How do senior paramedics decide when to stop resuscitation? Research project to help inform guidelines

Paramedic Ali Coppola is undertaking a masters in clinical research (MClinRes) to explore pulse-less electrical activity (PEA) cardiac arrest
Emergency medical service. Paramedic is pulling stretcher with patient to the ambulance car.

Paramedics make life and death decisions as part of their everyday role.

Most decisions are made based on evidence-based guidelines – including what to do in different cases of cardiac arrest.

One form of cardiac arrest – pulseless electrical activity (PEA) – has limited guidelines, meaning paramedics continue to resuscitate the patient, even if it might not be in the patient’s best interest.

Ali Coppola, paramedic with South Western Ambulance Service Foundation Trust (SWAST) is undertaking a masters in Clinical Research (MClinRes) at the University of Plymouth to look further into cases of PEA to take the first steps to informing future practice.

Ali Coppola from South Western Ambulance Service Foundation Trust (SWAST) said:

Some TV shows would have you believe that when someone goes into cardiac arrest, you shock them with a defibrillator and they’ll come back to life, but that simply isn’t the case. There are in fact four different types of cardiac arrest rhythms.

Ali Coppola MClinRes Paramedic resuscitation 

Four types of cardiac arrest rhythm

Rhythms where advanced life support and defibrillator shocks should be used:

  • Rapidly regular beating heart – pulseless ventricular tachycardia – use defibrillator.
  • Rapidly irregularly beating heart – ventricular fibrillation – use defibrillator.

Non-shockable rhythms where advanced life support should be used:

  • No electrical activity – asystole – evidence-based guidelines from the UK Resuscitation Council (2015) state in the absence of a reversible cause resuscitation can be ceased after 20 minutes. 
  • Fast or slow electrical activity, but not enough to pump blood around body – pulseless electrical activity (PEA) – limited guidelines to tell you when to cease resuscitation.

Heartbeat

“Prognosis for a non-shockable rhythm is usually poor,” Ali said. “Figures show that only 2.4 per cent of these patients survive and make a full recovery. Some patients survive but suffer bad neurological damage and have a limited quality of life.
“In the case of PEA, there are currently no specific guidelines to tell us when to withdraw resuscitation – we have to keep going and transport the patient to hospital. This is because there isn’t enough evidence to guide us. The only time we can stop resuscitation is following a discussion with a senior paramedic to see if they agree that continued resuscitation is not in the best interests of the patient.”
Ali’s two-year-long research project takes on a variety of methods – analysing the number of PEA cases where resuscitation has been ceased taking patient, clinical and systems factors into account. She will then speak to senior paramedics and find out how these factors support decision-making, in a bid to collate as much local evidence as possible to inform future practice.
“We want to make sure we do everything we can to help our patients, that’s our absolute commitment,” Ali said. “But do we always act in the best interest of our patients by continuing to resuscitate when a good prognosis is so poor? When resuscitation does not work, when the patient naturally comes to the end of their life, it’s my belief that we should support them through a dignified death. It’s important to collate as much evidence as possible to establish when this stage should come.
“By doing this research, I honestly don’t know what I’m going to find. It might be that it brings more questions than answers, which is equally as helpful as we want to make sure we’re investigating in research topics which are important to our patients. The most important aspect to all of this is ensuring we get the best outcome for our patients. As paramedics we work in their best interests at a time when patients are unable to make decisions for themselves.”

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