Resuscitation decision-making in out-of- hospital cardiac arrest: A mixed methods exploration of ambulance personnel experiences, preparation and support

Abstract

Background: Emergency ambulance personnel are highly trained to maximise patient survival from out-of-hospital cardiac arrest. However, resuscitation efforts will only revive the patient if provided without delay and in the context of a reversible cause of cardiac arrest. Researchers have repeatedly examined predictors of survival from cardiac arrest, and ambulance personnel in many countries are authorised to cease or withhold resuscitation efforts following validated termination of resuscitation rules and guidelines. Research suggests significant variation in resuscitation decisions, and attribute some of this inconsistency to the decision makers. However, few researchers have addressed the experiences of ambulance personnel making these decisions. Aim: To describe the experiences of ambulance personnel tasked with decisions to commence, continue, withhold or terminate resuscitation and explore how they are prepared and supported to make and enact these decisions. Methods: A mixed methods exploratory sequential research design consisting of interviews with ambulance personnel (Study One), then focus groups with ambulance educators and peer supporters (Study Two), and finally an online survey of graduating paramedic students (Study Three). Research was underpinned by a Naturalistic Decision Making theoretical lens and a critical realist worldview. Findings: Certainty of a poor prognosis was necessary but not sufficient to enact a decision to withhold or terminate resuscitation. Ambulance personnel also needed significant self-efficacy, skills and experience to manage the subsequent scene of a patient death. Critical non-technical skills include sensitive and supportive communication with crew, bystanders and family, delivering death notification and providing post-mortem care. Attention to these skills is scant in existing formal ambulance personnel education. Ambulance personnel are primarily dependent on clinical exposure and life experience to develop confidence in this area. The Anderson Model of Ambulance Resuscitation Decision-making presents the integrated findings of this research project. Conclusions: Resuscitation decision-making can be challenging, even for experienced ambulance personnel. Opportunities to rehearse difficult conversations could improve ambulance personnel nontechnical skills and self-efficacy. Some novice ambulance personnel – including paramedic graduates - have had little or no exposure to resuscitation decision-making or patient death. Therefore, mentoring, senior on-scene or phone backup and personalised post-event peer support are critical to professional development and emotional coping.