Natalie Anderson is presenting her research exploring paramedic experiences with resuscitation decision-making at the 6th International Public Health Palliative Care Conference in Sydney. In this blog she focuses on the implications of her PhD findings from a public health palliative care perspective.Follow @CerebralNurse
Every year, NZ ambulance personnel are responded to thousands of pulseless patients, found collapsed in the community. Fire & Emergency New Zealand commonly co-respond, but ambulance paramedics are New Zealand’s definitive providers of out-of-hospital resuscitation care – it is rare to have a doctor on-scene.
Cardiac arrest is a feature of all deaths, so resuscitation efforts are sometimes unwanted or inappropriate, and often unsuccessful. Acknowledging this, NZ paramedics are authorised to withhold (not start) or terminate (stop) resuscitation in accordance with guidelines, then formally verify death (National Ambulance Sector Clinical Working Group, 2017). Resuscitation is only attempted by emergency ambulance staff in a little under half of the pulseless patients they encounter. Even where resuscitation is attempted, the majority will be terminated (stopped) on scene. This means over 85% of cardiac arrested patients attended by paramedics are ultimately declared dead in the community (Dicker, Davey, Smith, & Beck, 2018; Dicker, Oliver, & Tunnage, 2018).
With a background in psychology and experience with clinical education and resuscitation, I was interested in paramedics’ decisions to start and stop resuscitation. The decision to start, continue or stop resuscitation seemed complex and important and I was curious about how they were prepared and supported to make and enact these decisions. Before I developed my research questions, I reviewed the existing research exploring resuscitation decision making in out of hospital cardiac arrest. Research had focused on optimising survival from cardiac arrest and developing ways to predict survival or futility, but very little was known about the experience of paramedics making and enacting decisions to start or stop resuscitation (Anderson, Gott, & Slark, 2017). A subsequent scoping review also highlighted how little was known about preparation and support of paramedics for the challenges of unsuccessful resuscitation and patient death (Anderson, Slark, & Gott, 2019).
My PhD research has explored paramedics’ perspectives on – and preparation and support for – resuscitation decision-making. I undertook a mixed-methods sequential exploratory research project including systematic reviews of the literature, interviews with ambulance personnel, focus groups with ambulance educators and peer support staff and an online survey of graduating paramedic students
Findings showed that the decision to withhold or terminate resuscitation can be emotionally, clinically and ethically challenging – even for highly-experienced paramedics. Knowledge of the patient and context can be difficult to elicit, with limited or conflicting information provided by those present at the scene. A patient in cardiac arrest cannot tell you what their wishes are, and even where family are present, they often haven’t discussed resuscitation or had wishes documented. Ambulance personnel can feel pressured by family members and bystanders who have called an ambulance expecting or even demanding resuscitation efforts – and success. Inexperienced ambulance personnel may ‘default’ to commencing or continuing highy-rehearsed resuscitation efforts and await senior support, because they feel unable to manage the scene of a patient death (Anderson, Gott, & Slark, 2018).
When I surveyed New Zealand paramedic students nearing the end of their three-year degree training, I asked what they felt most confident about, and what concerned them most about resuscitation decision making and patient death. Paramedic students were concerned that they make timely, appropriate resuscitation decisions which optimised care for patients and families, that they managed any conflict arising and that they controlled their own emotional responses to ensure they didn’t preclude professional performance. Paramedic students felt least confident in areas involving communication with bereaved family members such as breaking bad news and providing emotional and practical support. These are complex non-technical or psychosocial skills and although guidelines have been produced, there is no single checklist to memorise. Best practice should depend on the provider, the scene, the family, culture, nature of the death and other many other contextual factors. You can read more about the fascinating findings of this study, here: (Anderson, Slark, Faasse, & Gott, 2019).
These findings have implications for public health campaigns, particularly efforts to increase death literacy and advanced care planning. Recently, public health campaigns have promoted the ease and effectiveness of cardiopulmonary resuscitation (CPR). Easy-to-use fully-automated defibrillators are available in many public places, businesses and residential care facilities. Apps like GoodSam can alert any person trained in CPR to respond to a suspected cardiac arrest close to their location. With promotion of bystander CPR and public access to defibrillators, members of the public – including young children – are being taught to commence resuscitation efforts on all pulseless patients, with the expectation these actions will revive the patient (Bottiger et al., 2017).
These public health campaigns, along with news and entertainment media present CPR and defibrillation as highly-effective treatments and a panacea for death (Mgbako et al., 2014; Portanova, Irvine, Yi, & Enguidanos, 2015). First responders, bystanders and family members may expect resuscitation efforts to conclude with full recovery of the patient. Bystander resuscitation can and does save many lives, and these campaigns are important. What seems to be lacking is acknowledgement that CPR and defibrillation is only effective in sudden, reversible cardiac arrest and will not reverse ordinary dying (Launer, 2017).
So what does all of this mean?
Increasingly prepared by degree-based education, paramedics are trained to save lives and manage illness and injury. They are also key providers of care to patients dying in the community, often tasked with breaking bad news to family and supporting those involved in unsuccessful resuscitation efforts. Novice paramedics need and want more preparation and support to ensure they can recognise when resuscitation is unwarranted, unwanted or unsuccessful and provide skilled and compassionate care to the dying and bereaved. Public health campaigns to increase bystander resuscitation should acknowledge that CPR and defibrillation will not reverse ordinary dying. More research is needed to explore why people call ambulances when death is expected and what actions are most needed or appreciated by bereaved.
Anderson, N. E., Gott, M., & Slark, J. (2017). Commence, continue, withhold or terminate? A systematic review of resuscitation provider decision-making in out-of-hospital cardiac arrest. European Journal of Emergency Medicine, 24(2), 80-86
Anderson, N. E., Slark, J., Faasse, K., & Gott, M. (2019). Paramedic student confidence, concerns, learning and experience with resuscitation decision-making and patient death: A pilot survey. Australasian Emergency Care
Anderson, N. E., Slark, J., & Gott, M. (2019). How are ambulance personnel prepared and supported to withhold or terminate resuscitation and manage patient death in the field? A scoping review. Australasian Journal of Paramedicine, 16
Bottiger, B. W., Semeraro, F., Altemeyer, K. H., Breckwoldt, J., Kreimeier, U., Rucker, G., . . . Wingen, S. (2017). KIDS SAVE LIVES: School children education in resuscitation for Europe and the world. European Journal of Anaesthesiology, 34(12), 792-796
Mgbako, O. U., Ha, Y. P., Ranard, B. L., Hypolite, K. A., Sellers, A. M., Nadkarni, L. D., . . . Merchant, R. M. (2014). Defibrillation in the movies: a missed opportunity for public health education. Resuscitation, 85(12), 1795-1798