Withholding Resuscitation

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Withholding Resuscitation: A New Approach to Prehospital End-of-Life

Decisions

Sylvia Feder, MA, MICP; L. Matheny, MICP; S. Loveless Jr., PhD,

EMT-D; and D. Rea, MD, MPH

Background: 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.

Objective: 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.

Design: Observational study in which 16 of 35 local EMS agencies

volunteered to implement new guidelines for withholding resuscitation.

Setting: King County, Washington.

Patients: 2770 patients with EMS-attended cardiac arrest.

Intervention: 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.

Measurements: Proportion of resuscitations withheld in agencies

that implemented new guidelines compared with those that did

not.

Results: 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).

Limitations: The study was not a randomized, controlled trial;

individual agencies chose whether to implement the guidelines.

Conclusions: 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.

Ann Intern Med. 2006;144:634-640. www.annals.org