Paramedic and Emergency Medical Technicians Views on ...

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field Corita R. Grudzen, MD, MSHS, Stefan Timmermans, PhD, William J. Koenig, MD, Jacqueline M. Torres, Jerome R. Hoffman, MD, MA, Karl A. Lorenz, MD, MSHS, and Steven M. Asch, MD, MPH

Abstract Objectives: The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest. Methods: Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances. Results: Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role. Conclusions: Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it. ACADEMIC EMERGENCY MEDICINE 2009; 16:532–538 ª 2009 by the Society for Academic Emergency Medicine Keywords: resuscitation, ethics, emergency medical services, prehospital care, cardiac arrest

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lthough cardiac arrest is common in the United States, survival still remains low and has not improved over time.1 Without better matching of resuscitative attempts to clinical circumstances and patient preferences, indiscriminate resuscitation can lead to unwanted and unnecessary invasive medical procedures, potentially leaving patients in

functional states they would not have wished for and traumatizing their families. Los Angeles County emergency medical services (LAC EMS) is one of the largest EMS providers in the United States, with over 500,000 EMS responses per year and 43 agencies. In 2007, LAC EMS was called to 9,256 cardiac arrests, 94% of which were medical, or atraumatic. Similar to

From the Department of Emergency Medicine, Mount Sinai School of Medicine (CRG), New York, NY; the Department of Sociology, University of California at Los Angeles (ST), Los Angeles, CA; the Emergency Medical Services Agency, Los Angeles County (WJK), Los Angeles, CA; the School of Public Health (JMT) and the Department of Emergency Medicine (JRH), University of California at Los Angeles, Los Angeles, CA; and the Veterans Integrated Palliative Care Program (KAL), VA Greater Los Angeles Health Care System (KAL, SMA), Los Angeles, CA. At the time of the study, Dr. Grudzen was with the Robert Wood Johnson Clinical Scholars Program at the University of California at Los Angeles. Received November 25, 2008; revision received January 30, 2009; accepted February 12, 2009. Address for correspondence and reprints: Corita R. Grudzen, MD, MSHS; e-mail: [email protected]. This study was funded with a grant from the California Health Care Foundation, Grant 07-1155.

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ISSN 1069-6563 PII ISSN 1069-6563583

ª 2009 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2009.00427.x

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other large cities, only about 1.4% of these will survive neurologically intact.2 A community-partnered project was formed between LAC EMS and The University of California at Los Angeles (UCLA) to develop a new resuscitation policy to forgo resuscitation in selected patients that is scientifically valid and feasible to implement in the field. The UCLA ⁄ RAND Appropriateness Method was chosen to determine if the benefits of resuscitation outweigh the risks for various clinical scenarios or indicators. Content experts were provided a detailed literature review and rated the appropriateness (benefits outweigh the risks) and feasibility of a variety of indicators.3 Various stakeholders, including medical, legal, and patient representatives, reviewed the clinical indicators to determine which they felt would be feasible to translate into policy. Under the old policy, paramedics could forgo resuscitation only if there was a valid, written out-ofhospital do not attempt resuscitation (DNAR) order, or signs of obvious death. The new policy also allows paramedics to forgo resuscitation if family members verbally request it or if the patient is found in asystole on EMS arrival and 10 minutes have passed between collapse and initiation of cardiopulmonary resuscitation (CPR). The latter change was made based on data that patients with prolonged downtime without CPR found in nonshockable rhythms are highly unlikely to survive to hospital discharge neurologically intact,2,4,5 and therefore the risks of resuscitation in this group outweigh the benefits. At the same time, another policy was implemented that encouraged paramedics not to transport patients with cardiac arrest if they did not have return of spontaneous circulation after 20 minutes of resuscitation efforts. We know from studies of verbal DNAR policies in both King County, Washington,6 and southeastern Ontario7 that paramedics and emergency medical technicians (EMTs) are generally satisfied with such changes. Washington EMS personnel were permitted to forgo resuscitation with a family’s verbal request and ⁄ or if it was clear to them that the patient was ‘‘terminally ill.’’ They found that EMS systems that had implemented the guidelines withheld resuscitation in 11.8% of cases compared to 5.3% of cases among control EMS sites. Honoring verbal requests to forgo resuscitation made up 53% of cases. Ninety percent of EMS personnel found the decision to forgo resuscitation to be an easy, straightforward one in most cases. In southeastern Ontario, where nonstandard (i.e., verbal) DNAR requests are now honored, the vast majority of paramedics and surrogate decision makers were very comfortable with the new policy. While these studies tell us that EMS personnel are generally comfortable and satisfied with verbal DNAR policies, they were not designed to characterize paramedic attitudes and behaviors or to define barriers to policy implementation. A qualitative study such as this one allowed us to more fully describe the reception of such policies from the paramedic and EMT perspectives, gaining valuable information that can be disseminated to other agencies thinking about implementing such policies. Even if it is clear that the new LAC EMS policy produces more benefit than harm, it may not be followed if

