Sylvia Feder, MA, MICP; Roger L. Matheny, MICP; Robert S. Loveless Jr, PhD, EMT-D; Thomas D. Rea, MD, MPH
Acknowledgments: The authors thank Dr. Thomas Hearne, Dr. Mickey Eisenberg, Dr. Jack Murray, and John Jerin, King County Emergency Medical Services, for supporting the withholding resuscitation program; Ed Plumlee, King County Medic One, for advocating the program to the local fire chiefs; Linda Becker, King County Emergency Medical Service, for assistance with data acquisition; and Dr. Ned Feder for advice.
Grant Support: By the Medic One Foundation and King County Emergency Medical Services.
Potential Financial Conflicts of Interest: Grants: S. Feder, R.L. Matheny (Medic One Foundation).
Corresponding Author: Sylvia Feder, King County Medic One, 7064 South 220th Street, Kent, WA 98032; e-mail, email@example.com.
Current Author Addresses: Ms. Feder and Mr. Matheny: King County Medic One, 7064 South 220th Street, Kent, WA 98032.
Dr. Loveless: Kent Fire Department, 24611 116 Avenue SE, Kent, WA 98030.
Dr. Rea: University of Washington/King County Emergency Medical Services, 999 3rd Avenue, Suite 700, Seattle, WA 98104.
Author Contributions: Conception and design: S. Feder, R.L. Matheny.
Analysis and interpretation of the data: S. Feder, R.S. Loveless Jr., T.D. Rea.
Drafting of the article: S. Feder.
Critical revision of the article for important intellectual content: S. Feder, R.L. Matheny, R.S. Loveless Jr., T.D. Rea.
Final approval of the article: S. Feder, R.L. Matheny, R.S. Loveless Jr., T.D. Rea.
Statistical expertise: R.S. Loveless Jr., T.D. Rea.
Obtaining of funding: S. Feder, R.L. Matheny.
Administrative, technical, or logistic support: R.L. Matheny.
Collection and assembly of data: S. Feder, R.L. Matheny, R.S. Loveless Jr.
Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order.
To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines.
Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation.
King County, Washington.
2770 patients with EMS-attended cardiac arrest.
New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired.
Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not.
Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients).
The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines.
Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.
Emergency medical services (EMS) personnel attending out-of-hospital cardiac arrests sometimes attempt to resuscitate patients who do not want life-sustaining measures.
This study involving 2770 patients with EMS-attended cardiac arrests assessed outcomes of guidelines that permitted personnel to withhold resuscitation in patients with terminal illnesses when the patients or caregivers indicated, in writing or verbally, that they did not want resuscitation. Sixteen of 35 EMS agencies in King County, Washington, implemented the guidelines. Implementation and control agencies withheld resuscitation in approximately 11.8% and 5.3% of cardiac arrests, respectively. The difference was primarily due to honoring verbal requests.
In this observational study, self-selected agencies volunteered to implement guidelines.
Table 1. Characteristics of Participating and Nonparticipating Agencies
Table 2. Characteristics of Patients Who Had Cardiac Arrest according to Resuscitation Effort
Table 3. Type of Resuscitation Effort according to Study Group
Table 4. Type of Request To Withhold Resuscitation according to Study Group
Table 5. Type of Request To Withhold Resuscitation in the Intervention Group according to Patient Location
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Assoc. Prof, Dept. of Fam Med, University of Washington, Chair, WSMA EOL Consensus Coalition
May 23, 2006
To the Editor: The recent article on "Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions" by Feder et al describes an observational study started in King County, WA in 1998, and made reference to a specific, state-approved prehospital DNR order form. Since this study began, Washington replaced this form with the (Physician Orders for Life-Sustaining Treatment) POLST form. The accompanying editorial by Kellerman and Lynn describes the value of the POLST form as an example of an increasingly widespread standard form for seriously ill persons to document their treatment wishes as physician orders. POLST originated in Oregon and research has demonstrated its effectiveness in helping patients have their preferences for end-of-life care honored, even when EMS is contacted .
Encouraged by the success of the POLST program in Oregon, the Regional Ethics Network of Eastern Washington (RENEW) adapted the form for use in Washington State. The Washington State Medical Association (WSMA), the Department of Social and Health Services (DSHS) and the Washington State Dept of Health (DOH) approved a pilot of the POLST in two counties in Eastern Washington in 2000. Based on the results of that pilot , the DOH replaced the previously approved prehospital DNR order form with the POLST in 2001. Educational and promotional efforts have been ongoing. These include: DOH training for EMS responders in all counties in the state; WSMA publications and workshops targeting physicians as well as providing a POLST video and tools on its website ; the Association of Washington Public Hospital Districts (AWPHD) providing sample hospital policies and procedures, training videos, and webcasts for effective POLST form use in hospitals; collaboration in all these efforts with a state wide broad based community action coalition (Washington End-of-Life Consensus Coalition).
Based on these efforts and national studies3, the POLST program complements available advance directives and is extremely beneficial in confidently guiding EMS treatments in the field. Greater success of these efforts in WA and elsewhere, as described on the National POLST-Paradigm Initiative web site3, can apprise EMS professionals about the patient's treatment preferences and provide the physician's orders required to act on those wishes. This has benefit for the patient, the families of the dying, and the emergency responders. Feder, et al accurately state that these decisions are made at the EMT level. POLST provides the desired guidance for those decisions, and negates the legal and risk management concerns noted by the authors. As Oregon has demonstrated, continued perseverance in education and implementation in partnership with physicians, hospitals, nursing homes, and EMS responders, can help ensure that patients receive the treatments they want and not receive treatments they would have refused. With POLST, EMT responders can provide family support and avoid unwanted and ineffective resuscitation attempts. For Annals readers, it is important to note that a key to successful adoption of POLST is the support of a local community physician leader. Whatever the future for new guidelines like the ones studied by Feder et al, POLST and POLST-like forms and the crucial conversations among patients, families and medical providers that lead to their completion may most reliably guide emergency medical response for persons with advanced medical conditions.
Feder S, Maheny RL, Loveless RS Jr, Rea TD, Withholding resuscitation: a new approach to prehospital end-of-life decisions. Ann Intern Med. 2006;144:634-40
Kellermann A, Lynn J. Withholding resuscitation in prehospital care. Ann Intern Med 2006; 144:692-3
Meyers JL, Moore C, McGrory A, Sparr J, Ahern M. J Gerontological Nursing. 2004;30:37-46
Feder S, Matheny RL, Loveless RS, Rea TD. Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions. Ann Intern Med. ;144:634–640. doi: 10.7326/0003-4819-144-9-200605020-00006
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Published: Ann Intern Med. 2006;144(9):634-640.
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