A cardiac arrest is defined as a sudden cessation of mechanical activity of the heart and loss of spontaneous and effective circulation (Tang & Weil, 2008). According to the British Heart Foundation, Resuscitation Council (UK) & NHS England (2014), ambulance services respond to approximately 60,000 out of hospital cardiac arrests (OHCA) each year in the UK. Prehospital emergency medical services (EMS) attempt resuscitation in an estimated 30,000 of these cases (Perkins & Brace- McDonnell, 2015). Unless resuscitation is started promptly, death will occur within a few minutes (University of Warwick, 2018). Treatment for a cardiac arrest follows an algorithm known as ‘The Chain of Survival’. This includes: Early recognition and call for help, Early bystander Cardiopulmonary Resuscitation (CPR), Early defibrillation, and Early Advanced Life Support (ALS) and standardised post-resuscitation care (Perkins et al, n.d.). ALS involves airway management, administering drugs, and attempting to reverse any factors that may have caused the cardiac arrest (Perkins et al, n.d.).
In the UK, there are resuscitation guidelines outlined by The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) based on the 2015 UK Resuscitation Council Guidelines, which indicate when CPR should be commenced, continued or ceased. According to these guidelines, in the absence of an Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), there are few other circumstances where CPR should not be commenced or continued. These include:
– Conditions unequivocally associated with death (decapitation, massive cranial and cerebral destruction, hemicorporectomy, decomposition, incineration, hypostasis, and rigor mortis)
– A patient in the final stages of a terminal illness where death is imminent and unavoidable, and CPR would not be successful, but for whom no formal DNACPR decision was made
– Submersion for longer than 60 minutes
– If ALL of the following exist together: 15 mins since the onset of cardiac arrest; no bystander CPR prior to arrival of the ambulance; the absence of exclusion factors (drowning, hypothermia, poisoning or overdose, pregnancy); asystole for >30 seconds on electrocardiogram (ECG) monitor screen
DNACPR forms are advanced directives signed and issued by a doctor, designed to provide immediate guidance to healthcare professionals on what action to take, or not to take, should the patient suffer a cardiac arrest (Resus Council, n.d.). They are usually completed in those who are close to death or with an irreversible condition, or where it is deemed CPR would be ineffective or unbeneficial to the patient, and allow a natural, dignified death (Mockford et al, 2014).
However, survival rates to hospital discharge following an OHCA are poor with very little improvement over the last few decades (McNally, Stokes, Crouch, & Kellermann, 2009). Perkins & Brace- McDonnell (2015) report rates range between 2-12% among ambulance services. Marco & Schears (2002) have stated that survival rates are varied due factors such as time elapsed since arrest, bystander CPR, initial rhythm, age, long-term care, and medical condition. Perkins & Brace- McDonnell (2015) also identifies individual practitioner variation as a contributor.
Advances in medicine have resulted in an increasingly ageing population. (CITE) This in addition to more people living with multiple co-morbidities means that resuscitation is not necessarily appropriate for everyone and may not be in their best interests (Anderson, Gott, and Slark, 2017). Recent times have also seen progress towards patient-centred care with a more informed population and a greater focus on individual rights and values, particularly when it comes to resuscitation (Mentzelopoulous et al, 2018). This progress has been recognised through the introduction of ‘ReSPECT’ forms (Recommended Summary Plan for Emergency Care and Treatment) in 2017. A ReSPECT form summarises how the patient wants to be treated in an emergency, including in a cardiac arrest (Resuscitation Council UK, n.d.). Crucially, this also allows patients to indicate the extent to which they want to prioritise sustaining their life or prioritise being comfortable and pain-free (Compassion in dying, 2017).
Despite more people talking about resuscitation, it is becoming increasingly complex and challenging for those making the CPR decision. EMS staff still often find themselves in situations with ethical and moral dilemmas over what really is the best decision for the patient. There is a lack of support and guidance for EMS in these situations. Currently there are no considerations or guidance for these ethical or emotional challenges outlined in JRCALC resuscitation guidelines, resulting in a lot of decision-making uncertainty and “grey areas”. Additionally, research by Marco & Shears (2003) into current practices involved in the initiation, continuation, and termination of resuscitative efforts in the pre-hospital setting found that 23% of EMS consider existing resuscitation guidelines to be inadequate.
Cardiac arrests can be very disturbing and upsetting for those who witness them and can have lasting psychological effects. It also deprives the patient of their dignity and has very poor survival rates. However, if there is a reasonable chance that the benefits of CPR might outweigh its harms, CPR should be the default option (McClean, 2013). Given this, it seems necessary that a greater understanding of the factors that influence the decision-making process is required to help resus providers meet the clinical, ethical, emotional demands presented to EMS in OHCA and inform the development of more effective clinical guidelines education and clinical decision support, subsequently providing more person-centred care and better patient outcomes.
A systematic literature review (SLR) will be conducted to investigate this, with the aim of answering the following research question:
“Exploring the influences on those faced with making CPR decisions whether to commence, continue or cease resuscitation in an out of hospital adult cardiac arrest? A review of the literature.”
Themes that the author expects to emerge from conducting this SLR is: fear of litigation, and criticism from family members of the patient; factual information available to the emergency staff; guidance and research; personal and cultural values and beliefs; personal circumstances and experiences, patient characteristics (age, frailty, quality of life, co-morbidities); perceived futility; family and bystander presence.
The specific steps that will be followed in order to achieve the above aim are:
1. Investigate and present the historical background to the topic and define key concepts. Clarify rationale, its clinical context and link to practice, and provisionally identify expected key themes.
2. Develop a list of key words and establish inclusion and exclusion criteria. Using a systematic search strategy, and applying a structured approach, locate appropriate sources of literature on established databases and journals.
3. Select papers to be reviewed and analysed.
4. Using the Critical Appraisal Skills Programme (CASP), carry out a critical appraisal of selected literature. Present findings of critical appraisal in a table and either as a list or as a synthesis.
5. Analyse and objectively interpret findings, critically comparing the selected literature. Identify themes and implications for clinical practice.
6. Draw conclusions and recommendations based on findings presented in discussion sections recognising further work or research.
The following chapter will go on to provide a comprehensive detailed description of how the above research question has been addressed using a systematic approach.