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it is not accepted by the group expected to operationalize it. We know that ethical questions arise for paramedics when they are required to resuscitate patients who they believe are unlikely to benefit.8–11 We also know that large gaps exist between evidence-based medicine and clinical practice.12 The goals of this project were to assess paramedic and EMT perspectives and decision-making processes when forgoing or halting resuscitation in out-of-hospital cardiac arrest and leaving the deceased in the field. We wanted to understand the barriers and facilitators to implementation of the new policy from the paramedics’ and EMTs’ view. METHODS Study Design and Population This was a qualitative study of EMTs and paramedics to assess their comfort with forgoing or halting resuscitation in the field. The UCLA Institutional Review Board approved the study and oral informed consent was obtained from all participants as per the protocol. Survey and Focus Group Content and Administration Semistructured focus groups were conducted with a convenience sample of paramedics and EMTs on duty at fire stations within LAC. The goal was to draw from a geographically diverse group of large and small EMS agencies. Large agencies were defined as those with more than four fire stations in their catchment area and small agencies as those with four or fewer fire stations. Eligibility criteria included paramedics and EMTs 18 years or older who had worked within LAC EMS for at least 1 year. Focus groups were scheduled in coordination with EMS leadership, who suggested various agencies to recruit from in an attempt to achieve diversity by location and agency size. The research team contacted the individual EMS agencies themselves. The focus groups were scheduled at a time when the paramedics were thought to be the least busy, and EMS agency leadership arranged for the fire station’s units to be unavailable for nonemergent calls during the 1hour session. On arrival at the agency, all paramedics on duty were brought into a private room without EMS leadership and were invited to participate by the principal investigator. Participation was voluntary and confidential, and participants were assured none of their individual comments would be shared with EMS leadership. In addition, the focus group leader made participants aware that she had no position of authority or influence within the agency. All sessions were digitally recorded and transcribed by a professional transcription service. All focus groups were conducted by the principal investigator (CRG). A brief structured survey was administered to and completed by all participants prior to the discussion. After the survey, the focus group leader followed a semistructured discussion guide to tailor the discussion to the study objectives (Table 1 ).13 The session began by asking about a recent or memorable cardiac arrest and what factors affected the paramedics’ decision whether or not to resuscitate or transfer the patient. Topics discussed during the focus group included barriers and facilitators to full implementation

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PARAMEDIC AND EMT VIEWS ON FORGOING AND HALTING RESUSCITATION IN THE FIELD

Table 1 Focus Group Discussion Guide

1. Tell us how long you have been a paramedic and where you work. a. Have you been involved in many patients with atraumatic cardiac arrest? b. Tell us about the last case you saw or one that left a big impression on you. c. What was unique about this case? How does it compare to others? d. How important are cardiac arrests in your workload? 2. What is a realistic goal of resuscitation in cardiac arrest? a. What can be done to stop a resuscitation? 3. Tell us what you know about the new 814 policy for forgoing or stopping resuscitation in cardiac arrest. a. How does it compare to the old policy? b. Do you have any concerns about it? c. If you were in charge, how would the policy be different? d. Have you had a case under the new 814 policy? i. If so, describe in detail what happened? e. How was it different than other cases you have been involved in? 4. How did family members respond to the new policy? a. Are there any problems carrying out the new policy? b. Tell us about a time that you stopped or didn’t start resuscitation under the new policy. c. How did ED staff members respond to the new policy? d. What can be done to make your role in resuscitations easier? From your perspective, what can be done to improve resuscitative care?

