Original Title: Avis - Révision des critères de non-initiation et d’arrêt des manœuvres de réanimation appliqués par les techniciens ambulanciers paramédics en contexte préhospitalier

Authors' objectives: In Québec, cardiopulmonary resuscitation (CPR) protocols describe paramedics’ management and action sequences with out-of-hospital cardiac arrests (OHCA). In addition to these, there are two protocols that provide guidance on the steps to follow when resuscitation becomes futile, i.e., when the victim would not benefit from rapid transport to the hospital for further life-saving interventions. Additional protocols are also available to guide practice when, exceptionally, resuscitation should not be initiated by paramedics on the scene. These withholding and termination of resuscitation protocols have not been fully revised in more than 10 years in light of the latest evidence and guidelines. Some experts also note that Québec’s protocols may be too conservative when it comes to stop resuscitation in comparison to other provinces and countries. In addition, ethical and legal considerations related to current criteria have been raised in coroner’s reports lately. The Institut national d’excellence en santé et en services sociaux (INESSS) has been mandated by the Ministère de la Santé et des Services sociaux (MSSS) to review the criteria for the withholding and termination of resuscitation after an OHCA in the primary care paramedic protocols used with adults. The withholding resuscitation protocols are the MED-LEG.2, MED-LEG.3, and MED-LEG.4 and the termination of resuscitation protocols are the RÉA.2 and RÉA.4. The criteria used in the COVID-19 pandemic are also reviewed in this process. The purpose of this update is to ensure optimal quality and consistency of care, while promoting the judicious use of paramedical and medical resources, in a context where survival after an OHCA is low.

Authors' results and conclusions: RESULTS: (#1: Withholding resuscitation): In Québec, the criteria for withholding CPR are those targeted by professional societies and emergency medical services (EMS) organizations. • The criteria for not initiating resuscitation applied in Quebec through three protocols (MED-LEG.2, MED-LEG.3 and MED-LEG.4) are consistent with the guidelines and identical to those used by other EMS organizations in Canada, namely: – presence of obvious death or injury incompatible with life; – presence of a valid do-not-resuscitate order. Legal pitfalls are noted into the protocol describing the do-not-resuscitate orders’ management. • The protocol detailing the procedures to follow in the presence of a do-not-resuscitate order (MED-LEG.3) has legal pitfalls, which raise issues about respecting a person’s wishes to be non-resuscitated. – The MED-LEG.3 protocol is based on the Civil Code of Québec, but does not incorporate all other related rules and laws in force. – The current wording of the MED-LEG.3 protocol does not allow the respect of the person’s wish to refuse resuscitation in all circumstances if a opposite opinion is expressed by a third party. (#2: Termination of resuscitation — non-traumatic OHCA): BLS and ALS rules show good diagnostic performance. • Two termination of resuscitation rules are predominantly used in the out-of-hospital setting based on the type of resuscitation care provided: basic life support (BLS) or advanced life support (ALS). • The BLS and ALS rules are validated and appropriate, and can be used in Québec context in order to identify victims of OHCA with minimal chances of survival who would not benefit from rapid transport to the hospital. • The BLS and ALS rules are effective rules for 1) identifying OHCA victims for whom the probability of survival is very low (

