Limiting treatment in pre-hospital care: A prospective, observational multicentre study.
DNAR
EMS
HEMS
decision-making
end-of-life
ethics
termination of cardiopulmonary resuscitation
Journal
Acta anaesthesiologica Scandinavica
ISSN: 1399-6576
Titre abrégé: Acta Anaesthesiol Scand
Pays: England
ID NLM: 0370270
Informations de publication
Date de publication:
09 2020
09 2020
Historique:
received:
25
02
2020
revised:
17
05
2020
accepted:
26
05
2020
pubmed:
11
6
2020
medline:
14
8
2021
entrez:
11
6
2020
Statut:
ppublish
Résumé
Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.
Sections du résumé
BACKGROUND
Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care.
METHODS
A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included.
RESULTS
There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions.
CONCLUSION
Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.
Types de publication
Journal Article
Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
1194-1201Informations de copyright
© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Références
Kangasniemi H, Setälä P, Huhtala H, et al. Out-of-hospital cardiac arrests in nursing homes and primary care facilities in Pirkanmaa, Finland. Acta Anaesthesiol Scand. 2018;62:1297-1303.
Wissenberg M, Folke F, Hansen CM, et al. Survival after out-of-hospital cardiac arrest in relation to age and early identification of patients with minimal chance of long-term survival. Circulation. 2015;131:1536-1545.
Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA. 2000;284:47-52.
Mentzelopoulos SD, Haywood K, Cariou A, Mantzanas M, Bossaert L. Evolution of medical ethics in resuscitation and end of life. Trends Anaesth Crit Care. 2016;10:7-14.
Ferrand E, Marty J, Group FL. Prehospital withholding and withdrawal of life-sustaining treatments. The French LATASAMU survey. Intensive Care Med. 2006;32:1498-1505.
Setälä P, Hoppu S, Virkkunen I, Yli-Hankala A, Kämäräinen A. Assessment of futility in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2017;61:1334-1344.
Verhaert DVM, Bonnes JL, Nas J, et al. Termination of resuscitation in the prehospital setting: a comparison of decisions in clinical practice vs. recommendations of a termination rule. Resuscitation. 2016;100:60-65.
Skrifvars MB, Vayrynen T, Kuisma M, et al. Comparison of Helsinki and European Resuscitation Council “do not attempt to resuscitate” guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activit. Resuscitation. 2010;81:679-684.
McGinley J, Waldrop DP, Clemency B. Emergency medical services providers' perspective of end-of-life decision making for people with intellectual disabilities. J Appl Res Intellect Disabil. 2017;30:1057-1064.
Mirarchi FL, Cammarata C, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: do prehospital providers understand physician orders for life-sustaining treatment documents? J Patient Saf. 2015;11:9-17.
von Elm E, Altman DG, Egger M, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453-1457.
Aaltonen M, Forma L, Rissanen P, Raitanen J, Jylhä M. Jylha M. Transitions in health and social service system at the end of life. Eur J Ageing. 2010;7:91-100.
Aaltonen M, Raitanen J, Forma L, Pulkki J, Rissanen P, Jylha M. Burdensome transitions at the end of life among long-term care residents with dementia. J Am Med Dir Assoc. 2014;15:643-648.
Sanford AM, Orrell M, Tolson D, et al. An international definition for “nursing home”. J Am Med Dir Assoc. 2015;16:181-184.
Bossaert LL, Perkins GD, Askitopoulou H, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 11. The ethics of resuscitation and end-of-life decisions. Resuscitation. 2015;95:302-311.
Saarto T, and Expert Working Group. Providing palliative treatment and end-of-life care. Reports and Memorandums of the Ministry of Social Affairs and Health. 2017;44:7-12.
Laakkonen M-L, Finne-Soveri UH, Noro A, Tilvis RS, Pitkala KH. Advance orders to limit therapy in 67 long-term care facilities in Finland. Resuscitation. 2004;61:333-339.
