resuscitation decision index: a new approach to decision-making in prehospital cpr

Resuscitation 48 (2001) 255–263

Resuscitation decision index: a new approach to decision-makingin prehospital CPR

W. Meyer a,*, F. Balck b

a Unit for Social and Community Psychiatry, St. Bartholomew’s and the Royal London School of Medicine, London E7 8QR, UKb Institute of Psychological Medicine, Clinic of the Technical Uni6ersity of Dresden, Dresden, Germany

Received 21 June 1999; received in revised form 18 July 2000; accepted 18 July 2000

Abstract

Retrospective and prospective studies have been undertaken to assess physicians’ practice-patterns by studying cardiopulmonaryresuscitation (CPR) case summaries. Most summaries reveal similar influences by the physician, patient and situation-relatedvariables on the patterns of resuscitation. The initiation of resuscitation efforts is addressed frequently, but, very few studiesdiscuss the topic of termination of resuscitation. Prehospital emergencies are addressed very rarely. The objective of this study wasto introduce a new methodological approach towards initiation and termination of resuscitation efforts in prehospital situations.The subject studied were the physicians’ decisions concerning initiation/withholding, termination/withdrawal and the resultingearly survival rates. The result is termed the ‘Resuscitation decision index’ (RDI). The ‘RDI’ could be a tool allowing comparisonson a quantitative level, between different EMS systems or disciplines and giving an insight into the decision process. The ‘RDI’can enhance audit of resuscitation. The process of decision-making can be used to help future theoretical decision-makingstrategies. © 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Resuscitation-psychology; Physicians’-psychology; Decision-making; Physicians’-factors; Attitude-of-health-personnel; Patients’-factors;Situational factors

Resumo

Realizaram-se diversos estudos prospectivos e retrospectivos a partir de registos realivos as praticas de reanimacao com aintencao de caracterizar padroes de pratica medica nesta area. A analise dos registos revela que a pratica da reanimacao e doprocesso de decisao que lhe esta inerente, sao influenciadas de forma equivalente por variaveis relacionadas com o medico, odoente e a situacao clınica. A decisao de iniciar a reanimacao tem sido analisada com frequencia, o que nao acontece com adecisao de terminar. A questao especifica do contexto pre-hospitalar tem sido pouco abordada. O objectivo deste estudo foi o detentar introduzir uma metodologia de abordagem coerente sobre o inıcio e interrupcao dos esforcos de reanimacao no contextopre-hospitalar. Avaliou-se a questao especıfica da relacao entre a decisao de nao iniciar ou interromper reanimacao e a taxa desobrevivencia precoce apos manobras de reanimacao. O processo e designado de ‘‘ındice de decisao em ressuscitacao’’ (RDI). ORDI pode ser um instrumento facilitador de comparacoes com base em criterios quantitativos, avaliando diferentes organizacoesde emergencia e permitindo avaliar o processo de decisao. O RDI pode melhorar o processo de auditoria nesta area. A avaliacaodeste processo de decisao pode contribuir para definir estrategias futuras e orientacoes teoricas mais objectivas no processo dedecisao. © 2001 Elsevier Science Ireland Ltd. Todos os direitos reservados.

Pala6ras cha6e: Psicologia-Reanimaçao; Psicologia-Medicos; Tomar decisoes; Factores Medicos; Atitudes do pessoal da saude; Facotres-Pacientes;Factores-situacionais

www.elsevier.com/locate/resuscitation

1. Introduction

Decisions regarding cardiopulmonary resuscita-tions (CPR) are an important and stressful part ofphysicians’ lives. Since only a minority of resusci-

tation attempts are successful [1,9,12,13,15,19,21,23–25], physicians have to face failed resuscita-tion attempts [22]. For the patient the worst out-comes may be death, severe neurologicaldeficiency or prolonged coma. For the health caresystem, these decisions may have prolonged finan-cial consequences.* Corresponding author.

