The minutes until the emergency physician arrives at the scene – Do paramedics face an ethical dilemma when caring for advanced incurably ill and cardiac arrest patients? – a prospective questionnaire - based study

Abstract

Backgound: In Germany, prehospital emergency medicine implies a “rendezvous” system where paramedics and an emergency physician arrive at the scene separately. If paramedics arrive first, they are obliged to perform all possible actions in order to save the patient´s life. But due to a legally contradictory situation, this may lead to moral distress and an ethical dilemma, so far hardly considered scientifically, when comfort care might be more appropriate than aggressive life-saving measures for patients with an advanced incurable disease and cardiac arrest. Methods: A mixed method approach was used to explore the experiences and attitudes of German paramedics by using a newly designed, piloted questionnaire which is based on the limited existing literature and exploratory expert interviews. Results: 295 paramedics participated and 283 questionnaires could be included for analysis. Nearly 80% of the paramedics experienced moral distress when performing cardiopulmonary resuscitation (CPR) or providing medical care to patients with an advanced incurable disease. In approximately one-third of such first-at-scene situations, the respondents decided to refrain from CPR on their own responsibility or not to intervene with extended medical measures. In these first-at-scene situation most of the participating respondents also felt that they were acting outside their prescribed legal competence. The respondents listed the patient´s (actual or presumed) will, previous involvement of palliative home care, estimated overall prognosis, a suggested dying process, and the relatives´ perception and wishes as criteria for refraining from emergency measures. 71.4% of the respondents claimed to have sufficient expertise for making a CPR decision on their own responsibility, 64.0% supported a concept that extends the legal responsibility of paramedics in case of CPR. 50.9% of paramedics felt sufficiently competent in independently administering care to advanced incurably patients, 57.6% of respondents advocated a transfer of (legal) competence. Conclusion: Despite legal uncertainties, aggressive measures were foregone in one third of first-at-scene situations, based on criteria-driven decisions. Extending legal competencies to paramedics while at the same time optimizing training and providing further conceptual and structural support (such as palliative home care, crisis intervention teams and implementation of advance care planning) could help solve these dilemmas.