Vanttaja K, Seinelä L, Valvanne J. Elämän loppuvaiheen sairaalasiirrot ja hoidon suunnittelu tehostetussa palveluasumisessa Tampereella 2011 [Hospital trasferrings and treatment planning at the end of life in skilled nursing facilities in Tampere 2011. Gerontologia. 2015;29:61-74.
Reuter P-G, Agostinucci J-M, Bertrand P, et al. Prevalence of advance directives and impact on advanced life support in out-of-hospital cardiac arrest victims. Resuscitation. 2017;116:105-108.
Rajagopal S, Kaye CR, Lall R, et al. Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest. Resuscitation. 2016;109:110-115.
Wiese CHR, Bartels UE, Ruppert DB, Graf BM, Hanekop GG. Prehospital emergency physicians' experiences with advance directives in Germany: a questionnaire-based multicenter study. Minerva Anestesiol. 2011;77:172-179.
Official Statistics of Finland, National Institute for Health and Welfare. Institutional care and housing services in social care 2016. National Institute for Health and Welfare 2017. http://urn.fi/URN:NBN:fi-fe2019111337862 (Accessed 19 Nov 2019)
Worldwide Palliative Care Alliance. WHO global atlas of palliative care at the end of life. Vol. 2018. 2014. Available from: http://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf (Accessed 25 Nov 2019)
Pitcher D, Fritz Z, Wang M, Spiller JA. Emergency care and resuscitation plans. BMJ. 2017;356:j876.
National Supervisory Authority for Welfare and Health. [Treatment plans and DNAR decisions in long-term care facilities and emergency medical service 3.6.2015.]. Available from: https://www.valvira.fi/-/hoitosuunnitelmat-ja-dnr-paatos-pitkaaikaishoidossa-seka-ensihoito (Accessed 25 Nov 2019).
Loizeau AJ, Shaffer ML, Habtemariam DA, Hanson LC, Volandes AE, Mitchell SL. Association of prognostic estimates with burdensome interventions in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178:922-929.
Waldrop DP, Clemency B, Lindstrom HA, Cordes CC. “We Are Strangers Walking Into Their Life-Changing Event”: How Prehospital Providers Manage Emergency Calls at the End of Life. J Pain Symptom Manag. 2015;50:328-334.
Cardona-Morrell M, Chapman A, Turner RM, et al. Pre-existing risk factors for in-hospital death among older patients could be used to initiate end-of-life discussions rather than Rapid Response System calls: a case-control study. Resuscitation. 2016;109:76-80.
Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. Functional trajectories among older persons before and after critical illness. JAMA Intern Med. 2015;175:523-529.
Pape M, Rajan S, Hansen SM, et al. Survival after out-of-hospital cardiac arrest in nursing homes - a nationwide study. Resuscitation. 2018;125:90-98.
van de Glind EMM, van Munster BC, van de Wetering FT, van Delden JJM, Scholten RJPM, Hooft L. Pre-arrest predictors of survival after resuscitation from out-of-hospital cardiac arrest in the elderly a systematic review. BMC Geriatr. 2013;13:68.
Reignier J, Dumont R, Katsahian S, et al. Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal. Crit Care Med. 2008;36:2076-2083.
Rocker G. Life-support limitation in the pre-hospital setting. Intensive Care Med. 2006;32:1464-1466.
Kangasniemi H, Setälä P, Huhtala H, et al. Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey. Scand J Trauma Resusc Emerg Med. 2019;27. https://doi.org/10.1186/s13049-019-0663-x
Waldrop DP, McGinley JM, Clemency B. Mediating systems of care: Emergency calls to long-term care facilities at life’s end. J Palliat Med. 2018;21:987-991.
Mentzelopoulos SD, Slowther A-M, Fritz Z, et al. Ethical challenges in resuscitation. Intensive Care Med. 2018;44:703-716.
Suna T. Finnish National Archive of Health Information (KanTa): general concepts and information model. FUJITSU Sci Tech J. 2011;47:49-57.