0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (00 )00264 -1

W. Meyer, F. Balck / Resuscitation 48 (2001) 255–263256

Fig. 1. Patient, physician and situation-related factors regarding initiation and termination of resuscitation (case summary studies,hypothetical situations). See Refs. [2,3,7,8,10,11,14,18]

1.1. Case summary studies (hypotheticalsituations)

There is little research which addresses thevariables in decisions to initiate or terminate car-diopulmonary resuscitation. There are few studiesdealing with decision making in CPR in the out-of-hospital setting.

Knowledge of these factors is derived predomi-nantly from studies using case summaries (casevignettes), where physicians have been asked howthey would decide in certain hypothetical situa-tions. The graphs summarise the factors concern-

ing decision making in hypothetical (Fig. 1), andreal retrospective and prospective studies (Fig. 2).The findings are divided into those related topatient, physician and situation-related variables.

Case summary studies give a good indicationof patient and physician-related factors, both re-garding initiation and termination. Most of thecase vignettes address clinical situations. Twostudies deal with decisions in the emergency de-partment [2,3], one study addresses prehospitaldecisions [18]. The question of the influence ofsituational factors was not studied using casesummaries.

Fig. 2. Results of studies (retrospective and prospective) of real resuscitation situations and patient, physician and situation-relatedfactors concerning initiation and termination of resuscitation. See Refs. [4,6,11,17,20,24]

W. Meyer, F. Balck / Resuscitation 48 (2001) 255–263 257

Fig. 3. Possible decisions regarding pre-hospital resuscitation(RDI).

item is, therefore, plotted as ‘withholding ofresuscitation’.

Where the physician has initiated resuscitation,at some time he will have to answer the secondquestion: ‘should I withdraw?’ During resuscita-tion he might ask himself this question repeatedly.Dependent on the patient’s condition and thecourse of the resuscitation, resuscitation may bewithdrawn. In Resuscitation index this is plottedas ‘withdrawal of resuscitation’.

Repeating the question ‘should I withdraw’ andarriving at the answer no, resuscitation continuesand confronts the physician with the third ques-tion: ‘has the patient survived?’ If the answer is no,resuscitation is withdrawn. If the answer is yes,further treatment begins. In RDI this decision isplotted as ‘resuscitation and survival’.

As all the three conclusions and both the out-comes are based on the patients condition and thecourse of the resuscitation effort, all imply deci-sion making by the resuscitating physician. With-out such decision making a patient could notproceed to further treatment or be declared dead.

2.2. Data collection

To study the initiation and termination of pre-hospital CPR using the RDI, we chose emergencyphysicians working on doctor equipped ambu-lances in four north German cities (Hamburg,Lubeck, Kiel, Rendsburg). They were asked todocument all prehospital emergencies involvingCPR and/or declaration of death. Doctors fromsix hospitals from 16 medical, surgical and anaes-thetic departments were prepared to participate inthe study.

There was a variance in the duration of theEMS rota of the physicians involved. This variedaccording to the department the physicians wereworking in, the shortest being a day, the longestbeing two months. Moreover, there were variancesregarding the distribution of day and night shifts.

2.3. Introduction to the study

More than a hundred emergency physicians andconsultants were introduced to the study andasked to participate. After the consultants hadgiven their consent to the study, the design, ques-tions and aims of the study were described indepartment meetings. Since the information ob-tained included personal data of the doctor in-

1.2. Studies (retrospecti6e and prospecti6e) of realresuscitation situations

There are three retrospective [4,17,24] and twoprospective studies [6,11] of actual situations. Onestudy addresses prehospital resuscitation [17].None of the studies of real situations address thequestion of termination of resuscitation.

2. Methods

2.1. Resuscitation decision index

The Resuscitation decision index (RDI) offers anew approach to preclinical CPR decision making.It includes information about initiation and termi-nation of resuscitation efforts, and primary out-come (Fig. 3).

