Skip to main content
Download PDF

Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine volume 30, Article number: 24 (2022) Cite this article

Abstract

Aim

This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest.

Methods

We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings.

Results

We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.

Conclusions

Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest.

Background

Out-of-hospital cardiac arrest is associated with poor survival rates [1]. The initial professional treatment of out-of-hospital cardiac arrest patients requires the prehospital resuscitation providers (providers) to decide whether to withhold, initiate, continue, or terminate the prehospital cardiopulmonary resuscitation. This medical decision-making is a deliberative process that combines conscious and unconscious influences derived from medical evidence, personal and medical beliefs, and, where possible, knowledge of patient preferences [2]. Clinical guidelines based on medical factors, such as comorbidities or initial cardiac rhythm assist decision-making in prehospital resuscitation in some countries, while other countries rely on individual judgement [3]. Even though resuscitation decision-making is based on medical evidence, non-medical factors can influence decision-making, even where guidelines and clinical rules are applied, which may in turn influence patient survival [2, 4].

Anderson et al. described the factors influencing the treatment of out-of-hospital cardiac arrest and identified five themes: the arrest event, the patient characteristics, the resuscitation scene, the perspective of the resuscitation provider, and medico-legal concerns [2]. The study explored both medical and non-medical factors and found that non-medical factors may change the course of action especially if the medical factors point in diverging directions [2]. As the field of resuscitation evolves, the context in which healthcare professionals make decisions changes. Recent studies describe new aspects, including non-medical factors, in decision-making in prehospital resuscitation [5,6,7,8,9]. We aimed to review original studies on non-medical factors that pre-hospital care providers describe as important for decision-making in adult resuscitation..

Methods

We conducted a mixed-methods systematic review with a narrative synthesis and reported this according to the Cochrane Qualitative Research Methods Group guidelines [10] and the PRISMA guidelines for reporting of systematic reviews [11]. As PRISMA is not designed for mixed-methods systematic reviews, we applied the fields relevant to our study (See Additional file 1). A systematic mixed-method review allows for the inclusion of multiple methodologies to combine the strengths of quantitative and qualitative methods but also makes it possible to compensate for the limitations in each method [12]. Our protocol was published on PROSPERO on March 17, 2021 (PROSPERO registration number CRD42021237078).

Selection criteria and search strategy

We searched for peer-reviewed quantitative, qualitative, and mixed-methods studies containing empirical data on non-medical factors in prehospital resuscitation of out-of-hospital cardiac arrest and their influence on the providers’ decision-making. Non-medical factors are medically extraneous factors, not necessarily based on symptoms or tests, and therefore can be difficult to define precisely [13, 14]. We used the existing literature on non-clinical and non-medical factors to outline the definition of non-medical factors [15,16,17]. This literature does not necessarily originate from the emergency medical setting and the non-medical factors had to be adapted to the prehospital resuscitation decision-making. See Table 1 for examples. We included studies concerning decision-making in prehospital resuscitation of adults > 18 years and non-medical factors as described by the resuscitation providers employed in EMS systems. We only included mixed populations of in-hospital healthcare personnel and prehospital providers if we could determine that the majority of the study population were EMS workers. Mixed populations of paediatric patients and adult patients were included if the majority of the patients were adults. We contacted the authors of two studies with a mixed population for additional information on the proportion of prehospital participants. We excluded studies concerning in-hospital decision-making, paediatric resuscitation, post-resuscitation care, and register-based studies where decision-making was not described by the providers.

Table 1 Examples of non-medical factors
Full size table

We conducted our search guided by the PRISMA Search Report Extension [18]. A research librarian assisted the search in the following electronic databases: PubMed, MEDLINE, EMBASE, CINDAHL, Cochrane Library, and PsycINFO (See Additional files 2 and 3 for the full search strategy and the list of search terms). We performed the final search on June 11, 2021. To ensure data completion, we used Scopus to identify articles that cited the included papers and used the snowballing method to identify additional eligible studies from the reference lists of the included studies [19] and screened the reference lists of systematic reviews meeting our inclusion criteria for eligible studies. We used Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org) for data management. Authors LM and JK conducted the title and abstract screening independently. Conflicts were resolved in consultation with author SM.

Data extraction

Authors LM and JK independently extracted data on study title, journal title, methodology, and participants, setting characteristics (e.g., country of origin, type of emergency medical system, legislation concerning termination of resuscitation), phenomena of interest, and outcomes of relevance to the review questions. Qualitative data consisted of themes and subthemes including relevant illustrations. Quantitative data consisted of outcomes based on descriptive or inferential statistical tests. Disagreements were resolved through discussion with author DN.

