Catherine R Counts1, Jennifer Blackwood2, Ryan Winchell3, Christopher Drucker2, Ann L Jennerich4, Sylvia Feder5, Kathy Pompeo6, Jody Waldron7, Michael R Sayre8, Peter J Kudenchuk9, Thomas Rea10. 1. Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States. Electronic address: crcounts@uw.edu. 2. Emergency Medical Services Division of Public Health - Seattle & King County, United States. 3. University of Washington School of Medicine, United States. 4. Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, United States. 5. King County Medic One, United States. 6. Shoreline Fire Department, United States. 7. Department of Medicine, Division of General Medicine, University of Washington, United States. 8. Department of Emergency Medicine, University of Washington, United States; Seattle Fire Department, United States. 9. Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of Cardiology, University of Washington, United States. 10. Emergency Medical Services Division of Public Health - Seattle & King County, United States; Department of Medicine, Division of General Medicine, University of Washington, United States.
Abstract
BACKGROUND: Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care. METHODS: We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts. RESULTS: Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05). Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison). CONCLUSIONS: Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.
BACKGROUND: Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care. METHODS: We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts. RESULTS: Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05). Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison). CONCLUSIONS: Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.