of the new policy as well as EMS personnel experience and satisfaction with it. The interviewer also assessed how the new policy was received and viewed by superiors, colleagues, and family members. Data Analysis Data collection and analysis followed the well-established methodologic principles of grounded theory methodology.14 Using this qualitative analysis approach, we began not with a well-defined hypothesis, but by inductively developing a series of codes based on the discussions, which were then combined into similar themes. From there, we developed conceptual processes to explain participants’ actions. The unit of analysis was the incident, in this case the cardiac arrest, not the individual provider. Data collection stops when new data no longer change emerging theories. This results not in statistically tested hypotheses, but with a set of probability statements about the relationship between concepts developed from empirical data. During the first session, a research assistant (JMT) was present and took field notes. Two authors (ST, SMA) reviewed the field notes and the transcript to provide feedback to the focus group leader (CRG). After the first two focus groups, two of the co-authors (CRG, ST) and a research assistant (JMT) individually read through the transcripts and identified codes that emerged from the text. Then, as a group, we combined the codes into similar themes, which included the conceptual elements and their properties. Core concepts were defined as those that explained most of the participants’ main concern with as much variation as possible. They had the most powerful properties to determine why paramedics resuscitated or transported a patient and remained parsimonious. At this same session, we also began to design conceptual processes to explain paramedic decision-making regarding cardiac arrest. Three authors (CRG, JMT, ST) then reviewed each subsequent transcript to make sure that the conceptual framework captured the full variation of the

focus group, and the same authors (CRG, JMT, ST) met as a group again after completion of the fourth focus group to check for the explanatory strength across the entire data set. We continued to add codes to the model until no new concepts emerged. Any discrepancies were resolved by consensus. Although no new core concepts emerged from the fourth focus group, one additional focus group was conducted to assure

Table 2 EMS Personnel Characteristics: Responses to a Structured Written Survey (N = 36)

Variable Age, yr 18–24 25–34 35–44 45–54 55–64 Sex Female Male Agency size Small Large Role EMT Paramedic Years of practice 1–5 6–10 11–15 16–20 >20 Cardiac arrests ⁄ yr 0 1–10 11–20 21–30 31–40 >40

n

%

1 6 13 14 2

3 17 36 39 5

0 36

0 100

19 17

53 47

2 34

6 94

10 5 6 4 11

28 14 17 11 30

4 17 6 1 2 6

11 47 17 3 5 17


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significant variability by geographic location and agency size. After completion of the last focus group, the transcripts and conceptual models were reviewed again (JMT) and any missing elements were added. Comments were edited for grammar. RESULTS Written Structured Survey Five focus groups were conducted with an average 7.2 participants in each group (range, 5–11). The mean ± SD age of the 36 participants was 41.8 ± 9.0 years (range, 21–56 years) and all were male (see Table 2). Paramedics and EMTs had seen a mean ± sd of 21.1 ± 22.6 cardiac arrests in the prior 12 months. Participants had spent a mean ± SD of 15.2 ± 9.9 years in practice (range, 1 to 30 years). In response to the written survey completed before the focus group discussion, 33 of the 36 participants (92%) rated the new resuscitation policy as useful or very useful, and 26 of 36 (72%) indicated that it was easy or very easy to carry out. Other survey responses are listed in Table 2. Semistructured Focus Group Discussion During the focus groups, participants viewed the barriers and facilitators to implementation of both policies (i.e., forgoing resuscitation altogether versus initiating resuscitation and, if unsuccessful, stopping) as similar, so we analyzed the results in general. We first describe core concepts that explain why resuscitation or transport did or did not take place and whether the policy was adhered to. These were divided into two main categories: 1) provider factors and 2) arrest characteristics. Core concepts that emerged within provider factors included the following: a) provider knowledge, attitudes, and beliefs regarding resuscitation and b) group dynamics, which included interactions among EMS