Assessment of methodological quality

Authors LM and JK critically appraised the included studies independently using the mixed methods appraisal tool (MMAT) [20]. The MMAT assesses both qualitative, quantitative, and mixed methods studies using different templates for each method. Every template contains five different criteria to be assessed, thus allowing one robust score to be used for multiple study types [20]. This enables appraisal scores ranging from 0% (no criteria met) to 100% (all five criteria met).

Data synthesis

We undertook a sequential exploratory synthesis in which qualitative data are synthesised first followed by a synthesis of the quantitative findings to generalise and test the qualitative findings [12]. The findings are then incorporated into an overall synthesis and interpretation. Our qualitative synthesis consisted of a thematic content analysis inspired by Malterud [21]. The subsequent quantitative synthesis including a meta-analysis was not possible due to heterogeneity of interventions and outcome measures, and instead, we used a narrative approach. In the final synthesis, we incorporated the quantitative findings with the themes and subthemes identified during the thematic content analysis. See Additional file 4.

Ethics

Due to the nature of the study, ethical approval was not required.

Results

Study selection and study characteristics

We identified 19,943 papers through database searches and included 27 papers after screening. Of the 143 papers excluded after full-text review, 59 had study outcomes irrelevant to our study such as decision-making factors based on registry data and not data described by providers, 51 were opinion or discussion papers without data, 16 were from an in-hospital setting, seven contained in-hospital providers’ opinions on OHCA. In eight papers, a full-text article could not be obtained, and two papers were abstracts without full-texts available. See Fig. 1 for a flowchart of the study process. The included papers contained data from 25 unique studies. Of these papers, 12 were qualitative studies [5, 8, 22,23,24,25,26,27,28,29,30,31], two mixed-method studies [32, 33], and 13 quantitative studies [34,35,36,37,38,39,40,41,42,43,44,45,46]. The papers were published between 1993 and 2021. See Table 2 for the study characteristics. Of the included papers, 24 concerned prehospital providers only, while three papers [34, 35, 42] included both prehospital and in-hospital healthcare professionals (with a majority of prehospital providers). See Table 3 for additional study characteristics.

Fig. 1
figure 1

PRISMA flowchart of the inclusion process

Full size image
Table 2 Study characteristics and critical appraisal score
Full size table
Table 3 Additional study characteristics
Full size table

Quality assessment

For quality appraisal scores, see Table 2. The MMAT quality score varied among the studies. The qualitative papers had a median score of 100% (range 0–100%), the quantitative papers had a median score of 80% (range 60–100%), and the mixed methods papers had a median score of 60% (range 20–100%).

Descriptions of non-medical factors influencing prehospital providers’ decision-making

Our analysis revealed five main themes and 13 subthemes. See Fig. 2. Both qualitative and quantitative studies covered all themes, but we identified differences between qualitative and quantitative findings regarding emotions, values, and personal beliefs of providers and their influence on decision-making. These were found mainly in qualitative studies. Quantitative studies mostly concerned the patients’ age, the providers’ characteristics and experience, and advance directives. All five main themes were covered by studies from various geographical origin. See Table 4 for an overview of factors and how they influence decision-making.

Fig. 2
figure 2

A visual presentation of the identified themes and their relations

Full size image
Table 4 Non-medical factors and their influence on decision-making
Full size table

Applying patient-related factors and perspectives

Patient characteristics

Patient age formed a part of the decision-making [41]. In younger patients, some providers would almost always perform resuscitation [42] and continue resuscitation for longer [8, 27, 29, 31, 32]. Old age in itself was not described as a reason to cease treatment, but young age was reported to be a reason to initiate resuscitation [29] and treat the patient more aggressively [31]. The providers felt a greater weight of responsibility and emotional burden when terminating resuscitation in younger patients [8]. In line with this finding, patients’ age above 79 years increased the perception of inappropriate resuscitation attempts [35].

Social status was considered in decision-making [29, 31]. A patient’s social status was thus explicitly reported not to influence resuscitation [29] while another study noted the patient’s social value did influence the decision-making [31]. Social value was described as certain personal patient attributes that are highly valued by an ensemble of members of a society [31]. Patient gender was not mentioned in any studies.


