Field termination of resuscitation: Easing burden of paramedics

Paramedics suffer from considerable psychological discomfort when implementing prehospital termination of resuscitations (TOR), according to a recent Singapore study, and even structured training seems unable to combat this distress.

“The structured training programme is the first of its kind in Singapore and, to our knowledge, in Asia that addresses the gaps in the training of TOR application. This study has uncovered many contextual challenges and the limitations of such approach in improving paramedics’ psychological comfort levels towards TOR,” the researchers said.

Ninety-six paramedics (mean age, 31.1±6.7 years; 51.0 percent male) participated in the survey and were asked to accomplish the Morrison questionnaire, a 22-item inventory used to measure the respondent’s psychological comfort with field pronouncement of death. Assessments were performed 22 months before and 1 month after a 3-hour training session.

At baseline, the average overall psychological comfort total (PCT) score was 60.5±8.36 percent. Possible values ranged from 0 percent to 100 percent, with higher sores indicating greater level of comfort with field TOR. After the training, PCT dropped slightly and nonsignificantly to 59.92±8.73 percent (paired difference, –0.58, 95 percent confidence interval [CI], –3.24 to 2.15; p=0.668). [Int J Environ Res Public Health 2021;18:1050]

The structured training had no significant benefit on three out of five Morrison domains: sociocultural attitudes on resuscitation and TOR (p=0.065), interaction with colleagues and bystanders (p=0.731), and informing the survivors (p=0.614).

In contrast, the paramedics reported significant improvements in terms of feelings towards resuscitation and TOR (paired difference, 4.77, 95 percent CI, 1.42–8.13; p=0.006), while comfort levels regarding multitasking worsened significantly (paired difference, –4.11, 95 percent CI, –7.82 to –0.41; p=0.03).

“When dissected, three out of five domains did not show a significant change. The varying levels of emphasis on different targeted domains may have contributed to this finding,” the researchers said.

The structured intervention employed online videos, lectures, role-play simulations, and group sessions, with a particular focus on feelings and sociocultural attitudes regarding resuscitation and TOR, as well as skills to be able to inform the surviving relatives. On the other hand, it allotted lower emphasis to interactions with bystanders and colleagues.

“Compared to other healthcare settings, Singapore paramedics face a different set of challenges such as a time-constrained communication due to operational demands, legal constraints in death pronouncement such as nonbinding ‘do-not-resuscitate’ orders, and differing public expectations regarding transport to the hospital for further resuscitation,” the researchers said.

“In light of these circumstances, a single structured training session may have been insufficient to increase the paramedics’ confidence when communicating with families. The repeated questionnaire was performed before the actual implementation of TOR, limiting the ability to see the impact of structured training on actual practice,” they added.