title: [To resuscitate or not? The emergency physician's decision in the prehospital setting].
abstract: OBJECTIVE
  To identify factors affecting the decision to withhold resuscitative attempts or to terminate cardiopulmonary resuscitation (CPR) in the prehospital setting.
  
  
  METHODS
  In a physician-based emergency medical system (EMS) standardised interviews with the emergency physicians were performed within 24 hours after unsuccessful or withheld CPR-efforts.
  
  
  RESULTS
  Over a period of one year 170 prehospital cardiac arrests were evaluated. 47 patients (28 %) were declared dead on arrival by the emergency physician. The decision to withhold CPR was based on obvious clinical signs of death (32 patients) or the diagnosis of cardiac arrest due to severe trauma (8 patients). In 4 cases the terminal state of a fatal illness was the emergency physician's criterion not to initiate resuscitative efforts. In 3 patients an extended response time (more than 10 minutes) was mentioned, in combination with a primary rhythm of either asystole or electromechanical dissociation and additional information given by the family doctor. In 123 patients CPR was attempted. In 72 cases (59 %) resuscitative efforts were terminated as no return and stabilisation of spontaneous circulation was achieved. In 58 patients the decision to stop CPR was based on the evidence of cardiac death. Additional criteria for the termination of the resuscitation attempt were the duration of CPR, an extended response time, pre-existing diseases, age, pupillary status, missing brain stem reflexes, the reason of cardiac arrest, information given by the family or the family doctor and secondarily evolving signs of death. In 14 patients the emergency physicians reported that their decision to terminate CPR was primarily based on these co-factors, the evidence of cardiac death was not explicitly mentioned in these cases.
  
  
  CONCLUSIONS
  In the pre-hospital setting the decision to withhold or to withdraw CPR is mostly based on reliable criteria such as obvious clinical signs of death, fatal trauma or evidence of cardiac death. Nevertheless, in a small but considerable number of cases exceptions to this rule are made by emergency physicians.
authors.affiliation: Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsklinikum Göttingen. mmohr@gwdg.de
authors.forename: M
authors.initials: M
authors.lastname: Mohr
authors.forename: M
authors.initials: M
authors.lastname: Busch
authors.forename: J
authors.initials: J
authors.lastname: Bahr
authors.forename: D
authors.initials: D
authors.lastname: Kettler
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D003643:Death; D004632:Emergency Medical Services / Q000941:ethics*; D005260:Female; D006323:Heart Arrest / Q000628:therapy; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010820:Physicians; D016414:Resuscitation Orders; D013997:Time Factors
vernacular_title: Reanimieren oder nicht? Die notärztliche Entscheidung im Rettungsdienst.