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providers, and between EMS providers and EMS leadership, police, the coroner, and emergency department (ED) staff. Within arrest characteristics, core concepts included 1) patient factors, 2) family dynamics, and 3) logistics surrounding the arrest. Themes within each core concept and representative quotes are listed in Tables 3 and 4. 1. Provider Factors. Provider Knowledge, Attitudes, and Beliefs Regarding Resuscitation (Table 3A). EMS personnel had an overwhelmingly positive view of the new policy and felt the benefits of the policy change to patients, family members, EMS, and the public prevailed. A paramedic at a busy agency recalled, ‘‘We got a call about an unconscious male in full arrest. When we get there the family is in tears. They said, ‘We’re looking for the DNR. We don’t have it.’ There were three family members present. Everybody’s got the same thought and that’s good enough for us. We don’t need the paper… It really worked out nice because there was a lot of stress and worries. They were trying to be with their family member at the same time trying to look for this paper… That’s where the new policy comes in. We never saw the DNR form; we just took their word and the process… The new run sheet has a box on the bottom to check for verbal DNR.’’ Many also expressed that with time they developed more confidence and comfort with the new policy. The majority considered it empowering, rather than taking away procedures. As one paramedic said, ‘‘This policy is now in the back of our head. When should we pronounce? We now have the ability to decide whether or not we should take someone to the emergency room or just leave the body in their bed.’’ Only one paramedic mentioned concern that the policy might result in fewer opportunities to practice procedures (e.g., intubations).

Table 3 Provider Factors Important in Decisions Regarding Resuscitation and Transport in Cardiac Arrest, by Core Concept Theme

Representative Quotes

A. Provider Knowledge of, Comfort with, and Attitude Towards the Policy Policy benefits outweighs harms for patients 1) ‘‘I don’t think it is harmful to patients because if there’s any chance at all that they’re viable patients then we’re going to work on them.’’ 2) ‘‘I think everybody here would agree if it’s someone who has a chance, we’re going to resuscitate anyhow.’’ Paramedics feel empowered by policy 1) ‘‘Before this policy, we were working them up because that’s what it says…so you were bound to do those things.’’ 2) ‘‘I think it’s a really great policy for all of us. For all these years, up until now, it’s been so futile and it comes up again and again.’’ 3) ‘‘Now we have the latitude to do what I think we would like to do, which is really good customer service too.’’ B. Group Dynamics Tension between EMS, police, and ED staff 1) ‘‘I try to liaise with the PD to allow us to call the coroner to expedite the regarding resource utilization engine company’s departure and the PD and this city wouldn’t allow us to, which is a shame.’’ 2) ‘‘We can’t leave this person alone in a public place. So either we’re tied up or the police are tied up for that unknown length of time.’’ 3) ‘‘But the reality is depending on what’s going on in the city, … we may not get PD forever. The coroner’s not going to get called until the PD gets there. So we could literally wait two, two and a half hours for the PD to show up’’ PD = police department.

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Table 4 Arrest Characteristics Important in Decisions Regarding Resuscitation and Transport in Cardiac Arrest, by Core Concept

Theme A. Patient Factors Paramedics feel confident that they can identify patients who have little chance of survival

B. Family Dynamics Family emotional preparedness affects decisions regarding resuscitation and transport

C. Logistics Location of arrest, presence of onlookers, and space for resuscitative efforts all affect decisions regarding resuscitation and transport