Fig. 3 illustrates the three questions the physi-cian has to answer the three steps in decisionmaking and two outcomes. The physician has toanswer the question: ‘should I initiate resuscita-tion?’ If the answer is yes, resuscitation is started.If the answer is no, the physician has made thedecision ‘withholding of resuscitation’. The first


volved, it was left up to the individual to partici-pate or not. To encourage as many as possible toparticipate, termination interviews were conductedon an individual basis to discuss problems. Fur-thermore, physicians were visited during the studyperiod of 14 months on a weekly basis to discussthe on-going process.

2.4. Questionnaires used

All the participating physicians were asked tofill in a questionnaire with biographical details(physicians questionnaire). These were age, gen-der, medical and emergency experience, type ofhospital, specialisation, marital status, number ofchildren, religion, personal losses, professionalhelp, type of problem awareness, and number ofquestionnaires completed.

Immediately after the prehospital emergency,physicians completed a questionnaire including thepatient and situation related variables for eachpatient they had seen.

Independent patient related variables were; di-agnosis, patient’s age, gender and profession.Within situation related variables, three categorieswere asked, the time before the emergency, thephysicians’ appraisal of the emergency, the charac-teristics of the emergency and the attitude of rela-tives present.

Questionnaires were left in the doctor’s roomand a polling box was left to take completedquestionnaires.

2.5. Sample drawing

This investigation studied physicians treatingpatients either in need of resuscitation or declared

dead. Since it was left to the individual physician,as to how many questionnaires were completed thesample (705 cases) studied had to be considered.We had to take into account the number of casestreated per physician, the normal distribution ofthe cases treated and the possible effects of re-peated measurements.

2.5.1. Number of cases treated per physicianThe number of the completed questionnaires per

physician was between 1 and 35 with a median of13 questionnaires per physician (Fig. 4).

To eliminate mistakes due to the varying num-ber of questionnaires per physician, a second sub-sample of cases was studied along with the mainsample (86 physicians, 705 patients). This secondsample with the same number of patients wasstudied additionally.

2.5.2. Normal distributionThe normal distribution of the cases treated in

the overall sample and two sub-samples were stud-ied because of variance only physicians with aminimum number of cases treated were regardedas eligible for calculation.

Initially the complete sample of all the partici-pating physicians (86 physicians, 705 cases treated)and two sub-samples were calculated; sub-sampleNo. 1 including all the ‘physicians having docu-mented at least three resuscitations and all decla-rations of death during this time’ and No. 2 those‘physicians having documented at least five resus-citations and all declarations of death during thistime’.

In the complete sample, we found a normaldistribution of the duration of resuscitation. In thesub-sample No. 1 distribution was not normal. Inthe sub-sample with five resuscitations, however, anormal distribution was found. Sub-sample No. 2was used therefore for further calculation. Theseincluded tests for the effect of repeated measure-ments in the cases treated.

2.5.3. Effect of repeated measurementsIn sub-sample No. 2 there were no significant

effects of repeated measurements and, this sub-sample was distributed normally. For further cal-culations we used the overall sample� all physicians documenting resuscitations and

all declarations of death during the study (705cases treated, 86 physicians);

Fig. 4. Variance in the number of questionnaires per physi-cian.


and sub-sample No. 2� physicians who had documented at least five

resuscitations and all declarations of death dur-ing this time (315 cases treated, 41 physicians).

2.6. Methods of calculation

All the statistics were calculated using SPSSprogram package for personal computers.

Metrically and ordinally scaled variables weretested for normal distribution. For non-normaland/or ordinally scaled variables x2-tests wereused. For the part of the study demonstrated inthis paper, all independent variables were grouped.Results were plotted according to significant dif-ferences in the RDI (*P50.005, **P50.001).

3. Results

3.1. Description of the samples

In both the samples there were more male thanfemale physicians. They were predominantlyanaesthetists and internists. The mean age of thedoctors was 33.9 years. The mean of their medicalexperience was almost 5 years and they had amean experience in emergency medicine of morethan 10 months. Most were married and withoutchildren. The longer portion stated that they didnot belong to any religion, followed byProtestants.