Ethical reflections concerning the patient’s wishes and quality of life Perceptions of the patient’s prognosis and expected quality of life were described as influencing decisions [5, 22, 27, 30, 34, 41, 44]. The subjective assessment of morbidity or the patient’s clinical presentation tended to dominate decision-making over chronological age, explained by the fact that exact age and known comorbidities are often not known prehospitally [22]. The perception that resuscitation was inappropriate was significantly higher in patients where the providers found the first physical impression of the patient to be “poor” or “bad”. Providers mentioned the quality of life [27, 30], where an expected low quality of life in case of successful resuscitation would make providers question the treatment. When providers were legally obliged to initiate resuscitation, they described having concerns about the patient’s expected quality of life after resuscitation [44].

In some studies, patient wishes and advance directives were important factors in decision-making [23, 28, 33], while others reported a lack of consideration for patient wishes and formal documentation [22]. In some studies, the majority of participants would honour an advance directive [33, 39, 45]. In other studies, half of the participants would not honour an advance directive [42, 43]. Honouring an advance directive could be influenced by the age of the patient and the gender and experience of the provider [36, 39, 43]. Providers would most likely seek documentation of an advance directive if they were male or more experienced or if the patient was 60 years or older [39, 43].

Some studies highlighted concern for the patient’s best interests [22, 30, 47], either by discontinuing resuscitation in patients with a low expected quality of life in case of survival [30] or by giving the patient the benefit of the doubt continuing resuscitation for a longer period [23]. The patient’s best interests were not evaluated exclusively through advance directives expressing the patient’s wishes, but rather by conferring with the family and crewmembers [22].

Some providers believed that a seriously ill and old patient had the right to die a “natural death” or die with dignity [29]. Dignity was not only described as upholding the patient’s wishes but also the act of avoiding apparently futile procedures [25]. Providers highlighted the right to a dignified death [25] or to die without interference [29] and were concerned with the patients’ dignity in cases where they could not legally terminate resuscitation [44].

Involving and involvement of bystanders and family members

Family wishes and emotions

The patient’s family and their wishes, emotions, and/or expectations could pressure providers to the initiation, continuation [24, 29, 30, 32], and termination [29] of resuscitation. Some providers mentioned that the family’s religion could lead to pressure to continue obviously futile resuscitation when according to the religious beliefs, everything possible had to be done including transportation to the hospital [32]. In cases where the family wished for termination, the providers described the family as expressing fear of suffering or a permanent vegetative state for the patient [29]. Some providers would not follow family wishes [42]. Others believed family members’ verbal wishes should be honoured [45]. Family wishes were mentioned as a reason for not complying with the guidelines [37, 46]. The family’s despair led them to beg or plead for the continuation of resuscitation—a request that the providers often complied with [24, 29], but the emotions of the families also increased the providers’ uncertainty if their decision went against the expressed wishes of the family [24, 30]. Some providers voluntarily involved the relatives in the decision-making process to obtain information or to aid the families in their mourning [29, 41].

Some providers continued resuscitation to accommodate the perceived needs of the family members [5, 24, 29]. This included continuing resuscitation to ensure that everything possible had been done to save the patient [24], but also to give the family time to realise the patient’s imminent death [5]. The family’s acceptance of a severely ill or older patient’s death could make providers more likely to withhold resuscitation [29]. On the other hand, providers feared increasing unrealistic expectations of survival if they continued resuscitation to allow the family to say goodbye [24, 33, 44]. Continuation of resuscitation and transportation to the hospital was the providers' way to deal with their inadequacy in meeting the family’s needs [24] and avoid facing the relatives with information that resuscitation was futile [29]. The in-hospital environment was perceived by providers as making it easier for the family to accept termination of resuscitation [32]. Close identification with the family made some providers more subjective in their decision-making and lead to the continuation of futile resuscitation [24]. Cultural barriers and an inability to identify with the emotional response of the family could lead to transportation of the patient to avoid confrontation [37].

The presence of bystanders

The presence of other bystanders than the family could influence the providers to continue resuscitation [36] to show that something had been done to attempt to save the patient’s life [24] or for providers to look their best in front of spectators [27]. The providers in one study displayed frustration with the bystanders’ unrealistic expectations [8]. These high expectations could influence the providers to continue resuscitation and transport the patient [29, 32]. When bystanders had initiated resuscitation, providers felt an obligation to continue resuscitation to respect the resuscitation attempt [5], to assure bystanders that their effort was important for a good outcome [29], and encourage them to do resuscitation again in a similar situation [42].

The personal conditions of providers

Provider’s characteristics and experience

Pre-existing conditions among others, length of service, type of daily work, or training were described as influencing decision-making [23]. Surgeons could be more likely to initiate resuscitation compared to anaesthesiologists and general practitioners [40]. One other study, however, found no association between profession and the perception of the appropriateness of resuscitation [34]. The level of training was associated with doubts concerning withholding resuscitation with paramedics being more likely to be troubled than EMTs [38]. Providers who had received specific training were more inclined to find resuscitation appropriate [34] and providers with palliative training found it more reasonable to resuscitate dying and terminal patients [39].

