Background: Third-degree atrioventricular (AV) block can result in sudden cardiac death if no reliable escape rhythm is present. Here, we report a case of an 86-year-old female patient who developed a third-degree AV block leading to cardiac arrest. Surprisingly, sinus rhythm returned after 4 min of asystole, and she showed complete neurological recovery.
Case summary: Emergency services were contacted by the husband of an 86-year-old woman after she was found unconscious. Ambulance personnel diagnosed a third-degree AV block without an escape rhythm and transcutaneous pacing was started. At arrival on the emergency ward, pacing was inadequate, resulting in absence of circulation for ~10 min. After consultation with the family, the patient turned out to have signed a ‘do not resuscitate’ order. Given the impression that the considerable delay deemed favourable neurological recovery unlikely, it was decided together with the family to stop the resuscitation. Subsequently, she had an intermittent junctional escape rhythm but eventually developed a documented asystole of more than 4 min. Against all expectations, she regained sinus rhythm and fully recovered. Eventually, a pacemaker was implanted and she was discharged home without neurological sequalae of the cardiac arrest.
Discussion: Autoresuscitation, also known as the Lazarus syndrome, is the spontaneous return of circulation after cardiac arrest and is incidentally seen after failed cardiopulmonary resuscitation (CPR). Autoresuscitation in the absence of CPR is highly unusual, but could, in this case, be due to the total AV block as the cause of the cardiac arrest.
BACKGROUND: Around the world, many paramedics are authorised to withhold or terminate resuscitation. Research indicates this can be a challenging part of their role. Little is known about graduating paramedic student confidence, concerns and learning in this area.
METHODS: An online cross-sectional survey of students nearing completion of a paramedic degree in New Zealand, including piloting of a newly-developed confidence scale.
RESULTS: Seventy-two participants reported varying exposure to termination of resuscitation and patient death. Participants felt most confident providing technical procedurally-based care and least confident with non-technical skills. Participants' greatest concerns included making 'the right call', supporting grieving family, controlling emotions and encountering conflict. Clinical exposure with supportive mentoring, clinical simulation, peer reflection and resolved personal experience with death, were considered most useful for professional development.
CONCLUSIONS: Exposure to termination of resuscitation and management of the scene of a patient death is variable amongst graduating paramedics. Novice paramedics may benefit from opportunities to observe and rehearse non-technical skills including delivering death notification and communicating with bystanders and bereaved family. The Confidence with Resuscitation Decision-Making and Patient Death Scale has favourable psychometric properties and utility as an outcome measure for future research in this area.
Psychanalyste, j'ai réalisé en août dernier un stage d'immersion d'une semaine dans un service de réanimation. Pourquoi de réanimation ? Parce que c'est en ce lieu, sans doute, avec les services de soins palliatifs, que se trouvent le plus crûment exposés les instincts de vie et de mort. De cette intrication des pulsions et des instincts de vie et de mort je souhaite me faire ici le témoin. Témoin aussi du jeu entre réalité psychique interne - monde sensoriel et émotionnel - et environnement externe - le monde qui donne à sentire et à voir. Car là aussi, comme pour l'intrication/désintrication des instincts de vie et de mort, il y a une conflictualité potentielle du dehors/dedans : chambres de résonances, échos diffractés, amplications et transformations...
PURPOSE: The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice.
DESIGN: This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines.
METHODS: In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria.
FINDINGS: Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study.
CONCLUSIONS: It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.
Aim: Resuscitation of cardiac arrest involves invasive and traumatic interventions and places a large burden on limited EMS resources. Our aim was to identify prehospital cardiac arrests for which resuscitation is extremely unlikely to result in survival to hospital discharge.
Methods: We performed a retrospective cohort analysis of all cardiac arrests in San Mateo County, California, for which paramedics were dispatched, from January 1, 2015 to December 31, 2018, using the Cardiac Arrest Registry to Enhance Survival (CARES) database. We described characteristics of patients, arrests, and EMS responses, and used recursive partitioning to develop decision rules to identify arrests unlikely to survive to hospital discharge, or to survive with good neurologic function.
