is vital, as delays reduce the odds of return of circulation, and increase subsequent morbidity and mortality [2]. Emergency ambulance staff attending cardiac arrests are often expected to make rapid judgements in demanding circumstances, with limited available information [3]. With increasingly aged and comorbid populations, initiation of resuscitation or prolonged resuscitation efforts may not be appropriate for all patients found in cardiac arrest in the community [4], [5]. In recognition of the limitations of resuscitation, select emergency ambulance providers in many countries are authorised to commence, continue, withhold or terminate resuscitation in accordance with local guidelines [6], [7]. Evidence-based rules for termination of resuscitation have been developed and implemented [6], [8], but intra-arrest prognostication can be fraught with uncertainty and there is a lack of international consensus [5], [9], [10].

Resuscitation decision-making research designs commonly involve retrospective analysis of cardiac registry data and clinical records, and although this has significant utility in associating arrest variables with patient outcomes, it may not capture the complex and idiosyncratic experience of resuscitation decision-makers [11]. The purpose of this study was to identify the clinical, ethical, cognitive and emotional challenges that emergency ambulance personnel experience when making decisions to commence, continue, withhold or terminate resuscitation. Identifying challenges encountered by emergency ambulance personnel called to patients in cardiac arrest has important implications for guideline development and the preparation and support of ambulance personnel.

In New Zealand, cardiac arrests in the community are usually attended by ambulance personnel with varying levels of qualification and skill authorisation. Intensive Care Paramedics are the definitive prehospital resuscitation providers attending most community cardiac arrests, although basic life support ‘co-responders’ – often the New Zealand Fire Service – are commonly first on scene. Medical advisors can be consulted by phone, but doctors rarely attend emergency callouts [7], [12].