The provider’s gender and age was described as influencing decisions [31, 36, 42]. One study did not find an association between age and withholding resuscitation [45]. Personal experience and years of service made the providers more confident in their decision-making [8, 22, 23, 31, 32, 38, 39, 41,42,43]. Two papers did not find an association between experience and honouring a do not attempt resuscitation order (DNACPR) [44, 45]. Some províders described that specific experiences had influenced their decision-making [5, 29, 30], e.g. receiving flowers or letters from elderly patients who survived a cardiac arrest, and made them more prone to initiate resuscitation despite old age [29].

Emotions and personal values

The providers described an uncertainty in decision-making [8, 22, 24, 28, 29, 31, 46] in unexpected situations [8]. This was often described in situations with a lack of information [22, 31]. Uncertainty could lead to prolonged resuscitation [8, 46]. providers feared overlooking information that was important for the treatment and not having done everything possible to save the patient [22, 29]. Others feared legal consequences, criticism, or disciplinary procedures if they did not initiate or continue resuscitation [23, 27,28,29, 32, 44].

The providers acknowledged that their emotions, beliefs, and values provided a lens through which they viewed the patient’s and family’s emotions and reactions and that this might influence the decision-making [8]. Some providers noted that their own religious beliefs influenced their decision-making [33] while two studies did not support this association between religion and decision-making [34, 39].

Team interaction

Agreement within the team and the respect of other team members’ opinions were important [5, 23, 26, 32]. Team members who wanted to continue resuscitation prevailed over those who would not [5, 22, 23, 26, 27, 30, 32]. Several studies reported that non-physician providers contacted a physician to ensure everything had been done before terminating resuscitation [22, 23, 27, 30, 32]. Some providers mentioned that the composition of the prehospital crew (e.g., type of work, experience, etc.) influenced the decision-making [23].

Being influenced by external factors

Emergency medical service system and work environment

The providers described being influenced by the level of support from their employer [23] and the emergency healthcare system’s reputation [29,30,31]. The providers wished to contribute to a positive EMS reputation and sometimes adjusted their actions according to the perceived wishes of bystanders [29].

Some providers continued resuscitation for teaching or training purposes [29, 31, 42]. One study found provider fatigue as an influence referring to the long and odd working hours in the EMS [23], which led to deciding faster to transport or continuing longer at the scene to avoid an accusation of not having done enough [23]. Threats from the family could lead providers to commence or continue resuscitation and transport the patient [8, 29, 32, 46]. Scene safety was not cited as an issue in one study [38]. Rural versus urban area of service was a factor in one study with providers in rural areas more likely to terminate resuscitation compared to providers in urban areas [36].

Legislation and official guidelines

Providers found that legislation and official guidelines influenced decisions [35, 39]. Some found them helpful [25], while others felt uncertain about legal obligations [23, 33]. In one study, only 9.8% of providers felt competent to handle advance directives [39], while in another study, 73.7% felt confident terminating resuscitation when a DNACPR was present [33].

The cardiac arrest setting

The providers reported that the prehospital setting influenced decision-making [8, 22, 32, 37]. Specific areas with high mortality and morbidity, such as nursing homes and low socioeconomic areas, influenced treatment [22] as did the location of arrest e.g. public place [37]. Weather conditions and other environmental conditions e.g., cramped, dark places could influence resuscitation [8, 32, 37]. Logistical limitations e.g. difficulties of doing CPR during transport were mentioned in one study [8], while another study did not find the distance to the hospital to influence the decision-making [32].

Navigating conflicts


Ethical conflicts between guidelines, legislation, and beliefs The providers experienced conflicts between the law, the guidelines, and the patient’s wishes [23, 26] [44]. Specifically, they mentioned the lack of formal documentation in situations where family members stated that the patient did not wish to be resuscitated [23] and believed that ethically correct decisions sometimes resulted in deviations from guidelines or legislation [26, 28].

Conflicting values

The providers described various values and beliefs that created conflicts during decision-making [33]. The family could express different opinions on resuscitation than those noted by the patient in advance directives [23, 25, 26, 29, 32]. To avoid conflicts, providers would continue or transport the patient during resuscitation [32]. Providers experienced conflicts between their own values and the expectations from the legislative system [24, 30]. They feared the negative consequences if they did not transport the patient [30] and felt a conflict between the perceived legal obligation to save lives contrasting with the best interest of the patient [24].