Results: From 2015-2018, 1750 patients received EMS dispatch for cardiac arrest in San Mateo County. We excluded 44 patients for whom resuscitation was terminated due to DNR directives. Median age was 69 years (IQR 57 - 81), 563 (33.0%) patients were female, 816 (47.8%) had witnessed arrests, 651 (38.2%) received bystander CPR, 421 (24.7%) had an initial shockable rhythm, and 1178 (69.1%) arrested at home. A simple rule (non-shockable initial rhythm, unwitnessed arrest, and age 80 or greater) excludes 223 (13.1%) arrests, of whom none survived to hospital discharge.
Conclusion: A simple decision rule (non-shockable rhythm, unwitnessed arrest, age 80 or greater) identifies arrests for which resuscitation is futile. If validated, this rule could be applied by EMS policymakers to identify cardiac arrests for which the trauma and expense of resuscitation are extremely unlikely to result in survival.
Context: Prioritizing amongst potentially conflicting end-of-life values may help patients discriminate amongst treatments and allow clinicians to align treatments with values.
Objectives: To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.
Methods: Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.
Results: Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared to 69% and 21% respectively for patients prioritizing relief of discomfort, and 78% and 33% respectively for patients unsure of their prioritized value (p<0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (OR 0.958 per year; 95%CI 0.935,0.981) and more likely with better self-perceived health (OR 1.402 per level of health; 95%CI 1.090,1.804).
Conclusion: Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.
Importance: Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear.
Objective: To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR.
Data Sources: PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018.
Study Selection: Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported.
Data Extraction and Synthesis: The study was performed according to the PRISMA guidelines.
Main Outcomes and Measures: The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment.
Results: Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71).
Conclusions and Relevance: Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.
Introduction: The perceptions of medical futility and decisions about termination of resuscitation (TOR) for out-of-hospital cardiac arrest (OHCA) are highly heterogeneous and dependent on the practice of the attending emergency physicians. The objective of this study was to report and investigate the knowledge, attitudes, and practices regarding medical futility and TOR during management of OHCA in Hong Kong.
Methods: A cross-sectional survey was conducted among emergency medicine physicians in Hong Kong. The questionnaire assessed participants’ background, knowledge, attitudes, and behaviours concerning medical futility and TOR in management of OHCA. Composite scores were calculated to reflect knowledge, attitudes, and practices of OHCA treatment. Subgroup analysis and multiple regression analysis were used to explore the relationship between participants’ background, knowledge, attitudes, and behaviours.
Results: The response rate to this survey was 57% (140/247). Independent predictors of less aggressive resuscitation in OHCA patients included status as a Fellow of the Hong Kong College of Emergency Medicine (ß= -0.314, P=0.028) and being an Advanced Cardiac Life Support instructor (ß= -0.217, P=0.032). There was no difference in aggressiveness of resuscitation in terms of years of clinical experience (ß=0.015, P=0.921), knowledge of TOR (ß=0.057, P=0.509), or attitudes about TOR (ß= -0.103, P=0.214). The correlation between knowledge and attitudes was low (Spearman’s coefficient=0.02, P=0.795).
Conclusion: Clinical practice and behaviour of TOR was not demonstrated to have associations with knowledge or attitude. Status as a Fellow of the Hong Kong College of Emergency Medicine or Advanced Cardiac Life Support instructor were the only two parameters identified that had significant relationships with earlier TOR in medically futile patients with OHCA.
Importance: Several clinical decision rules (CDRs) have been developed to help practitioners know when to safely terminate resuscitative efforts after in-hospital cardiac arrest (IHCA). The UN10 rule, a CDR that uses 3 intra-arrest variables, has been shown to predict a poor chance of survival to discharge. However, its large-scale applicability in clinical settings remains unknown.
Objective: To assess the performance of a parsimonious CDR in a national cohort of individuals with IHCA.
