Abstract
BACKGROUND: In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminally ill patients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given. METHODS: The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminal illness was determined, as was the proportion of terminally ill patients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request. RESULTS: Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001). INTERPRETATION: Paramedics are frequently called to attend terminally ill patients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death.
Full Text
The Full Text of this article is available as a PDF (248.8 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Adams J. G. Prehospital do-not-resuscitate orders: a survey of state policies in the United States. Prehosp Disaster Med. 1993 Oct-Dec;8(4):317–322. doi: 10.1017/s1049023x00040577. [DOI] [PubMed] [Google Scholar]
- Crimmins Timothy J. Ethical issues in adult resuscitation. Ann Emerg Med. 1993 Feb;22(2 Pt 2):495–501. [PubMed] [Google Scholar]
- Delbridge T. R., Fosnocht D. E., Garrison H. G., Auble T. E. Field termination of unsuccessful out-of-hospital cardiac arrest resuscitation: acceptance by family members. Ann Emerg Med. 1996 May;27(5):649–654. doi: 10.1016/s0196-0644(96)70170-1. [DOI] [PubMed] [Google Scholar]
- Fitzgerald D. J., Milzman D. P., Sulmasy D. P. Creating a dignified option: ethical considerations in the formulation of prehospital DNR protocol. Am J Emerg Med. 1995 Mar;13(2):223–228. doi: 10.1016/0735-6757(95)90099-3. [DOI] [PubMed] [Google Scholar]
- Hall S. A. An analysis of dilemmas posed by prehospital DNR orders. J Emerg Med. 1997 Jan-Feb;15(1):109–111. doi: 10.1016/s0736-4679(96)00250-8. [DOI] [PubMed] [Google Scholar]
- Iserson K. V. Foregoing prehospital care: should ambulance staff always resuscitate? J Med Ethics. 1991 Mar;17(1):19–24. doi: 10.1136/jme.17.1.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Iserson K. V., Stocking C. Standards and limits: emergency physicians' attitude toward prehospital resuscitation. Am J Emerg Med. 1993 Nov;11(6):592–594. doi: 10.1016/0735-6757(93)90008-y. [DOI] [PubMed] [Google Scholar]
- Jecker N. S., Schneiderman L. J. Ceasing futile resuscitation in the field: ethical considerations. Arch Intern Med. 1992 Dec;152(12):2392–2397. [PubMed] [Google Scholar]
- Rausch P. G., Ramzy A. I. Development of a palliative care protocol for emergency medical services. Ann Emerg Med. 1991 Dec;20(12):1383–1386. doi: 10.1016/s0196-0644(05)81088-1. [DOI] [PubMed] [Google Scholar]
- Sachs G. A., Miles S. H., Levin R. A. Limiting resuscitation: emerging policy in the emergency medical system. Ann Intern Med. 1991 Jan 15;114(2):151–154. doi: 10.7326/0003-4819-114-2-151. [DOI] [PubMed] [Google Scholar]
- Smith G. New EMS Palliative Care/DNR protocol will replace existing hospice protocol. Md Med J. 1995 Sep;44(9):717–722. [PubMed] [Google Scholar]
- Sosna D. P., Christopher M., Pesto M. M., Morando D. V., Stoddard J. Implementation strategies for a do-not-resuscitate program in the prehospital setting. Ann Emerg Med. 1994 May;23(5):1042–1046. doi: 10.1016/s0196-0644(94)70101-6. [DOI] [PubMed] [Google Scholar]