Short summary

Out-of-hospital cardiac arrest in Denmark is always treated with involvement of a prehospital physician. Previously, it has been shown that the physicians' decision to resuscitate may be a complex matter influenced by factors not easily documented in the patients' medical records. We will perform a series of studies, to investigate whether the present Danish principles of resuscitation at the discretion of the pre-hospital physician may result in lack of uniformity in treatment and furthermore elucidate the ethical issues surrounding resuscitation carried out by pre-hospital physicians.

Rationale

According to Danish legislation, the declaration of life extinct is a decision to be made by a physician. The time lapse from the moment a patient enters cardiac arrest and till irreversible death occurs cannot be uniformly defined. Barring the occurrence of reliable signs of death there is no exact definition of the moment when it is obvious that resuscitation is futile and that death has occurred. The decision to initiate or refrain from resuscitation may thus be disputed and should be based on individual assessment of the ethical aspects of resuscitation. While the ethical aspects of life-and-death decisions are often considered in plenary within the hospital, the pre-hospital physician may be faced with the ethical dilemma whether to initiate or refrain from resuscitative efforts in cardiac arrest. Due to the organization of the emergency medical systems, the pre-hospital physician is expected to handle this dilemma without recourse to collegial advice as usually only one pre-hospital physician is present. This may reduce the quality of the important life-and-death decisions. The absence of collegial advice is in stark contrast to the conditions that apply within the hospitals. Within the hospitals, the public nature of plenary-type consultation that occurs when discussing resuscitation usually is aided by the explicit formulation of the ethical considerations that comes with the public nature of plenary-type consultation. This arguably in itself has a positive influence on the quality of the decision-making. Although the ethical principles guiding pre-hospital resuscitation form an integral part of the guidelines for resuscitation, it is not known to what extent ethical considerations drive the decisions to perform pre-hospital resuscitation. The documentation of ethical considerations has previously been proven to be sparse in the pre-hospital setting.

Only a few papers have investigated the drivers of the pre-hospital physicians' attempt to resuscitate or not. These studies have concluded that pre-hospital physicians may base their decision to resuscitate or to refrain from resuscitation not only on combinations of validated criteria, but also on intuitive perceptions of outcome, obvious deterioration of functional independence, pre-existing obvious cognitive impairment, prolonged anoxia, terminal cancer, or cardiac arrest in connection with trauma. The decision drivers probably include both patient related factors (e.g. known comorbidity, patients' delay, relatives' delay), ethical issues as well as system related factors (e.g. delay in handling the emergency call, response time).  

PURPOSE

The overall purpose of this project is to elucidate the present knowledge concerning ethical issues pertaining to pre-hospital resuscitation. Furthermore, by interviewing pre-hospital physicians and analyzing the potential ethical considerations stated by the physicians, another aim of the study is to produce a template covering potential ethical considerations that are put into play when deciding to resuscitate or not. This template is intended to be made universally available to all pre-hospital services dealing with these life and death considerations. A generally accepted set of decision drivers is not established. Should a template with mandatory ethical questions to be answered in conjunction with resuscitation be accepted and applied, the perspective of this project would be that all future patients suffering from cardiac arrest would receive a treatment based on the same ethical principles/standards. This would probably reduce the risk of random treatment based on the prejudices of the single physician acting at the scene. An increased focus on these decision drivers may help to qualify and enhance future considerations whether resuscitation should be attempted in any given patient. This, in effect, would lead to elimination of any suspicions of unequal treatment.

The project is intended to form a Ph.D. thesis consisting of four parts:

1) A retrospective descriptive study concerning the current practice in the Danish pre-hospital system towards the ethical aspect of decision-making and the documentation of these. 

2) A qualitative study describing the thoughts and considerations made by the pre-hospital physicians when faced with the decision to refrain from or terminate pre-hospital resuscitative efforts.

3) A mixed methods study describing the feasibility of the application of a mandatory template consisting of ethical considerations to be answered in all efforts of resuscitation by selected physician manned pre-hospital emergency medical services.

4) The compilation of a proposed universally applicable template describing ethical considerations to be made by the pre-hospital physicians when faced with the decision to refrain from or terminate pre-hospital resuscitative efforts. 

Description of the cohort

Prehospital physicians from the 5 Regions of Denmark. 

Data and biological material

Medical journals, interviews and observations. 

Collaborating researchers and departments

The Pre-hospital Research Unit, Region of Southern Denmark, Institute of Regional Health Research, University of Southern Denmark
Mobile Emergency Care Unit, Dpt. Anesthesiology V, Odense University Hospital, Denmark

• Søren Mikkelsen, MD, PhD, Consultant, Professor

Head of Research, Pre-hospital and Emergency Medicine Research Unit, Aalborg University Hospital

• Erika F. Christensen, MD, Consultant, Professor

Department of Infectious Diseases, The Department of Immigrant Medicine,Odense University Hospital

• Dorthe Susanne Nielsen, RN, Associate Professor, PhD

Philosophy, Department for the Study of Culture, University of Southern Denmark

• Lars Grassmé Binderup, Pro-dean, Associate Professor, PhD 
• Caroline Schaffalitzky de Muckadell, Associate Professor, PhD 

Emergency Medicine Research Unit, Odense University Hospital

• Annmarie Touborg Lassen, MD, PhD, DMS Consultant, Professor, Head of Research