Design, Setting, and Participants: This retrospective cohort study used a nationwide cohort from the American Heart Association Get With the Guidelines-Resuscitation IHCA registry to derive a sample of 96 / 509 patients from 716 US hospitals who experienced IHCA from January 1, 2000, to January 26, 2016. Data analysis began in January 2018 and concluded in June 2018.
Exposures: The UN10 rule uses 3 variables: (1) unwitnessed arrest, (2) nonshockable rhythm, and (3) no return of spontaneous circulation within 10 minutes of resuscitative efforts. The CDR indicates futility if all 3 criteria are met. This CDR was analyzed according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline.
Main Outcomes and Measures: The primary outcome was survival to hospital discharge following resuscitation. Favorable neurologic status at discharge was also assessed. Overall rates of survival and survival with favorable neurologic status (cerebral performance category score, 1 or 2) were compared with predicted values by the UN10 rule using 2×2 contingency tables.
Results: Of 96 / 509 patients, 55/761 (57.8%) were men, and the mean (SD) age was 67.1 (15.3) years. In total, 18/713 patients (19.4%) survived to discharge, and 16/134 patients (16.7%) were discharged with a favorable neurologic status. Overall, 15/838 patients (16.4%) met all 3 criteria for futility in the UN10 rule. A total of 1005 patients (6.3%) who met the UN10 rule survived to discharge, and 754 (4.8%) survived with favorable neurologic status. The percentage of patients meeting the UN10 rule (ie, predicting futile resuscitation) who actually survived in our study cohort was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%). The positive predictive value of the UN10 rule was 93.7% (95% CI, 93.3%-94.0%), which was lower than the initial derivation cohort (100%; 95% CI, 97.5%-100%) and validation cohort (98.9%; 95% CI, 96.5%-99.7%).
Conclusions and Relevance: Patients who met the UN10 rule were associated with unfavorable neurologic status and low rates of survival after IHCA. Yet their survival rates are higher than reported in the initial validation study, raising the question of whether the UN10 rule may have limited utility as a definitive measure of futility during resuscitations in real-world clinical settings.
OBJECTIVES: Studies have shown improved patient quality of life with supportive care rather than aggressive treatment at the end of life. This study evaluated the symptoms that patients in Thailand with gynecologic cancers experienced and the interventions that they received at the end of life.
METHODS: The medical records of patients admitted to a tertiary cancer center in Thailand who died in the hospital from gynecologic malignancies between January 1, 2011 and December 31, 2016 were reviewed. Inclusion criteria were patients who had been been diagnosed with gynecologic cancers (ovarian, endometrial, cervical, vulvar, or peritoneal cancers or uterine sarcomas) and had died in the hospital during that period. Patients whose medical records were incomplete or unavailable were excluded from the study. Data on demographics, symptoms, interventions, and end-of-life care were collected.
RESULTS: A total of 159 patients were included in this analysis. The mean age at death was 54.3 (range 15-91) years. Over half (54.7%) of the patients were diagnosed with ovarian or peritoneal cancer, 26.4% with uterine cancer or sarcoma, 16.4% with cervical cancer, and 1.3% with dual primary cancers. Symptoms at time of admission were poor oral intake (68.6%), abdominal distention or discomfort (63.5%), pain (42.8%), nausea or vomiting (35.2%), and fever or signs of infection (27.0%). The mean number of hospitalizations during the last 6 months was 3.6. Thirty-six patients (22.6%) had major surgery during the last 6 months of life, with 14 patients (8.8%) having it performed during their last admission before death. The mean length of the last hospital stay was 22.3 (range 6-31) days, and 61 patients (38.4%) were admitted to the intensive care unit. Eleven patients (6.9%) had chemotherapy in their last 14 days of life and 10 (6.3%) received cardiopulmonary resuscitation. Almost all patients (153, 96.2%) had do-not-resuscitate (DNR) consents. The mean time between the DNR consent and death was 6.3±9.7 days.
CONCLUSION: Multiple hospital admissions, aggressive treatments, and invasive procedures were common among patients with gynecologic cancer at the end of life. Better symptom management, end-of-life preparation, and communication are needed to enhance patients' quality of life in Thailand.
