Decision-making in prehospital resuscitation: The ethical aspects of out-of-hospital cardiac arrest treatment

Louise Milling

Research output: ThesisPh.D. thesis

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Approximately 4800 people suffer from out-of-hospital cardiac arrest (OHCA) in Denmark every year. In all of Denmark, an ambulance is dispatched to patients with cardiac arrest. Furthermore, a prehospital physician will in practice always be involved in deciding: Whether resuscitation should be initiated/continued or terminated. In the latter case, the decision will have huge consequences because it is irreversible – in a self-fulfilling prophecy, the patient will undeniably die if resuscitation is terminated. Previous studies have elucidated this decision-making process and discovered that the decision relies on both medical factors as well as non-medical factors. Treatment guidelines are often constructed around medical factors and rarely mention the decision-making process. The overall aim of this PhD project was to explore and describe ethical considerations in OHCA decision-making through three studies. First, we conducted a mixed-method systematic review exploring non-medical factors including ethical considerations in OHCA and their influence on decision-making during prehospital resuscitation. A wide variety of non-medical factors were discovered. These were divided into five themes:

The patient’s characteristics including ethical considerations concerning the patient.
The relatives’ and bystanders’ values and beliefs towards resuscitation,
The healthcare professionals' characteristics, experience, values, and emotions together with the team work on-site
External factors such as legislation and the prehospital work environment • Conflicts and challenges in decision-making. 

This study underlined the complexity of OHCA decision-making, and highlighted areas that could be improved. Studies on ethical considerations were scarce and heterogenic with mostly low quality. In the second study, we investigated the prehospital clinicians’ documentation of ethical considerations in the prehospital medical records. Of the 16,495 included medical records, 710 (4.3%) contained ethically relevant statements. The ethical statements in the 710 medical records were analysed by two philosophers. According to the four basic bioethical principles defined by Beauchamp and Childress, the ethical content was divided into themes of autonomy (e.g. patient’s wishes about resuscitation) and beneficence/non-maleficence. Furthermore, the principle of justice was indirectly present through heterogenic management of do-not-attempt cardiopulmonary resuscitation and relatives’ wishes. The quality of documentation was generally vague and unclear which made it difficult to follow the reasoning behind the final decision. In the third study, we qualitatively explored the prehospital physicians’ decision-making process with an emphasis on ethical considerations. Through comprehensive participant observation (>800 hours), 22 structured observations of OHCA treatment, and 17 semi-structured interviews with the physician responsible, we identified three overall themes. 1) Expectations from the physicians towards patient prognosis and the expectations from the relatives and bystanders towards decision-making; the patient’s, relatives’, and 2) the physician’s values and beliefs, and 3) the dilemmas occurring when values conflicted or the physicians’ were in doubt. We found various ethical considerations concerning autonomy, beneficence, non-maleficence, justice, and dignity. Our studies underscore the complexity of decision-making while highlighting areas of improvement. An overall finding was a pronounced variation and heterogeneity in ethical considerations and practices. The patient’s autonomy was a general theme throughout all three studies with the assessment of the patient’s wishes and preferences proving difficult. We found variations in practices and attitudes towards advance directives, made to indicate patient wishes. We observed difficulties with the assessment and utilisation of DNACPRs. Similarly, the inclusion of family wishes, preferences, and statements varied. These areas as well as expectations from patients, relatives, and society, and the influence of prehospital clinicians’ values and beliefs may amplify disparities in OHCA decision-making.
Translated title of the contributionBeslutningstagning ved præhospital genoplivning: De etiske aspekter i behandlingen af hjertestop uden for sygehuset
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
  • Mikkelsen, Søren, Principal supervisor
  • Binderup, Lars Grassmé, Co-supervisor
  • Nielsen, Dorthe Susanne, Co-supervisor
  • Christensen, Erika Frischknecht, Co-supervisor, External person
Date of defence10. Mar 2023
Publication statusPublished - 27. Feb 2023


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