Ethical issues in termination of resuscitation decision-making: an interview study with paramedics and relatives of out-of-hospital cardiac arrest non-survivors

Abstract

Background: In out-of-hospital cardiac arrest (OHCA), decisions to terminate resuscitation or transport the patient to hospital are ethically fraught. However, little is known about paramedics' ethical concerns in these decision-making processes.

Objective: To develop an understanding of how paramedics experience ethical concerns in OHCA decision-making processes, and how this relates to the ethical concerns of patients' relatives.

Design: A qualitative study using semi-structured interviews with paramedics and relatives of OHCA non-survivors.

Setting: Two ambulance trusts in England.

Participants: Thirty-one paramedics, identified as decision-makers in adult OHCA events in which cardiopulmonary resuscitation (CPR) had been initiated, were interviewed. Fourteen interviews with relatives of OHCA non-survivors were also conducted.

Analysis: The interviews were analysed thematically, using a coding framework and following an empirical ethics approach.

Results: Four themes were developed: preventing harm to patients, best interests, caring for the patient's family and moral distress. Paramedics conceptualised preventing harm both as saving lives and as preventing an undignified death or a life with severe brain damage. Paramedics' and relatives' views of best interests were influenced by values such as patient dignity and assumptions about age and quality of life. Paramedics expressed a duty of care towards the patient's family. Relatives conveyed the importance of clear communication and acts of care performed by the ambulance crew, underscoring the ethical commitment that paramedics had towards patients' families. Paramedics described decision-making processes that relied on clinical guidelines, rather than personal values and beliefs; this sometimes led to moral distress.

Conclusion: Non-protocolised ethical considerations are important in paramedic decision-making about terminating CPR in OHCA events. While paramedics use established guidelines and processes to reach decisions that prevent patient harm, they experience moral distress when personal convictions clash with guidelines. Training around ethical reasoning and decision making may help paramedics reduce their moral distress and provide consistent and transparent decisions for patients and their families.

Keywords: accident & emergency medicine; cardiopulmonary resuscitation; medical ethics; qualitative research.