The providers' values could conflict within the resuscitation team [5, 8, 23, 31]. In all studies, disagreements arose over the appropriate level of aggressiveness of treatment. The providers balanced futile care against a well-founded decision and described conflicts and challenges in choosing whether to initiate or continue resuscitation in cases where information was lacking [5, 8]. For example, almost all participants in one study would initiate resuscitation despite the feeling of providing futile care [5].

Discussion

In this systematic review concerning non-medical considerations in decision-making during prehospital resuscitation, we identified various themes influencing prehospital providers' decision-making, including patient-, family-, and provider-related factors as well as external factors such as legislation. Furthermore, we identified conflicts occurring between the influences coming from various actors, and differences between findings in qualitative and quantitative studies. Our findings underline the importance of contributions from both study methodologies to gain a better understanding of the decision-making process and the various influences. The study aims and the topics in the included studies varied from end-of-life to sudden cardiac death, which may explain variation in study results. However, this is a reflection of the wide spectrum of cardiac arrest scenarios that providers attend.

Non-medical factors are diverse. We identified several areas of potential improvement in out-of-hospital cardiac arrest decision-making: First, several factors, which should ideally be avoided, were described as part of decision-making. Examples of this include social status, the location of the cardiac arrest, and provider bias which risk challenging the bioethical principle of justice and hence should be avoided in decision-making [48]. However, complete avoidance of such factors may be difficult to attain. Instead, efforts to encourage providers to consciously reflect on non-medical factors in decision-making may be helpful.

Secondly, some non-medical factors, which should be included, were not always considered. One of the most researched non-medical factors were DNACPRs. Interestingly, studies on DNACPRs and their use in decision-making showed diverging results. The handling of advance directives differed and we found diversity in individual studies where participants were divided almost equally between their beliefs on DNACPR and their handling in practice [41,42,43]. Current guidelines underline that information about the patient’s wishes and values on resuscitation should be sought and included in resuscitation decision-making [3], but our findings suggest that providers find it difficult to do this in practice. Up to 10% of out-of-hospital cardiac arrests involve DNACPRs and in these cases, conflicts can occur between the patient’s family and providers [49]. Most of the included studies were conducted in a prehospital setting without a universal termination of resuscitation rule [50], but in the few studies where these rules were implemented, non-medical factors were described as influencing treatment and could also collide with the provider’s personal beliefs [32]. These conflicts of priorities, together with ethical conflicts, conflicts of expectations, fear of litigation and uncertainties, can influence decision making in unfortunate ways and furthermore cause moral distress in healthcare professionals [51]. Interventions to support providers’ prehospital resuscitation decision-making could target these situations, and future studies could shed further light on the conflicting factors in resuscitation and the dilemmas in providers’ coping.

Limitations

Our study has several limitations. The study aims and the topics in the included studies varied from end-of-life to sudden cardiac death. Thus, variation in study results may have occurred. The included studies are from a wide range of countries and have different study aims, EMS structure, and publication years. This precluded a meta-analysis. Furthermore, non-medical factors are difficult to define. We may thus have overlooked some studies. The resuscitation guidelines are updated every 5 years. This may induce changes in the resuscitation practices and thus contribute to limitations in our study. However, we found representations of all themes in both newer and older studies. As clinical decision-making including ethical considerations is a sensitive area, response bias may have occurred. Three qualitative studies rated as high quality with the critical appraisal tool [5, 30, 31], did not state their methodological orientation nor supported the analysis process with any references. As qualitative studies explore the content and meaning of empirical data, not precisely stating the methodological orientation and referencing the theoretical approach makes it difficult to decipher how the authors analysed their data. Thus, it should be noted that high reporting rates according to MMAT do not necessarily equate to high‐quality studies.

Conclusion

When deciding whether to initiate, continue, terminate, or refrain from resuscitation, prehospital resuscitation providers are influenced by a plethora of factors of which some are not strictly medically related. The providers report that patient- and family-related factors influence their decision-making process. They further report that they are influenced by personal conditions and external factors. Additionally, the providers may experience that conflicts between various factors complicate decision-making. Future research should consider non-medical factors and their role in decision-making.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

References

  1. Myat A, Song K-J, Rea T. Out-of-hospital cardiac arrest: current concepts. Lancet. 2018;391(10124):970–9.

    Article  PubMed  Google Scholar 

  2. Anderson NE, Gott M, Slark J. Commence, continue, withhold or terminate? A systematic review of decision-making in out-of-hospital cardiac arrest. Eur J Emerg Med. 2017;24(2):80–6.

