Withholding advanced cardiac life support in out-of-hospital cardiac arrest: a prospective study

To evaluate the decision criteria leading to refrain from starting cardiopulmonary resuscitation (CPR) in the prehospital setting.

We conducted a prospective, descriptive study, in a physician-staffed emergency medical service during a 12 month period. All patients presenting with a cardiac arrest were included. Patients were allocated to two groups: immediate decision to give CPR (R group) or withholding CPR (NR group). Characteristics of patients including previous health status, time intervals, therapies and outcomes, were collected. Data were compared between the two groups, *p<0.05.

One hundred and fourteen patients (aged 61+/-18 years) were enrolled in R group and 113 (73+/-19 years*) in NR group. Patients of NR group more frequently presented with a deterioration of functional independence (51% versus 10%*), cognitive impairment (21% versus 8%*) and higher McCabe score and Knaus class (McCabe 2: 24% versus 2%*; Knaus class D: 23% versus 3%*). Presence of a bystander (75% versus 44%*) or basic life support (BLS) started by the bystander (40% versus 12%*) were more frequent in R than NR. Age (OR, 1.1; 95% CI, 1.0-1.1), McCabe score >0 (OR, 10.5; 95% CI, 1.4-79.0), lack of bystander BLS (OR, 11.2; 95% CI, 2.2-60.7) and ineffectiveness of BLS by EMTs (OR, 12.1; 95% CI, 2.0-72.8) were independent factors of withholding CPR. The physician conducted often the discussion alone (48%).

Decision criteria leading to refrain from starting CPR in the prehospital setting are age, previous health status and initial BLS. Further thought should be allowed to ensure a share in the decision-making process in this particular practice.