The patients’ mean age was 63.8 years. Sixty-sixof the patients were male. Retired persons were

Fig. 6. RDI and number of questionnaires.

the most prominent group. In the overall sample(705 cases treated) the diagnosis of cardiac arrestdominated (35.3%), followed by ‘death prior tobeing seen by the physician’ (15.7%) and cardio-genic shock (13.4%). Within survivors, the largestgroups were cardiac arrest (8.3%) and cardiogenicshock (3.8%) (Fig. 5).

3.2. Resuscitation decision index

The sample described in the graph includes all705 cases treated by 86 physicians participating inthe study. Cases were defined as patients eitherdeclared dead or in need of resuscitation. Resusci-tation was defined as administration of artificialventilation and external chest compressions.

The RDI reveals that in 39.3% of cases resusci-tation was withheld, and initiated in 60.7%. In45.5% of cases resuscitation was withdrawn. 15.1%of the overall sample of 705 patients survivedinitially. This equals 25.1% of patients, in whomresuscitation was initiated.

3.3. Resuscitation decision index and physiciansparticipation in the study

The graphs of the RDI show plots for theoverall sample (705 cases) and illustrate the signifi-cance of the differences between the groups for theoverall sample and sub-sample No. 2 (315 cases)(Fig. 6).

Those physicians who filled in fewer question-naires decided to withhold resuscitation less often(31.0%) than the others (41.5%). This was com-pensated by more decisions to withdraw resuscita-Fig. 5. Resuscitation decision index.


Fig. 7. RDI and physicians’ specialisation.

4.1. Problems experienced in studying decisionsregarding resuscitation

It is likely, that there are specific reasons for thesmall numbers studies. We speculate that physi-cians do not like to be studied in situations wherethey have to decide about ‘life and death’. Tworeactions may occur; physicians may decline toanswer or they may reply in the hope of finding ananswer for themselves.

We, therefore, left it entirely to the physicians asto whether and to what extent they participated toavoid effects which would alter the results.

Moreover, we let the physicians know that wewere not examining the total number of emergen-cies occurring during the study. This would havegiven some indication concerning the preparednessof physicians to participate, but the directness ofthis method might have altered the data obtained.

The number of cases documented per physicianvaried considerably between 1 and 35. The numbercorrelated with decisions to initiate or terminateresuscitations.

We have to ask why the more active physiciansreported less on their activity. Two interpretationscan be considered; firstly, physicians might viewtheir participation in the study as a chance toreflect on their decision-making, but might fear thepossibility of negative results. Did they, therefore,complete fewer questionnaires than they actuallyattended? Secondly, they may have anticipatedtheir decision-making but were unsure of it andwere thus reluctant to fill in more questionnaires.

Both the hypotheses suggest that a proportionof physicians may have some conflict with theirdecision making. The findings may mean that theyare somehow unable to cope with the decisionsthey have made. This study needs replication. Ifthe results are confirmed, the issue of supportgiven to physicians in this decision making re-quires careful examination.

4.2. The Resuscitation decision index in relationto ‘initiation of resuscitation’

Fig. 8 compares the decision to initiate resusci-tation (left) and RDI (right) regarding physicians’specialisation.

Surgeons decided significantly more often toinitiate resuscitation (87.5%) compared withanaesthetists or physicians (64.4 and 54.0%). The

tion (54.2%) compared with physicians who com-pleted more questionnaires (43.2%). Survival wasthe same in both the groups (14.8, 15.2% respec-tively). This was not influenced by other indepen-dent physician-, patient-, or situation-relatedvariables (Fig. 6).

3.4. Resuscitation decision index and physicians’speciality

A further question addressed in this study waswhether the item physician’s speciality correlatedwith the RDI (Fig. 7).