    Article  PubMed  Google Scholar 

  3. Mentzelopoulos SD, Couper K, Voorde PV, Druwé P, Blom M, Perkins GD, et al. European Resuscitation Council Guidelines 2021: ethics of resuscitation and end of life decisions. Resuscitation. 2021;161:408–32.

    Article  PubMed  Google Scholar 

  4. Sasson C, Forman J, Krass D, Macy M, Kellermann AL, McNally BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circ Cardiovasc Qual Outcomes. 2009;2(4):361–8.

    Article  PubMed  Google Scholar 

  5. Leemeyer AR, Van Lieshout EMM, Bouwens M, Breeman W, Verhofstad MHJ, Van Vledder MG. Decision making in prehospital traumatic cardiac arrest; a qualitative study. Injury. 2020;51(5):1196–202.

    Article  PubMed  Google Scholar 

  6. Mikkelsen S, Schaffalitzky de Muckadell C, Binderup LG, Lossius HM, Toft P, Lassen AT. Termination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene. Scand J Trauma Resusc Emerg Med. 2017;25(1):35.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Henry B, Verbeek PR, Cheskes S. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: ethical considerations. Resuscitation. 2019;137:1–6.

    Article  CAS  PubMed  Google Scholar 

  8. Anderson NE, Gott M, Slark J. Grey areas: New Zealand ambulance personnel’s experiences of challenging resuscitation decision-making. Int Emerg Nurs. 2018;39:62–7.

    Article  PubMed  Google Scholar 

  9. Milling L, Binderup LG, de Muckadell CS, Christensen EF, Lassen A, Christensen HC, et al. Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests. BMC Med Ethics. 2021;22(1):1–10.

    Article  Google Scholar 

  10. Harris JL, Booth A, Cargo M, Hannes K, Harden A, Flemming K, et al. Cochrane Qualitative and Implementation Methods Group guidance series-paper 2: methods for question formulation, searching, and protocol development for qualitative evidence synthesis. J Clin Epidemiol. 2018;97:39–48.

    Article  PubMed  Google Scholar 

  11. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health. 2014;35:29–45.

    Article  PubMed  Google Scholar 

  13. Haimi M, Brammli-Greenberg S, Waisman Y, Stein N, Baron-Epel O. The role of non-medical factors in physicians’ decision-making process in a pediatric telemedicine service. Health Inform J. 2020;26(2):1152–76.

    Article  Google Scholar 

  14. Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors’ decision-making biases. J Eval Clin Pract. 2001;7(2):97–107.

    Article  CAS  PubMed  Google Scholar 

  15. Hajjaj FM, Salek MS, Basra MK, Finlay AY. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. J R Soc Med. 2010;103(5):178–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42(5):769–76.

    Article  CAS  PubMed  Google Scholar 

  17. Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Intern Med. 1979;90(6):957–64.

    Article  CAS  PubMed  Google Scholar 

  18. Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, et al. PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. Syst Rev. 2021;10(1):39.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Papaioannou D, Sutton A, Carroll C, Booth A, Wong R. Literature searching for social science systematic reviews: consideration of a range of search techniques. Health Info Libr J. 2010;27(2):114–22.

    Article  PubMed  Google Scholar 

  20. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the mixed methods appraisal Tool (MMAT). J Eval Clin Pract. 2018;24(3):459–67.

    Article  PubMed  Google Scholar 

  21. Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795–805.

    Article  PubMed  Google Scholar 

  22. Anderson NE, Gott M, Slark J. Beyond prognostication: ambulance personnel’s lived experiences of cardiac arrest decision-making. Emerg Med J. 2018;35(4):208–13.

    Article  PubMed  Google Scholar 

  23. Brandling J, Kirby K, Black S, Voss S, Benger J. Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study. BMC Emerg Med. 2017;17:24.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Bremer A, Dahlberg K, Sandman L. Balancing between closeness and distance: emergency medical services personnel’s experiences of caring for families at out-of-hospital cardiac arrest and sudden death. Prehosp Disaster Med. 2012;27(1):42–52.

    Article  PubMed  Google Scholar 

  25. Davey P, Lees A, Godbold R. Exploring New Zealand paramedic attitudes towards advance directives: an ethical analysis. Australas J Paramed. 2016;13(4):01–10.

    Google Scholar 

  26. Karlsson M, Karlsson N, Hilli Y. Ethical dilemmas during cardiac arrest incidents in the patient’s home. NursEthics. 2019;26(2):625–37.

    Google Scholar 

  27. Larsson R, Engström Å. Swedish ambulance nurses’ experiences of nursing patients suffering cardiac arrest. Int J Nurs Pract. 2013;19(2):197–205.