Representative Quotes 1) ‘‘We have some convalescent homes where if they’re not breathing, they’re dead in my opinion. I just pronounce them all…they never come back anyways, and if they do they just die in the ICU another day.’’ 2) ‘‘No sense working up a person in a convalescent home if they’re asystole…As soon as you get in the door of the ED, they check things out and they call it within thirty seconds.’’ 1) ‘‘I mean you can tell by the family when you walk in. If they’re hysterical, ‘Do something, do something!’ or if they’re more like, ‘Oh well, we knew it was coming’.’’ 2) ‘‘I think we’re pretty good at kind of gauging the crowd, kind of getting the feel. Obviously if we get there and they’re in a hospital bed and the family’s all gathered around the bed, we know that that’s what they want.’’ 3) ‘‘If you’ve got someone that you know has been ill for a long time and the family’s there, and they’re relieved it’s one thing, versus somebody that wasn’t expecting it even though they know the patient didn’t want to be resuscitated, the family is in disarray.’’ 1) ‘‘We had one at Sizzler in front of the salad bar and the guy was obviously dead, but there are all these people around—people are stepping over him, trying to get their salad.’’ 2) ‘‘It wasn’t good to have small children looking at their dad lying in the garden.’’ 3) ‘‘It was awkward because of the situation. We had to drag her (the wife) out from the bedroom into the living room because it was a small area. We had intubated her and had lines in her. The husband was there by himself so we were there for well over an hour. We didn’t want to leave him there alone with his wife by himself.’’

Another paramedic from a smaller agency that receives fewer calls for cardiac arrests emphasized that the policy allowed for improved communication with caregivers: ‘‘We received a textbook call about a man in cardiac arrest and citizen CPR was in progress. When we arrived at the man’s home his live-in nurse was extremely upset so I took her to the back room to talk. I think one of the great things about this policy is that it really helps people deal with the situation. For them it’s a rollercoaster ride, here comes the lifesavers that are going to save my loved one, take him to the hospital, and all is going to be good. We know that’s not the case. With the policy in place we can talk more candidly with them and it works really well. We can set them up for what is to be expected.’’ Not all paramedics shared the same positive views on the new policy. One paramedic in particular felt differently: ‘‘It’s better for the family to see you work on their loved one. You are leaving a lasting impression in their minds that you’ve done everything you possibly could to bring this person back. But we know, based on experience, that there’s probably no hope to bring this person back.’’ Only one paramedic expressed this particular opinion, while the majority felt that it was better to give the family realistic expectations and not provide false hope. Group Dynamics (Table 3B). Tensions exist between EMS providers and EMS leadership, police, and the coroner regarding how best to utilize resources when a

patient is left in the field. The time to police arrival varied by agency, and long waits were an issue at some agencies when a paramedic stays on scene to support the family and must wait for police. One paramedic recalled, ‘‘If we had worked up that person and pronounced him, there’s nobody to take charge because in this case the guy was a renter and the manager found him. So even if it had been timely, we still would have been there for that two and a half, three hours. Then we have to call the battalion chief and tell him that we’re going to be tied up until the police show up—who knows how long we’ll have to wait and from a resource standpoint it can be a big deal waiting.’’ In addition, there is sometimes friction between paramedics and emergency physicians over resource utilization. A paramedic explained, ‘‘Doctors would get upset with us in the past because you had to work up those 90-year-olds who really had no chance. We’d be doing CPR and their legs would be straight up in the air because they don’t straighten out anymore. We would take them into the hospital and the doctors would ask, ‘What are you bringing me this for?’ We would tell them they had a rhythm... We were working them up because they weren’t DOA. There’s nothing I can check on the run sheet to justify not resuscitating. Therefore, we were bound to bring in a patient like that.’’ Paramedics were unclear whether or not the policy improved relationships with emergency physicians or decreased their own or the EDs’ workload.