Surgeons decided less frequently to withholdresuscitation (12.5%) compared with anaesthetists(35.6%) or physicians (46.0%). The RDI revealsthat these differences were almost compensated bydifferent rates of withdrawal of resuscitation (sur-geons 66.7%, anaesthetists 49.1%, physicians38.7%). Survival rates of patients treated by sur-geons were 5.5% higher than those treated byanaesthetists or physicians. There was no influencefrom other independent physician-, patient-, orsituation-related variables.

4. Discussion

Decisions about resuscitation have not been ad-dressed sufficiently [16,22]. Most studies lack in-formation about termination of resuscitationefforts. Scant data is available on the influence ofsituations variables on the decisions to initiateresuscitation.


Fig. 8. Decision to initiate (left) and RDI (right) and physi-cians’ specialisation.

Fig. 10. Possible RDI.

In theory the rate of withholding resuscitationcould have been 85% (39.3+45.5%) (left graph).This, however, may mean that patients who mighthave a chance of surviving would not receive CPR.Therefore, a ‘safety margin’ has to be consideredin order to reach all patients, who might benefitfrom CPR. Leading physicians have commentedon the high margin of safety regarding resuscita-tion decisions [5]. So this margin could well havebeen less than the 45.5% found in this study (Fig.9). It is possible that the decision to withholdcould be 55%, leaving a 30% safety margin ofwithdrawal the 15% survival (Fig. 10).

Change in further benefit of RDI could be inthe assessment of the process of decision-makingand comparison with future decision-making.

The authors are aware that the decision aboutthe safety margin stays on a statistical level, stat-ing nothing about patient related discussion crite-ria. Patient related decision criteria, however, arenot the aim of this paper. Patient related variablesin connection with the RDI should be addressed infurther research.

4.4. The Resuscitation decision index in detectingpatterns of beha6iour

The RDI can be used to plot decision-makingprocesses. By the use of a scattergramm withinterpolated curves, patterns of decision-makingcan be illustrated and compared. This is demon-strated below (Fig. 11).

The convex top curve (surgeons) shows a lowincidence of withholding and a high incidence ofwithdrawal, whereas curves for anaesthetists aresmoother. The curves for physicians are even flat-

RDI also reveals that surgeons withdraw resuscita-tion efforts more frequently than their other col-leagues. Surgeons show an initial survival rate,5.5% higher than anaesthetists and physicians.

Thus the RDI reveals more information aboutthe decision making process. Moreover, mislead-ing interpretations by use of the item initiationalone are avoided. The questions of initiations,termination and initial survival are thus addressedmore effectively.

4.3. Resuscitation decision index in assessingpossible decisions

Studying the RDI reveals an initial survival rateof 15%, a rate of withholding resuscitation of39.3% and a rate of 45.5% of withdrawal of resus-citation (Fig. 9).

Fig. 9. RDI in reality.


Fig. 11. Behaviour patterns of surgeons, anaesthetists and physicians (scattergramm with interpolated curves).

ter, with a high incidence of withholding andlower incidence of withdrawal.

The curve of the RDI, is comparatively concave.The pattern of behaviour of physicians is verynear to that of the RDI, whereas that of surgeonsis the most distant. Anaesthetists come betweenthe two.

A further benefit of the RDI could be a graphi-cal comparison of decision-making processes.

5. Conclusion

The RDI may be considered as a useful methodto assess the decision making process in prehospi-tal resuscitations. In the conglomerate of patientrelated variables, individual physician factors, andsituational aspects, it may be a tool which revealsinformation in decision making without mislead-ing interpretations created by the terms ‘initiationand withdrawal’ alone. Secondly, the RDI mayallow comparisons on a quantitative level. Thus,different EMS systems, by different disciplines anddifferent situations within the emergency response,may be compared, providing clues to further re-search. Thirdly, RDI allows a graphical plot en-abling a visual assessment of decision-makingprocesses in prehospital CPR.

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resuscitation decision index: a new approach to decision-making in prehospital cpr

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