Treatment patterns and clinician stress related to care of out-of-hospital cardiac arrest patients with a do not attempt resuscitation order

Abstract

Objective: This research investigated treatment patterns for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders in Japanese emergency departments and the associated clinician stress.

Methods: A cross-sectional survey was conducted at 9 hospitals in Okayama, Japan, targeting emergency department nurses and physicians. The questionnaire inquired about the last treated out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation. We assessed emotional stress on a 0-10 scale and moral distress on a 1-5 scale among clinicians.

Results: Of 208 participants, 107 (51%) had treated an out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation order in the past 6 months. Of these, 65 (61%) clinicians used a "slow code" due to perceived futility in resuscitation (42/65 [65%]), unwillingness to terminate resuscitation upon arrival (38/65 [59%]), and absence of family at the time of patient's arrival (35/65 [54%]). Female clinicians had higher emotional stress (5 vs. 3; P = 0.007) and moral distress (3 vs. 2; P = 0.002) than males. Nurses faced more moral distress than physicians (3 vs. 2; P < 0.001). Adjusted logistic regression revealed that having performed a "slow code" (adjusted odds ratio, 5.09 [95% CI, 1.68-17.87]) and having greater ethical concerns about "slow code" (adjusted odds ratio, 0.35 [95% CI, 0.19-0.58]) were associated with high stress levels.

Conclusions: The prevalent use of "slow code" for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders underscores the challenges in managing these patients in clinical practice.

Keywords: Clinicians; Do not attempt resuscitation; Emergency department; Out-of-hospital cardiac arrest; Slow code; Stress.

Fig. 1

Flowchart for management of OHCA/DNAR patient after arrival in the ED. Abbreviations: OHCA, out-of-hospital cardiac arrest; DNAR, Do Not Attempt Resuscitation; ED, emergency department; ROSC, return of spontaneous circulation.

Fig. 2

For what reasons the resuscitation code was selected at the time of ED arrival according to the code status (a–c). The numbers adjacent to the bars represent the actual count of responses. Abbreviations: DNAR, Do Not Attempt Resuscitation.

Fig. 3

Clinician emotional stress or moral distress during or after treatment of OHCA/DNAR patients. An OHCA/DNAR patient is defined as a person without prehospital ROSC who was assumed to have a DNAR order based on communication between clinicians and EMS personnel or nursing home staff before arrival to the ED, or information obtained from the medical record. Top: VAS for emotional stress (a) and moral distress score (b) according to the presence or absence of DNAR order during transfer (n = 103). Box and vertical line in box indicate interquartile range and median, respectively. Error bars indicate min to max values. Middle: VAS for emotional stress (c) and moral distress score (d) categorized by gender: n = 52 for female (12 physicians and 40 nurses) and n = 51 for male (41 physicians and 10 nurses). Data are expressed as mean scores; error bars indicate 95% CI. Bottom: VAS for emotional stress (e) and moral distress score (f) categorized by profession n = 50 for nurses (40 females and 10 males) and n = 53 for physicians (12 females and 41 males). Data are expressed as mean scores; error bars indicate 95% CI. Indicators of significance were reported as **P < 0.01 and ***P < 0.001 in figures. Abbreviations: OHCA, out-of-hospital cardiac arrest; DNAR, Do Not Attempt Resuscitation; EMS, emergency medical services; ED, emergency department; ROSC, return of spontaneous circulation.