Cessation of Resuscitation in Pulseless Electrical Activity out of Hospital Cardiac Arrest: A Mixed Methods Study of Senior Paramedic Decision Making

Abstract BackgroundPulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. Typically, survival rates are poor and there is a paucity of evidenced-based guidelines for paramedics on when to cease resuscitation. This led to one UK Ambulance Service developing a local guideline to support senior paramedics when making cessation decisions. This study aimed to describe the patient characteristics, clinical features and system factors of pulseless electrical activity and explore the experiences of senior paramedics making autonomous cessation decisions. Design and MethodsAn explanatory sequential mixed method design conducted in a single UK Ambulance Service. Data was retrieved for all adult Out of Hospital Cardiac Arrest patients from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics ceased resuscitation for 50 PEA patients, a consecutive sample, which was reviewed in detail using descriptive statistics. Independent t-test and Chi Square examined associations between variables known to prognosticate survival. Interviews were conducted with six senior paramedics who remotely supported on-scene paramedics and findings were analysed using content framework analysis. ResultsPatient characteristics: Mean age 78 years, male (n=30, 60%), co-morbidities (n=40, 80%), witnessed collapse (n=37, 74%), bystander BLS (n=30, 60%). Clinical features: defibrillation (n=22, 44%), ROSC (n=8, 16%), heart rate< 50 (n=46, 92%), mean ETCO2 2.3kPa. System factors: Advanced life support duration 59mins. A significant association between witnessed cardiac arrest and bystander basic life support was found (95% p=.00). Themes arising from interviews were defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. ConclusionSenior paramedics interpreted and applied a multifactorial approach to ceasing resuscitation for patients with PEA. Patient characteristics, clinical features and system factors were balanced using clinical judgement, found to be vital to the decision-making process. This finding questions the appropriateness of paramedics making cessation decisions based on clinical features alone. As prognostic factors for survival were present, further investigation to identify the difference between an unsuccessful or futile resuscitation is required.