Exploring and improving resuscitation decisions in out of hospital cardiac arrest: synopsis of the PROTECTeD mixed-method study.

BACKGROUND: The PROTECTeD study sought to develop an evidence-based termination of resuscitation guideline for use within United Kingdom ambulance services. METHODS: This mixed-methods study comprised several work packages: Work package 1 - diagnostic test accuracy meta-analysis of termination of resuscitation rules Work package 2 - modelling performance of termination of resuscitation rules using data from the Out of Hospital Cardiac Arrest Outcomes registry Work package 3 - review of ambulance service practices Work package 4 - qualitative interviews with ambulance clinicians, emergency department clinicians and relatives of non-survivors Work package 5 - stakeholder consensus conference to develop a new termination of resuscitation guideline. RESULTS: We described the performance of 42 different termination of resuscitation rules. Our meta-analysis suggests the best performing termination of resuscitation rule is the Universal termination of resuscitation. We modelled the performance of 29 termination of resuscitation rules and found that none would be suitable for implementation within a United Kingdom context. We identified significant variation in how the termination of resuscitation guideline was implemented across the United Kingdom (UK) ambulance services. Ambulance clinicians experience conflict between what the guideline permits them to do and being able to act in the patient's best interest. They felt obliged to follow the guideline. Most emergency department staff believed that paramedics should be empowered to stop resuscitation where appropriate. However, some felt that more senior emergency department clinicians should make these decisions. Relatives needed to be informed about the resuscitation attempt and must feel confident that every effort had been made to save their relative. They also believed that they were able to provide useful information to inform paramedic decision-making. We drafted a new termination of resuscitation guideline in conjunction with clinical experts and multiple stakeholders at a consensus conference. We employed nominal group techniques to determine content and formulate treatment recommendations. DISCUSSION: Termination of resuscitation decisions are complex, requiring consideration of several important aspects, including what is in the patient's best interest. Our work suggests that the current ambulance guideline may restrict the paramedics ability to act in the patient's best interest, increasing the potential for moral injury. CONCLUSION: Paramedic decision-making is informed by both clinical and best interest considerations. Relatives are confident that paramedics do everything possible to save their loved one, and they are able to provide paramedics with information to guide decision-making. We developed a new evidence-based termination of resuscitation guideline, employing nominal group techniques, in collaboration with multiple stakeholders. LIMITATIONS: The evidence comprises observational studies that must be interpreted with caution. We captured the views of multiple stakeholders and patients with personal experience of cardiac arrest. Their insights may not be representative of the wider population who have not had the same experience. FUTURE WORK: Future research should encompass alternative predictors of poor outcome (e.g. clinical frailty) as well as technology (e.g. ultrasound) to enhance decision-making. Better understanding of how cardiac arrest transport decisions impact system performance and crew safety would be helpful. Little is known about paramedic decision-making in relation to unfavourable neurological outcome rather than fatal outcome. Paramedics may benefit from a decision-making framework. FUNDING: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/99/34.