La spécialité de la réanimation est une discipline jeune, née dans les années 1950, la dénomination de médecine intensive-réanimation pour les services médicaux étant récente. Elle est marquée par des évolutions techniques incessantes, tout en étant soumise à de fortes demandes sociétales. Symbolisant à la fois la performance et la toute-puissance médicales aux yeux du public, cette spécialité soulève de nombreuses questions éthiques parmi les patients, leurs proches et parmi les professionnels.
La réalité d'une clinique confrontant quotidiennement à la vie, la survie et la mort conduit les professionnels de ces services à s'ouvrir à d'autres disciplines pour préserver le sens du soin et son humanité. Les auteurs font le point sur ces enjeux contemporains en s'appuyant sur leur expertise en tant que réanimateurs polyvalents ou spécialisés, soignants, ou psychologues cliniciens. Ils approchent ces questions en croisant les regards sur le vécu émotionnel et psychique des professionnels, celui des patients ou celui des familles.
Une grande variété de situations sont abordées, reflétant la réalité des services, depuis la greffe et la dialyse, le vécu de conscience altérée, l'état de coma, de réveil, à la mort cérébrale ou au don d'organe.
[Extrait résumé éditeur]
An advance care directive (ACD) is a written expression of a person's preferences in relation to health care, which can appoint a trusted substitute decision-maker, describe personal values, and make explicit decisions consenting to, or refusing, certain treatments. When a person with a directive refusing life-sustaining treatments attempts suicide, opinions are divided as to the degree to which health care staff are bound by such a directive. In this section, I will provide an example of a patient who presents to hospital after attempting suicide who has a valid ACD refusing life-sustaining treatment. I will then describe the legislation relevant to ACDs in Victoria, Australia and ethical arguments relating to the application of an ACD in this context. I will present a decision-making algorithm for health care staff faced with the difficult decisions arising from such a presentation.
Few data are available regarding treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department (ED). We aimed to evaluate 28-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the ED. Patients with solid malignancy who initiated mechanical ventilation in the ED of a tertiary hospital were retrospectively identified and stratified into four groups according to the presence of lung cancer and metastasis. Among 212 included patients, the mortality rates by the 28th hospital day were as follows: 44.2% (19/43) in non-lung cancer patients without metastasis, 63.2% (43/68) in non-lung cancer patients with metastasis, 52.4% (11/21) in lung cancer patients without metastasis, and 66.2% (53/80) in lung cancer patients with metastasis. In multivariable analysis, lung cancer patients with metastasis had significantly higher odds ratio for 28-day mortality than non-lung cancer patients without metastasis (adjusted odds ratio [OR] = 7.17, 95% confidence interval [CI] = 2.14–24.01). Sepsis-related respiratory failure (adjusted OR = 2.60, 95% CI = 1.16–5.84) and cardiopulmonary resuscitation (adjusted OR = 13.34, 95% CI = 4.45–39.95) over respiratory failure without sepsis and acute organ dysfunction process measured by sequential organ failure assessment (SOFA) score (adjusted OR = 1.15, 95% CI = 1.05–12.6) were independently associated with an increase in mortality rate. In conclusion, the treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the ED were poor. Aggressive resuscitation versus end-of-life care in advance of an unexpected medical crisis should be considered in lung cancer patients with metastasis via a multidisciplinary approach with a consideration of underlying comorbid illnesses in the acute organ dysfunction processes.
Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and on substituted interest judgments. Patients' known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR.
