Elsevier

Resuscitation

Volume 188, July 2023, 109818
Resuscitation

Clinical paper
Quantifying physician’s bias to terminate resuscitation. The TERMINATOR study

https://doi.org/10.1016/j.resuscitation.2023.109818Get rights and content

Abstract

Context

Deciding on “termination of resuscitation” (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner’s discretion.

Aim

Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation.

Method

We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR.

Results

5,144 OHCAs involving 173 physicians were included. The cohort’s average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p < 0.001) physician effect on TOR decision.

Odds ratio for the “doctor effect” was 2.48 [2.13–2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69–65.50]), an age of more than 85 years (38.60 [28.67–51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26–2.00]).

Conclusions

We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.

Introduction

Deciding on “termination of resuscitation” (TOR) is a frequent dilemma for any physician whose activity includes cardiac arrests management. They can be brought to the point of interrupting basic life support (BLS) when the latter have been initiated by bystanders or first aiders. They can also choose to stop advanced life support (ALS) when it fails to elicit a return of spontaneous circulation (ROSC). Lastly, they can be brought to stop post-resuscitation care when anoxic sequelae post resuscitation prohibits satisfactory clinical outcome. Few guidelines exists concerning TOR.1, 2 In the setting of BLS for emergency medical technician, recommendations suggest that they terminate resuscitation based on the joint absence of witness, shockable rhythm and ROSC. In France, such decisions are constantly taken by physicians with the possibility to start an ALS procedure. Thus, a cardiac arrest without witness, a no-flow time of more than 5 minutes (time between cardiac arrest and first chest compressions), a low-flow time (duration of chest compressions before ROSC or death) of more than 20 minutes, all known to be associated to a weak prognosis, tend to lead towards TOR. Conversely, a young age, an initial shockable rhythm, both linked to a better outcome, prompts to pursue life-supporting care.3 Nevertheless, the final TOR decision remains above all at the physician’s discretion. Any such decision remains medically and ethically difficult.4, 5, 6, and knowing which factor contribute to cardiac arrest prognosis is of primary interest. One may assume that physicians integrate, consciously or unconsciously, factors based on culture, experience, or training. Environmental factors, such as the presence of family members for instance, may influence decision-making.7, 8, 9 The focus of this study is to test the hypothesis that some physicians have a greater or lower intrinsic tendency to terminate resuscitation than average regardless of clinical factors, tendency that we term the “doctor effect”, and quantify it using Generalized Linear Mixed Models.

Section snippets

Methods

In France, medical emergencies are managed by the SAMU–Emergency Medical System (SAMU-EMS). This organization relies on a medically assessed dispatch system and medical pre-hospital care.10 The national medical emergency telephone number, 15, connects the caller to an Emergency Physician. The latter has the possibility, if necessary, as in case of cardiac arrest to send a Mobile Intensive Care Unit (SAMU-MICU) with a team comprised of an emergency physician, a nurse and an ambulance driver. If

Population

During the study observation time, 7378 patients with OHCA were included. The cause of cardiac arrest was traumatic in 1046 (14%) of cases, and 977 (13%) were in cadaveric rigidity at SAMU-MICU arrival. These patients were excluded from the analysis. On the 5355 patients left, gender (N = 3; 0.05%), no-flow or low-flow duration (N = 147; 3%), initial rhythm (N = 40; 0.7%), or doctor identity (N = 21; 0.4%) were missing, and the corresponding patients were excluded from the analysis. Finally, 5144 

Interpretation

The existence of a different propensity to terminate resuscitation among physicians has been suspected but it’s the first time that it is evaluated using a quantitative strategy. Our study confirms, using a robust methodology, the existence of such a “doctor effect”, and measures its influence concerning TOR decisions. Before going further in the interpretation, a word of caution is to be added upon comparing odds-ratios between them: random effects was normalized to one SD, thus its reported

Conclusion

In this study, we demonstrate for the first time the existence of a “doctor effect,” i.e. physician's internal bias that influences TOR decisions in OHCA. The impact of this bias on our model is greater than that of a no-flow duration lasting ten to twenty minutes or the presence of significant pre-existing co-morbidities such as oncological, cardiovascular, or respiratory disease. While human judgment remains a part of this mediation, improving the comprehension of this heterogeneity,

CRediT authorship contribution statement

T. Laurenceau: Conceptualization, Methodology, Software & Formal analysis, Writing, Data management. Q. Marcou: Methodology, Software & Formal analysis, Data management. J.M. Agostinucci: Data management, Data collection. L. Martineau: Data collection. J. Metzger: Data collection. P. Nadiras: Data collection. J. Michel: Data collection. F. Adnet: Supervision. F. Lapostolle: Conceptualization, Writing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We thank G.Dybowski for his help in the proofreading of the manuscript.

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