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Paramedic Knowledge, Attitudes, and Training in End-of-Life Care

Published online by Cambridge University Press:  28 June 2012

Susan C. Stone ,
Jean Abbott ,
Christian D. McClung ,
Chris B. Colwell ,
Marc Eckstein  and
Steven R. Lowenstein
Susan C. Stone*
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
Jean Abbott
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
Christian D. McClung
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
Chris B. Colwell
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
Marc Eckstein
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
Steven R. Lowenstein
Affiliation:
Keck School of Medicine, University of Southern California, Los Angeles, California
*
Keck School of MedicineUniversity of Southern CaliforniaLos Angeles, California USA E-mail: [email protected]
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Abstract

Introduction:

Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills.

Methods:

A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under or over-preparation.

Results:

Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22–59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91–97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52–65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96–100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20–32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26–43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23–38%); and (3) verbal ADs (75% very important vs. 54% well-prepared, difference 21%: 95% CI = 12–29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23–39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.

Conclusions:

There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

Keywords

Do-Not-Attempt-to-Resuscitate ordersemergency medical servicesend-of-lifeparamedics
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 24 , Issue 6 , December 2009 , pp. 529 - 534
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2009

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References

1. Feder, S, Matheny, RL, Loveless, RS, Rea, TD: Withholding resuscitation: A new approach to prehospital end-of-life decisions. Ann Intern Med 2006;144(9):634–640.CrossRefGoogle ScholarPubMed
2. Hallstrom, AP, Ornato, JP, Weisfeldt, M, et al. : Public-access defibrillation and survival after out-of-hospital cardiac arrest. NEngl J Med 2004;351(7):637–646.Google ScholarPubMed
3. Dull, SM, Graves, JR, Larsen, MP, Cummons, RO: Expected death and unwanted resuscitation in the prehospital setting. Ann Emerg Med 1994;23(5):997–1002.CrossRefGoogle ScholarPubMed
4. Sabatino, CP: Survey of state EMS-do not attempt resuscitation laws and protocols. J Law Med Ethics 1999;27(4):297–315.CrossRefGoogle ScholarPubMed
5. ACEP policy statement: Discontinuing resuscitation in the out-of-hospital setting. ACEP1997, reaffirmed 2002. Available at http://www.acep.org/3,436,0.html Accessed 05 January 2008.Google Scholar
6. Kellermann, A, Lynn, J: Withholding resuscitation in prehospital care. Ann Intern Med 2006;144(9):692–693.CrossRefGoogle ScholarPubMed
7. Lynn, J, Goldstein, NE: Advance care planning for fatal chronic illness: Avoiding commonplace errors and unwarranted suffering. Ann Intern Med 2003;138(10):812–818.CrossRefGoogle ScholarPubMed
8. Lerner, EB Billittier, AJ, Hallinan, K: Out-of-hospital do-not-resuscitate orders by primary care physicians. J Emerg Med 2002;23(4):425–428.CrossRefGoogle ScholarPubMed
9. Marco, CA, Schears, RM. Prehospital resuscitation practices: A survey of prehospital providers. J Emerg Med 2003;24(1):101–106.CrossRefGoogle ScholarPubMed
10. Clawson, JJ, Dernocoeur, KB (eds): Principles of Emergency Medical Dispatch. 3d ed. Salt Lake City: Jones & Bartlett and ACEP, 2005.Google Scholar
11. The Project for Education of Physicians on End of life Care: EPEC EM Available at http://epec.net/EPEC/Webpages/epecem.cfm.Google Scholar
12. McNemar, Q: Note on the sampling error of the difference between correlated proportions or percentages. Psychometrika 1947;12(2):153–157.CrossRefGoogle ScholarPubMed
13. Shears, RM, Marco, CA, Iserson, KV: “Do not attempt resuscitation”(DNAR) in the out-of-hospital setting. Ann Emerg Med 2004;44(1):68–70. (Policy resource and education based on ACEP policy statement, 2003.)CrossRefGoogle ScholarPubMed
14. Guru, V, Verbeek, PR, Morrison, LJ: Response of paramedics to terminally illpatients with cardiac arrest: An ethical dilemma. CMAJ 1999;161(10):1251–1254.Google Scholar
15. ACEP policy statement. Ethical issues for resuscitation, approved, 2001. Available at http://www.acep.org/1,437,0.html. Accessed 05 January 2008.Google Scholar
16. NASEMSD, NAEMSP. National guidelines for statewide implementation of EMS “Do not resuscitate” (DNR) programs. Available at http://www.naemsp.org. Accessed 05 January 2008.Google Scholar
17. Sanders, MJ (ed.): Mosby's Paramedic Textbook. 3d ed. Revised. St Louis: Elsevier, 2007.Google Scholar
18. Bledsoe, BE, Porter, RS, Cherry, RA (eds): Essentials of Paramedic Care. 2d ed. New Jersey: Pearson Prentice Hall, 2007.Google Scholar
19. Caroline, N (ed): Nancy Caroline's American Academy of Orthopedic Surgeons: (AAOS) Emergency Care in the Streets. 6th ed. Boston: Jones & Bartlett, 2008.Google Scholar
20. Chapleau, W, Burba, AC, Pons, PT, Page, D, (eds.): The Paramedic. New York: McGraw-Hill, 2008.Google Scholar
21. Partridge, RA, Virk, A, Sayah, A, et al. : Field experience with prehospital advance directives. Ann Emerg Med 1998;32(5):589–593.CrossRefGoogle ScholarPubMed
22. Heilicser, B, Stocking, C, Siegler, M: Ethical dilemmas in emergency medical services: The perspective of the emergency medical technician. Ann Emerg Med 1996;27(2):239–243.CrossRefGoogle ScholarPubMed
23. Jaslow, D, Barbera, JA, Johnson, E, Moore, W: Termination of nontraumatic cardiac arrest resuscitative efforts in the field: A national survey. Acad Emerg Med 1997;4(9):904–907.CrossRefGoogle ScholarPubMed
24. Pepe, PE, Swor, RA, Ornato, JP, et al. : Resuscitation in the out-of-hospital setting: Medical futility criteria for on-scene pronouncement of death. Prehosp Emerg Care 2001;5(1):79–87.CrossRefGoogle ScholarPubMed
25. Schmidt, TA, Hickman, SE, Tolle, SW, Brooks, HS: The physician orders for life-sustaining treatment program: Oregon emergency medical technicians' practical experiences and attitudes. J Am Geriatr Soc 2004;52(9):1430–1434.CrossRefGoogle Scholar
26. Sanders, AB: Futility in resuscitation from cardiac arrest: Role of out-of-hospital healthcare professionals. J Emerg Med 2003;24(1):87–89.CrossRefGoogle ScholarPubMed