    Article  PubMed  Google Scholar 

  28. Lord B, Récoché K, O’Connor M, Yates P, Servie M. Paramedics’ perceptions of their role in palliative care: analysis of focus group transcripts. J Palliat Care. 2012;28(1):36–40.

    Article  PubMed  Google Scholar 

  29. Naess AC, Steen E, Steen PA. Ethics in treatment decisions during out-of-hospital resuscitation. Resuscitation. 1997;33(3):245–56.

    Article  CAS  PubMed  Google Scholar 

  30. Nordby H, Nøhr Ø. The ethics of resuscitation: how do paramedics experience ethical dilemmas when faced with cancer patients with cardiac arrest? Prehosp Disaster Med. 2012;27(1):64–70.

    Article  PubMed  Google Scholar 

  31. Nurok M, Henckes N. Between professional values and the social valuation of patients: the fluctuating economy of pre-hospital emergency work. Soc Sci Med. 2009;68(3):504–10.

    Article  PubMed  Google Scholar 

  32. de Graaf C, de Kruif A, Beesems SG, Koster RW. To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study. Resuscitation. 2021;164:84–92.

    Article  PubMed  Google Scholar 

  33. Waldrop DP, Waldrop MR, McGinley JM, Crowley CR, Clemency B. Managing death in the field: prehospital end-of-life care. J Pain Symptom Manag. 2020;60(4):709-16.e2.

    Article  Google Scholar 

  34. Druwe P, Monsieurs KG, Piers R, Gagg J, Nakahara S, Alpert EA, et al. Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: the REAPPROPRIATE international, multi-centre, cross sectional survey. Resuscitation. 2018;132:112–9.

    Article  PubMed  Google Scholar 

  35. Druwé P, Benoit DD, Monsieurs KG, Gagg J, Nakahara S, Alpert EA, et al. Cardiopulmonary resuscitation in adults over 80: outcome and the perception of appropriateness by clinicians. J Am Geriatr Soc. 2020;68(1):39–45.

    Article  PubMed  Google Scholar 

  36. Haidar MH, Noureddine S, Osman M, Isma’eel H, El Sayed M. Resuscitation of out-of-hospital cardiac arrest victims in lebanon: the experience and views of prehospital providers. J Emerg Trauma Shock. 2018;11(3):183–8.

    PubMed  PubMed Central  Google Scholar 

  37. Hick JL, Mahoney BD, Lappe M. Factors influencing hospital transport of patients in continuing cardiac arrest. Ann Emerg Med. 1998;32(1):19–25.

    Article  CAS  PubMed  Google Scholar 

  38. Johnson DR, Maggiore WA. Resuscitation decision making by New Mexico emergency medical technicians. Am J Emerg Med. 1993;11(2):139–42.

    Article  CAS  PubMed  Google Scholar 

  39. Leibold A, Lassen CL, Lindenberg N, Graf BM, Wiese CH. Is every life worth saving: does religion and religious beliefs influence paramedic’s end-of-life decision-making? A prospective questionnaire-based investigation. Indian J Palliat Care. 2018;24(1):9–15.

    PubMed  PubMed Central  Google Scholar 

  40. Meyer W, Balck F. Resuscitation decision index: a new approach to decision-making in prehospital CPR. Resuscitation. 2001;48(3):255–63.

    Article  CAS  PubMed  Google Scholar 

  41. Mohr M, Bahr J, Schmid J, Panzer W, Kettler D. The decision to terminate resuscitative efforts: results of a questionnaire. Resuscitation. 1997;34(1):51–5.

    Article  CAS  PubMed  Google Scholar 

  42. Navalpotro-Pascual J, Lopez-Messa J, Fernández-Pérez C, Prieto-González M. Attitudes of healthcare professionals towards cardiopulmonary resuscitation: results of a survey. Med Intensiva. 2020;44(2):125–7.

    Article  CAS  PubMed  Google Scholar 

  43. Sam S, Pekmezaris R, Nouryan CN, Tan R, Conrardy A, Ward MF, et al. Survey of emergency medical services professionals’ experience with advance directives and medical orders for life-sustaining treatment. J Am Geriatr Soc. 2011;59(12):2383–4.

    Article  PubMed  Google Scholar 

  44. Sherbino J, Guru V, Verbeek PR, Morrison LJ. Prehospital emergency medical services’ ethical dilemma with do-not-resuscitate orders. CJEM. 2000;2(4):246–51.

