Withholding resuscitation: a new approach to prehospital end-of-life decisions.

BACKGROUND Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order. OBJECTIVE To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines. DESIGN Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation. SETTING King County, Washington. PATIENTS 2770 patients with EMS-attended cardiac arrest. INTERVENTION New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired. MEASUREMENTS Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not. RESULTS Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients). LIMITATIONS The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines. CONCLUSIONS Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.