Consideration of advance directives by emergency physicians in patients with cardiac arrest: a clinical vignettes-based qualitative study.

Abstract

Background: Emergency medical services (EMS) must incorporate the patient's physiologic state and end-of-life wishes when determining whether to initiate and/or continue cardiopulmonary resuscitation (CPR). This study aims to describe and analyze the use of advance directives (ADs) in CPR by emergency physicians (EPs).

Methods: A qualitative approach using semi-directed interviews was conducted. EPs were confronted with three fictitious clinical situations where they would have to take under their care a young patient with no previous history or treatment, presenting with a cardiac arrest and a do not attempt CPR (DNACPR) order.

Results: Twenty EPs, 10 men and 10 women (mean age 39.7 ± SD 11,21), were included either for individual interviews or a focus group. Without the AD, EPs all declared that they would have started CPR. With the AD, 6 physicians accepted ADs and did nothing, 5 physicians performed a time-limited trial to allow time for collegial discussion, and 9 physicians rejected ADs alone and resuscitated. Inductive analysis of the verbatims identified 4 themes (reflection, assessment of the medical situation, determining the validity of ADs, cognitive dissonance) and the opposability of ADs to medical decisions was the point of divergence within the focus group.

Conclusion: This difference seems to be explained by different thought processes, notably concerning two steps: determining the validity of ADs, and the cognitive dissonance induced by the situation. EPs seem to respect ADs in cardiac arrest when determining the validity of ADs can be quick and the physician understands why the AD was written.