    Article  CAS  PubMed  Google Scholar 

  45. Stone SC, Abbott J, McClung CD, Colwell CB, Eckstein M, Lowenstein SR. Paramedic knowledge, attitudes, and training in end-of-life care. Prehosp Disaster Med. 2009;24(6):529–34.

    Article  PubMed  Google Scholar 

  46. Tataris KL, Richards CT, Stein-Spencer L, Ryan S, Lazzara P, Weber JM. EMS provider perceptions on termination of resuscitation in a Large, urban EMS system. Prehosp Emerg Care. 2017;21(5):610–5.

    Article  PubMed  Google Scholar 

  47. Brandling J, Kirby K, Black S, Voss S, Benger J. Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study. BMC Emerg Med. 2017;17(1):24.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Mentzelopoulos SD, Slowther AM, Fritz Z, Sandroni C, Xanthos T, Callaway C, et al. Ethical challenges in resuscitation. Intensive Care Med. 2018;44(6):703–16.

    Article  PubMed  Google Scholar 

  49. Counts CR, Blackwood J, Winchell R, Drucker C, Jennerich AL, Feder S, et al. Emergency medical services and do not attempt resuscitation directives among patients with out-of-hospital cardiac arrest. Resuscitation. 2021;158:73–8.

    Article  PubMed  Google Scholar 

  50. Drennan IR, Case E, Verbeek PR, Reynolds JC, Goldberger ZD, Jasti J, et al. A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation. 2017;111:96–102.

    Article  PubMed  Google Scholar 

  51. Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. Understanding experiences of moral distress in end-of-life care among US and UK physician trainees: a comparative qualitative study. J Gen Intern Med. 2021;36(7):1890–7.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Research librarian Mette Brandt Eriksen and research librarian Sebrina Maj-Britt Hansen at the University of Southern Denmark are acknowledged for assistance in the composition of search terms and search strategies.

Funding

This study is supported by grants from the Danish Air Ambulance Research Foundation, The Region of Southern Denmark, and the University of Southern Denmark. This did not influence the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication. All authors are independent of funders and all authors had full access to all the data (including analyses reports and tables) in the study. All authors take responsibility for the integrity of the data and the accuracy of the data analysis.

Author information

Authors and Affiliations

  1. Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark

    Louise Milling, Jeannett Kjær, Ulrik Havshøj & Søren Mikkelsen

  2. Department of Regional Health Research, University of Southern Denmark, Odense, Denmark

    Louise Milling, Jeannett Kjær, Ulrik Havshøj & Søren Mikkelsen

  3. Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark

    Lars Grassmé Binderup & Caroline Schaffalitzky de Muckadell

  4. The Danish Clinical Quality Program, National Clinical Registries, Copenhagen, Denmark

    Helle Collatz Christensen

  5. Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark

    Erika Frischknecht Christensen

  6. Emergency Medical Services, Region North Denmark, Aalborg, Denmark

    Erika Frischknecht Christensen

  7. Emergency Medicine Research Unit, Odense University Hospital, Odense, Denmark

    Annmarie Touborg Lassen

  8. Department of Infectious Diseases, Sub-Department of Immigrant Medicine, Odense University Hospital, Odense, Denmark

    Dorthe Nielsen

  9. Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark

    Dorthe Nielsen

Authors
  1. Louise Milling
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeannett Kjær
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lars Grassmé Binderup
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Caroline Schaffalitzky de Muckadell
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ulrik Havshøj
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Helle Collatz Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Erika Frischknecht Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Annmarie Touborg Lassen
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Søren Mikkelsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Dorthe Nielsen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LM: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Completed first draft of the manuscript. JK: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Completed first draft of the manuscript. LGB: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Substantively revised the manuscript. CSdM: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Substantively revised the manuscript. UH: Substantively revised the manuscript EFC: Substantively revised the manuscript AL: Substantively revised the manuscript HCC: Participated in the acquisition of data, and substantively revised the manuscript. SM: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Substantively revised the manuscript. DSN: Contributed to the conception and design of the work; Participated in the acquisition, analysis, and interpretation of data; Substantially revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Louise Milling.

Ethics declarations

Ethics approval and consent to participate

According to Danish law, ethics approvals are not required for systematics reviews.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1

. PRISMA checklist.

Additional file 2

. Full search strategy.

Additional file 3

. List of search terms.

Additional file 4

. Overview of the synthesis process.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Milling, L., Kjær, J., Binderup, L.G. et al. Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review. Scand J Trauma Resusc Emerg Med 30, 24 (2022). https://doi.org/10.1186/s13049-022-01004-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13049-022-01004-6

Keyword

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

ISSN: 1757-7241