En évoluant depuis les années 1980, la réanimation néonatale moderne a réduit de façon importante la morbi-mortalité des nouveau-nés prématurés. Cela a fait naître un ensemble de situations questionnantes en sauvant des vies au prix de séquelles parfois lourdes. Les pratiques des néonatologistes ont évolué allant de "l’arrêt de vie" à l’accompagnement du patient et de sa famille dans le cadre des soins palliatifs. Cette évolution a été ponctuée de plusieurs avis du Comité consultatif national d’éthique pour les sciences de la vie et de la santé (CCNE ; avis nos 63, 65 et 121) parlant d’abord "d’exception d’euthanasie" puis de grave transgression. Les études Épipage 1 et 2 ont influencé le CCNE en montrant par un suivi longitudinal une nette amélioration de la morbi-mortalité tous termes confondus sur les dernières décennies. Dans le même temps, les lois de 2002 et de 2005 relatives aux droits des malades et à la fin de vie étaient votées. Il persiste des situations difficiles, surtout dans les cas d’arrêt de nutrition et d’hydratation artificielles, le corps de l’enfant mourant de dénutrition semblant une vision insoutenable. Certains auteurs légitiment une "sédation terminale" systématique, concomitante de l’arrêt de la nutrition et de l’hydratation pour « limiter les souffrances ». D’autres parlent de "réparer une erreur de réanimation" pour les enfants vivants grâce à la réanimation. Ils pensent pouvoir "défaire" les choses et différencient ainsi une vie "naturelle" d’une vie "artificielle". Cela légitime la conduite d’une étude pour comprendre sur quels arguments sont prises les décisions de fin de vie en réanimation néonatale.
AIM: "Early" withdrawal of life support therapies (eWLST) within the first 3 calendar days after resuscitation from cardiac arrest (CA) is discouraged. We evaluated a prospective multicenter registry of patients admitted to hospitals after resuscitation from CA to determine predictors of eWLST and estimate its impact on outcomes.
METHODS: CA survivors enrolled from 2012-2017 in the International Cardiac Arrest Registry (INTCAR) were included. We developed a propensity score for eWLST and matched a cohort with similar probabilities of eWLST who received ongoing care. The incidence of good outcome (Cerebral Performance Category of 1 or 2) was measured across deciles of eWLST in the matched cohort.
RESULTS: 2688 patients from 24 hospitals were included. Median ischemic time was 20 (IQR 11, 30) minutes, and 1148 (43%) had an initial shockable rhythm. Withdrawal of life support occurred in 1162 (43%) cases, with 459 (17%) classified as eWLST. Older age, initial non-shockable rhythm, increased ischemic time, shock on admission, out-of-hospital arrest, and admission in the United States were each independently associated with eWLST. All patients with eWLST died, while the matched cohort, good outcome occurred in 21% of patients. 19% of patients within the eWLST group were predicted to have a good outcome, had eWLST not occurred.
CONCLUSIONS: Early withdrawal of life support occurs frequently after cardiac arrest. Although the mortality of patients matched to those with eWLST was high, these data showed excess mortality with eWLST.
BACKGROUND: We attempted to identify factors associated with physicians' decisions to terminate CPR and to explore the role of family in the decision-making process.
METHODS: We conducted a retrospective observational study in a single center in Taiwan. Patients who experienced in-hospital cardiac arrest (IHCA) between 2006 and 2014 were screened for study inclusion. Multivariate survival analysis was conducted to identify independent variables associated with IHCA outcomes using the Cox proportional hazards model.
RESULTS: A total of 1525 patients were included in the study. Family was present at the beginning of CPR during 722 (47.3%) resuscitation events. The median CPR duration was significantly shorter for patients with family present at the beginning of CPR than for those without family present (23.5 mins vs 30 min, p = 0.01). Some factors were associated with shorter time to termination of CPR, including arrest in an intensive care unit, Charlson comorbidity index score greater than 2, age older than 79 years, baseline evidence of motor, cognitive, or functional deficits, and vasopressors in place at time of arrest. After adjusting for confounding effects, family presence was associated with shorter time to termination of CPR (hazard ratio, 1.25; 95% confidence interval, 1.06-1.46; p = 0.008).
CONCLUSION: Clinicians' decisions concerning when to terminate CPR seemed to be based on outcome prognosticators. Family presence at the beginning of CPR was associated with shorter duration of CPR. Effective communication, along with outcome prediction tools, may avoid prolonged CPR efforts in an East Asian society.