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2. Arrest Characteristics Patient Factors (Table 4A). Paramedics feel confident they have the ability to discern which patients are unlikely to survive and recognize that few patients in convalescent homes who are resuscitated survive neurologically intact. They were frustrated by prior requirements to resuscitate all patients, even when it appeared futile. One paramedic described such an experience in the following way: ‘‘We got called for a 92 year old male who was found down, extremely jaundiced and asystolic on arrival. We gave a few rounds of drugs, and called to report asystole and pronounce. In the middle of the report he went into PEA. So we have to give two more rounds of drugs and he was a heavy carry all the way down the stairs and elevator into the hospital for a dead person.’’ They also expressed frustration at the time and effort involved in futile resuscitation when resources could be more wisely used to care for other patients. One veteran paramedic stated, ‘‘Up until now, all the years we’ve done this, it’s been so futile. It’s not worth the time and effort, and it comes up again and again. This last shift we were working on a cardiac arrest; meanwhile so many calls are coming in that we can’t handle that are probably more viable patients.’’ Family Dynamics (Table 4B). Family dynamics, such as agreement among family members and perceived acceptance of or emotional preparedness for death, play a large role in decisions about whether or not to transport. The following quote introduces the benefits of being able to cease resuscitation on site when appropriate: ‘‘Recently we had a gentleman who we ended up working on for a long time in his home. His wife and daughter were there and I was able to talk to them about what was going on. I was able to say, ‘Look, we are going to do all that we can but it doesn’t look good and I want you to be prepared for the fact that the chances of his survival are very slim.’ We did everything we could but we eventually had to pronounce him. It was better for the family though because they could say goodbye to him in their home versus a crowded hospital. Even though it is a bit uncomfortable for us to be right there as they said their goodbyes, I felt the discomfort for us is better in the long run for the family.’’ Logistics (Table 4C). Under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared for EMS to leave the body on scene, there was consensus among paramedics and EMTs that it was more appropriate to transport the deceased to the hospital. One paramedic shared one of his experiences with such a case: ‘‘I had one guy on a tennis court who went down and his buddy was doing CPR. It was a public place where people were coming to use the courts. There were kids around so he had to be transported. You almost have to transport them because of the public impression on you.’’ Another paramedic described a similar situation: ‘‘They pulled the kid out of the water, called the paramedics and did CPR. They did everything that they’re supposed to do, but then they pronounced him, so they left the kid there. It was a busy weekend, they had to cordon off the whole area and the family was there. If that was me, I would have said let’s just

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get him to the hospital and get him out of this environment.’’ Space constraints can also affect whether paramedics are able to successfully resuscitate patients and whether or not they feel it is appropriate to leave the body at the site of arrest. At times space may be limited, and as one paramedic pointed out, that can further complicate the resuscitative process. ‘‘We had an elderly lady whose husband called our dispatcher. It was a witnessed arrest so CPR was done right away. The patient never converted and she was asystole the whole time. There was some discussion as to whether or not we should leave her there. The husband was well into his 80s and the body was in a very small space. You’ve got to be on scene to make that judgment call.’’ DISCUSSION Assuming that certain patient characteristics are present, paramedics are generally enthusiastic about the policy change, view the ability to forgo or halt resuscitation in the field as empowering, and do not believe it presents harm to patients or families under most circumstances. While the vast majority of paramedics found the policy useful, only 72% found it easy to carry out, possibly because of the myriad of issues paramedics must consider when leaving a body on scene. Multiple factors affect whether paramedics will forgo resuscitation and ⁄ or leave the deceased in the field under the new policy. While most viewed it as beneficial to all involved, comfort with the policy, family dynamics, location of arrest, and staffing affected whether they decided to implement it. Family disagreement and perceived readiness to accept death facilitated forgoing or halting resuscitation in the field, while other factors, such as arrest in a public place or long waits for police arrival, were barriers to leaving the deceased in the field. The idea of ‘‘resuscitation as an act of hope’’ suggests that paramedics are sensitive to the emotional context and do not view their jobs in a distracted, technical sense. In the case of paramedics, being able to comfort, palliate, and act to ease bereavement or grief on scene could be powerful tools that might help them embrace a somewhat different role in these specific circumstances. Currently, in LAC, there is no official bereavement training for EMS personnel, although some agencies have initiated efforts on their own. All paramedics in LAC watch an annual EMS update video describing any future policy changes. In 2007, this featured a 15minute talk by the principal investigator (CRG) that described the changes to resuscitation policy and their rationale. In addition, individual agencies employ nurse educators who provide ongoing education and quality improvement by reviewing cases with paramedics. Although we verified that all paramedics who participated had indeed watched the EMS video update, we were unable to discern which agencies were providing more or less ongoing education and case review. We did find that all paramedics were familiar with the policy change and that those with

