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Withholding Resuscitation in Out-of-Hospital Arrests

In King County, WA, verbal DNR instructions can be honored for patients with terminal conditions.

Before 1998 in King County, Washington, guidelines directed emergency services personnel to initiate resuscitation of all people with cardiac arrest, unless obvious signs of death (e.g., rigor) were present or a state-approved prehospital do-not-resuscitate (DNR) order was available. In 1998, paramedics proposed and implemented a new guideline in 16 of 35 agencies. The new guideline allowed emergency personnel to withhold resuscitation if a patient had a terminal condition and the patient, a family member, or a caregiver indicated (verbally or in writing) that the patient did not want resuscitation.

In 1997 and 1999 (the years before and after the new guideline), 2770 people experienced nontraumatic out-of-hospital cardiac arrests and were attended to by emergency services personnel. In 1999, resuscitation was withheld more often among people served by agencies using the new guideline than among people served by agencies not using the new guideline (12% vs. 4%); the pre-1998 rate of withheld resuscitation was 6%. The difference during the study was due largely to honoring verbal requests. Ninety percent of emergency personnel rated decisions to withhold resuscitation in these cases as "easy," and almost two thirds said they would have attempted resuscitation in similar situations before the new guideline was in place.

Comment: This reasonable guideline led to fewer attempted resuscitations, on the request of patients with terminal illnesses or their families. The authors interpreted these results as improvements in end-of-life care that preserved patient autonomy and decreased suffering. Editorialists raise concerns about the difficulties in determining the presence of preexisting terminal conditions and wonder whether the new guideline might be applied differently in orderly and prosperous homes than in other home environments. Despite these concerns, they called the new guideline a welcome alternative to the American Heart Association’s recommendation to always attempt resuscitation.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine May 26, 2006

Citation(s):

Feder S et al. Withholding resuscitation: A new approach to prehospital end-of-life decisions. Ann Intern Med 2006 May 2; 144:634-40.

• Original article (Subscription may be required)
• Medline abstract (Free)

Kellermann A and Lynn J. Withholding resuscitation in prehospital care. Ann Intern Med 2006 May 2; 144:692-3.

• Original article (Subscription may be required)
• Medline abstract (Free)