OBJECTIVES: To describe the use of acute resuscitation plans (ARPs) among patients on a subacute geriatric ward and to identify factors associated with use of ARPs in these patients.
METHODS: The hospital records of all patients admitted to the geriatric medicine ward in 2016 were retrospectively audited.
RESULTS: An ARP was completed before separation for 333/442 (75.3%) admissions. In the event of arrest, 240 (54.3%) patients had an ARP specifying “care of the dying”, 93 (21.0%) had an ARP specifying “cardiopulmonary resuscitation” and 109 (24.7%) had no resuscitation plan. Age 85-94 years (OR 1.65, P = 0.04) and =95 years (OR 9.59, P = 0.003), as well as Charlson index of comorbidity =2 (OR 3.4, P < 0.001), Australian-born (OR 2.09, P = 0.002) and admission during October-December (OR 3.81, P < 0.001) were independently associated with increased use of ARPs.
CONCLUSIONS: Acute resuscitation plan use was associated with older age, higher comorbidity, birth in Australia and admission later in the year.
INTRODUCTION: There is no standard for categorizing reasons for death in those who achieve return of spontaneous circulation (ROSC) after cardiac arrest but die before hospital discharge. Categorization is important for comparing outcomes across studies, assessing benefits of interventions, and developing quality-improvement initiatives. We developed and tested a method for categorizing reasons for death after cardiac arrest in both in-hospital (IHCA) and out-of-hospital (OHCA) arrests.
METHODS: Single-center, retrospective, cohort study of patients with ROSC after IHCA or OHCA between 2008 and 2017 who died before hospital discharge. Traumatic arrests and patients with "do-not-resuscitate" orders prior to their arrest were excluded. Two investigators assigned each patient to one of five predefined reasons for death. Interrater reliability was assessed using Fleiss' kappa. For final categorization, discrepancies were resolved by a third investigator.
RESULTS: There were 182 IHCA and 226 OHCA included. There was substantial agreement between raters (kappa of 0.62 and 0.61 for IHCA and OHCA, respectively). Reasons for death for IHCA and OHCA were: neurological withdrawal of care (27% vs 73%), comorbid withdrawal of care (36% vs 4%), refractory hemodynamic shock (25% vs 17%), respiratory failure (1% vs 3%), and sudden cardiac death (11% vs 4%). The differences in reasons for death among the two groups were significant (p-value < 0.001).
CONCLUSIONS: Categorizing reasons for death after cardiac arrest with ROSC is feasible using our proposed categories, with substantial inter-rater agreement. Neurologic withdrawal of care is much less common in IHCA than OHCA, which may have implications for further research.
BACKGROUND: Women who suffer an out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. Understanding public perceptions of why this occurs is a necessary first step toward equitable application of this potentially life-saving intervention.
METHODS: We conducted a national survey of members of the public using Mechanical Turk, Amazon’s crowdsourcing platform, to determine reasons why women might receive bystander CPR less often than men. Eligible participants were adults (=18 years) located in the United States. Responses were excluded if the participant was not able to define CPR correctly. Participants were asked to answer the following free-text question: “Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Descriptive statistics were used to define the cohort. The free-text response was coded using open coding, and major themes were identified via classical content analysis.
RESULTS: In total, 548 subjects were surveyed. Mean age was 38.8 years, and 49.8% were female. Participants were geographically distributed as follows: 18.5% West, 9.2% Southwest, 22.0% Midwest, 27.5% Southeast, and 22.9% Northeast. After analysis, 3 major themes were detected for why the public perceives that women receive less bystander CPR. They include the following: (1) sexualization of women's bodies; (2) women are weak and frail and therefore prone to injury; and (3) misperceptions about women in acute medical distress. Overall, 41.9% (227) were trained in CPR while 4.4% reported having provided CPR in a medical emergency.
CONCLUSIONS: Members of the general public perceive fears about inappropriate touching, accusations of sexual assault, and fear of causing injury as inhibiting bystander CPR for women. Educational and policy efforts to address these perceptions may reduce the sex differences in the application of bystander CPR.