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less detailed knowledge of some specifics were not concentrated in any one agency. Because we could not conduct a focus group in each of the 34 agencies within LAC we decided to vary agencies by size and geographic location. The number of focus groups and participants from small and large agencies were about equal, as we were uncertain what differences might exist between them, such as volume of cardiac arrests, ongoing education efforts, and continuous quality improvement. We do know that the four participants who had not treated a cardiac arrest in the past year were from three separate agencies. Although they had not treated an arrest recently, they each had a minimum of 14 years’ experience as a paramedic (range, 14–27 years), and therefore had likely treated numerous cardiac arrests during their careers. LIMTATIONS Because we used a convenience sample of paramedics and EMTs, those who had a negative view of the policy may have attended the focus group, but elected not to participate. In addition, leadership within agencies that had a more positive view of the policy and more successful implementation may have been more likely to arrange time for a focus group. Even given that limitation, we only had one agency that we attempted to contact repeatedly but were never able to visit due to its complex bureaucratic and leadership structure. Once agency leadership agreed to participate, selection bias was limited as focus groups were scheduled by a supervisor who arranged for a number of ambulance crews to be taken off their tour of duty and all known invited participants attended. Because we reached theme saturation after four focus groups, we feel that we achieved a representative view from those who participated. Interestingly, all of our participants were male, and we are unable to know whether the policy might be received and implemented differently by women. Further study needs to be done to determine how such policies are received by those at risk for cardiac arrest and their families, as well as how processes can be improved from their perspective. While we were not able to assess surrogate experience directly using this approach, we learned secondhand from paramedics that families were generally grateful to be given the decision-making power to carry out their loved ones’ wishes. If forgoing and halting resuscitation in the field becomes more commonplace, further work must be done to enhance coordination between EMS, EDs, the police, and coroners to assure adequate staffing and coordination. In addition to affecting emergency care workload, widespread dissemination of policies that encourage forgoing and halting resuscitation and leaving the deceased in the field could result in a shift in place and way in which we die in the United States. CONCLUSIONS Paramedics and EMTs feel that the ability to forgo or halt resuscitation in the field empowers their decision-

making and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics and EMTs will forgo or halt resuscitation in the field. References 1. Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003; 107:2780–5. 2. Eckstein M, Stratton SJ, Chan LS. Cardiac arrest resuscitation evaluation in Los Angeles: CARE-LA. Ann Emerg Med. 2005; 45:504–9. 3. Grudzen CR, Liddicoat R, Hoffman JR, Koenig W, Lorenz KA, Asch SM. Developing quality indicators for the appropriateness of resuscitation in prehospital atraumatic cardiac arrest. Prehosp Emerg Care. 2007; 11:434–42. 4. Stueven H, Troiano P, Thompson B, et al. Bystander ⁄ first responder CPR: ten years experience in a paramedic system. Ann Emerg Med. 1986; 15:707– 10. 5. Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S. Can we define patients with no chance of survival after out-of-hospital cardiac arrest? Heart. 2004; 90:1114–8. 6. Feder S, Matheny RL, Loveless RS Jr, Rea TD. Withholding resuscitation: a new approach to prehospital end-of-life decisions. Ann Intern Med. 2006; 144:634–40. 7. Mengual RP, Feldman MJ, Jones GR. Implementation of a novel prehospital advance directive protocol in southeastern Ontario. Can J Emerg Med. 2007; 9:250–9. 8. Sherbino J, Guru V, Verbeek PR, Morrison LJ. Prehospital emergency medical services. Can J Emerg Med. 2000; 2:246–51. 9. Guru V, Verbeek PR, Morrison LJ. Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma. Can Med Assoc J. 1999; 161:1251–4. 10. Harlos M. Prenotification in cases of death at home [letter]. Can Med Assoc J. 2000; 162:631. 11. Innes G, Wanger K. Dignified death or legislated resuscitation? Can Med Assoc J. 1999; 161:1264–5. 12. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348:2635–45. 13. Devers KJ, Frankel RM. Study design in qualitative research–2: sampling and data collection strategies. Educ Health (Abingdon). 2000; 13:263–71. 14. Bryant A, Charmaz K. The Sage Handbook of Grounded Theory. London: SAGE Publications, Ltd., 2007.