Authors' recommendations: (#1: WITHHOLDING OF RESUSCITATION): Recommendation 1 To ensure that the individual’s wishes regarding the withholding of resuscitation are respected, the revision of the MED-LEG.3 protocol should be finalized based on the legal rules involved. To promote legislative consistency, ensure applicability in the field, and ensure concordance between all applicable legal rules, this revision should be carried out:  with the support of a task force composed of individuals with expertise in the legal, ethical and prehospital fields;  by ensuring that all the various possible arrangements are taken into account (e.g. obtaining consent to resuscitation, CPR refusal, representation of an incapacitated person, management of disagreements, divergent wishes of a third party regarding the initiation of resuscitation, etc.). Recommendation 2 To make the clearly expressed wishes of individuals regarding CPR enforceable, the necessary steps should be taken by the relevant authorities (e.g., the Direction médicale nationale des services préhospitaliers d’urgence) to clarify legally 1) the various tools for recording these wishes and 2) their potential application in the performance of paramedic duties. This clarification should allow for the agreement of a single document on which paramedics will base their decision to resuscitate or not. Tools that may contain a person’s wishes regarding CPR are:  do-not-resuscitate order (see Recommendation 1);  advance medical directives;  protection mandate;  levels of care and cardiopulmonary resuscitation form;  living will. Recommendation 3 The withholding resuscitation protocols that cover obvious death and mortal injuries (MED-LEG.2 and MED-LEG.4) should be clarified by the Comité ministériel de révision des protocoles. In addition to ensuring consistency of terms between the two protocols, the following concepts should be clarified:  use the concept of “irreversible death” rather than “impractical resuscitation” in the MED LEG.2 protocol;  replace the criterion of “unable to ventilate due to rigor mortis” with “rigor mortis, postmortem lividity or putrefaction” in the MED-LEG.2 protocol;  define rigor mortis, putrefaction and lividity in the MED-LEG.2 protocol (irreversible death);  clarify the roles and responsibilities of potential scene responders in each protocol (e.g., paramedics, police officers, coroners), who should subsequently be trained on the revised criteria (see Recommendations 9 and 10). (#2: TERMINATION OF RESUSCITATION - Choosing a rule and criteria for termination of CPR): Recommendation 4 The current criteria for stopping CPR in clinical protocols for paramedics in non-traumatic adult OHCA victims should be retained, subject to the following conditions:  include the criteria of “arrest witnessed by a bystander” AND “bystander CPR performed” together in the current exclusion criteria for the application of the BLS rule;  include the criterion of “pulseless electrical activity (PEA) without prognosis” in the termination of CPR algorithm (see Recommendation 5 for definition and application);  ensure that a single termination of resuscitation protocol for non-traumatic OHCA is applicable in all regions of Québec;  ensure consistency between the revised protocols and the criteria of the advanced care protocols SA20 (non-traumatic OHCA in adults) and SA20A (protocol for the management of ongoing resuscitation by primary care paramedics—adult);  ensure that protocol update is conducted by the relevant ministerial entities (e.g., the Comité ministériel de révision des protocoles) (see Recommendation 14). Recommendation 5 In non-traumatic OHCA, where heart rate is pulseless electrical activity (PEA) on the monitor after the 5 resuscitation cycles, clarification of the definition and management of the PEA could be considered. The inclusion of PEA without prognosis as a criterion for termination of resuscitation could also be considered, under these conditions:  in the absence of exclusion criteria AND when no shock was given after the 5 resuscitation cycles on scene AND in the absence of a pulse;  heart rate

Authors' methods: An extensive search of the scientific and grey literature was conducted using the rapid review method. Quantitative data related to clinical and epidemiological aspects were targeted, but also qualitative data on legal, ethical, social, organizational considerations, as well as those related to the pandemic context. Data were also collected through consultation with several experts: paramedics, emergency medical services (EMS) medical directors and administrators, emergency physicians, prehospital researcher, ethicists, and lawyer. Furthermore, the perspective of citizens was obtained through a consultation on various issues and considerations related to the withholding and termination of resuscitation in out-of-hospital setting. Two syntheses were performed depending on the nature of the data collected: 1) Synthesis of the scientific evidence of quantitative data; 2) Synthesis of the qualitative data. This synthesis identifies themes arising from the triangulation of consultation data and qualitative scientific data. All of the data collected was pooled to derive key findings and recommendations, which were then subjected to a deliberative process.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/revision-des-criteres-de-non-initiation-et-darret-des-manoeuvres-de-reanimation-appliques-par-les-techniciens-ambulanciers-paramedics-en-contexte-prehospitalier.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/revision-des-criteres-de-non-initiation-et-darret-des-manoeuvres-de-reanimation-appliques-par-les-techniciens-ambulanciers-paramedics-en-contexte-prehospitalier.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec