As many readers of this blog know I am very interested in prehospital research. I have been talking with one of my medical control doctors and the leader of our research journal club about actually initiating our own research projects. It is not as easy as just going out and doing a project. If your goal is to actually publish your research in a respected journal, you have to follow a process known as getting approval from an IRB - Institutional Research Board - before beginning research, which involves quite a number of hoops.
A potential problem for us is the possible opinion of the IRB that the project if it involves prehospital people should be sponsored not by the hospital IRB, but by the ambulance service's IRB. Our service doesn't have one -- at least not yet. I recently corresponded with the national medical director of our company, and was quite encouraged by his plans and commitment to prehospital research utilizing the company's resources, which probably will ultimately include a company IRB.
Yesterday we had our regional paramedic skill sessions, which presented an opportunity to question over a 100 paramedics about their attitudes. We decided to go ahead with a questionnaire, even though we have not yet gained IRB approval for this particular questionnaire, as a test run for future projects, and with luck we may be able to get this project approved as well.
I have been reading a book called An Introduction to EMS Research, which is informative on the subject.
Questionnaires are one of the easist forms of research, although as the book warns, they are not as simple as they might seem. The questions need to be carefully worded. It was interesting watching the medics answer the questions, and hearing their concerns about some of the questions. I realized how I could improve the questionannaire in the future.
The goal behind this particular questionnaire was to gauge paramedic attitudes toward the DNR issue, particuarly the issue of enabling a paramedic to accept a family's verbal request not to begin resucitation on a terminally ill family member in absence of DNR papers.
King County in Washington state recently changed their protocols to allow this option and they found a large reduction in rescusitations in those services that chose to adopt the new protocol.
Futile Rescusitations
I modeled the particular scenario after one I had encountered and described in Understand.
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Paramedic DNR Study
Hypothesis: Paramedics will not deviate from state guidelines to consider a family’s verbal requests not to initiate resuscitation on a terminal patient.
Results:
Hypothesis partially disproved. 27% of paramedics when confronted with family verbal request not to implement resuscitation on a terminal patient deviate from state guidelines by not implementing at least Basic CPR prior to receiving approval from Medical Control to withhold resuscitation.
80% of paramedics favor changing protocols to honor verbal family wishes in cases of terminal patients. This may be related to years experience as a paramedic but doesn’t appear to be related to experiences initiating resuscitation against family wishes.
48% of paramedics have initiated resuscitations against family wishes. Of medics who have initiated resuscitation against family wishes 83% were bothered by the experience.
When faced with a family’s verbal request to withhold resuscitation in absence of DNR papers, only 16% would begin full resuscitation. 56% would limit initial resuscitation to basic CPR. 27% would delay CPR while contacting medical control. Actions are unrelated to years on the job or past experience.
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State Guidelines
If the field technician arrives at the scene of a clinically dead patient before a medical order not to start resuscitative measures had been given, resuscitation will be initiated while communication is established, assessment information is gathered, and a medical decision is being made, except in cases of decapitation, decomposition, transection of the torso, or incineration.
Medical control must be established early to reduce delay as resuscitative measures cannot be withheld until ordered by the physician. The on-line Medical Control physician will be given information about early assessment, findings, and procedures initiated. The physician may then order withholding resuscitation before complete resuscitative efforts have been initiated.-REFERENCE #908,EFFECTIVE MARCH 27, 1996, GUIDELINES FOR WITHHOLDING RESUSCITATION
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Potential Study Drawbacks:
While 99% of paramedics said they were aware of state regulations, it is not clear that those who said they withhold CPR while contacting medical control were aware that that action violated state guidelines.
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Paramedic DNR Study (96 completed surveys) Rough Initial Results
Favor Change in Protocol to honor verbal request 80% (8.28 years exp)
Oppose Change in protocol to honor verbal request 20% (6.05 years exp)
When faced with family verbal wishes not to implement resuscitation of a terminal patient, paramedics answered they would:
A. Immediately Begin CPR/ACLS 16% (8.4 years)
B. Begin CPR, delay ACLS, contact med control 52% (7.62 years)
C. Begin CPR, delay ALS, wait for DNR papers 4% (9.75 years)
D. Hold off CPR, contact medical control 27% (7.96 years)
E. Presume Patient Dead 0%
Have Worked Codes against Family wishes 48%
Have Not Worked Codes against Family Wishes 52%
Of those who have worked Codes against family wishes
Not Bothered 17%
Somewhat Bothered 26%
Bothered 46%
Greatly 13%
Of Those Who Have Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 78%
Oppose Change to Honor Verbal Wishes 22%
Of Those Who Have Not Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 82%
Oppose Changer Change to Honor Verbal Wishes 18%
Have Worked Codes and Favor Change 38%
Have Not Worked Codes and Favor Change 43%
Have Worked Codes and Oppose Change 10%
Have Not Worked Codes and Oppose Change 9%
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I choose D - to hold off CPR and contact medical control. I admit I did not realize it was spelled out so clearly in the state guidlines that not initialing basic CPR was a violation of the guideline. I think many medics as well as doctors may be under the impression that simply contacting medical control is okay.
I found the fact that 80% of medics would like to change the guidelines to permit verbal wishes to be honored quite telling about medics's feelings about patient dignity and toward futile resucitations.
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Here's more info on the Washington King County Protocol
Ann Intern Med. 2006 May 2;144(9):634-40.
Withholding resuscitation: a new approach to prehospital end-of-life decisions.
Feder S, Matheny RL, Loveless RS Jr, Rea TD.
King County Medic One and Kent Fire Department, Kent, Washington, USA. sylvia_feder@kcfiremed.org
BACKGROUND: Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order. OBJECTIVE: To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines. DESIGN: Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation. SETTING: King County, Washington. PATIENTS: 2770 patients with EMS-attended cardiac arrest. INTERVENTION: New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired. MEASUREMENTS: Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not. RESULTS: Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients). LIMITATIONS: The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines. CONCLUSIONS: Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.
Withholding Prehospital Resucitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)
Withholding Prehospital Resucitation (Editorial)
