The LA story: what happened after a new policy allowing paramedics to forgo resuscitation attempts in prehospital cardiac arrest

Abstract

Background: Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.

Objective: To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.

Methods and results: All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p<0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p<0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p=0.024).

Conclusions: Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.