Factors influencing termination of resuscitation in children: a qualitative analysis

Abstract

Background: Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians. Methods: A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors. Results: Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept. Conclusion: Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

Verification of the termination of resuscitation rules in pediatric out-of-hospital cardiac arrest cases

“…Furthermore, various non-medical considerations, including parental emotional distress and moral distress among the medical staff, may influence the decision to terminate resuscitation in children. 4 Additionally, family and cultural values may strongly influence the perception that survival with poor neurological outcomes is acceptable. Therefore, despite its high accuracy, the adaptation of the TOR rule is limited to adults.…”

“… 1 , 2 , 3 Pediatric patients typically survive longer, making decisions regarding the termination of resuscitation (TOR) ethically complex. 4 Therefore, accurate prognosis prediction is crucial for determining a treatment plan that aligns with the family’s preferences.…”

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation

“…However, miss rates may exceed 6% in countries with lower proportions of in-field defibrillation attempts and shorter in-field resuscitation before patient transportation [ 44 ]. Furthermore, the application of termination-of-resuscitation protocols may vary widely at the country level (according to legal support) [ 6 , 44 ], regional healthcare system level (depending on the local frequency of witnessed arrest and bystander CPR) [ 45 ], emergency medical service (EMS) or hospital level (according to service-specific or institution-specific resuscitation policies) [ 44 , 46 ] and healthcare professional level (according to pertinent knowledge/expertise, confidence and right/responsibility to decide, possible fear of litigation and personal views) [ 6 , 47 , 48 , 49 ]. Such multiple sources of variation and the concurrent inability to issue a “universal/clear-cut” recommendation for a rule [ 4 ] may explain our results of the declining application of termination-of-resuscitation protocols.…”

Ethik der Reanimation und Entscheidungen am Lebensende

“…Vielen Ärzten fehlt das nötige Selbstvertrauen, ToR-Entscheidungen zu treffen. Einige berichten, dass sie nichtvalidierte oder kontroverse Faktoren als einzigen Grund für die Beendigung der Wiederbelebung verwenden [114,115,[120][121][122][123][124][125][126][127][128][129][130]. Die Entscheidungsfindung wird im Kontext neuerer erweiterter Wiederbelebungstechniken noch komplexer.…”