title: Termination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene.
abstract: BACKGROUND
  Discussions on ethical aspects of life-and-death decisions within the hospital are often made in plenary. The prehospital physician, however, may be faced with ethical dilemmas in life-and-death decisions when time-critical decisions to initiate or refrain from resuscitative efforts need to be taken without the possibility to discuss matters with colleagues. Little is known whether these considerations regarding ethical issues in crucial life-and-death decisions are documented prehospitally. This is a review of the ethical considerations documented in the prehospital medical records of patients in a Danish prehospital setting for whom the decision to resuscitate or not was made at the scene.
  
  
  METHODS
  The study is based on discharge summaries of all patients subjected to crucial life-and-death decisions by the Mobile Emergency Care Unit in Odense in the years 2010 to 2014. The medical records with possible documentation of ethical issues were independently reviewed by two philosophers in order to identify explicit ethical or philosophical considerations pertaining to the decision to resuscitate or not.
  
  
  RESULTS
  In total, 1275 patients were either declared dead at the scene without exhibiting layman's reliable signs of death or admitted to hospital following resuscitation. In a total of 62 patients, 85 specific ethical issues related to resuscitation were documented. The expressions of the ethical considerations were generally vague or unclear and almost exclusively concerned the interests of the patient and not the relatives. In the vast majority of cases where an ethical content was identified, the ethical considerations led to a decision to terminate treatment.
  
  
  CONCLUSIONS
  A strengthened practice of documenting ethical considerations in prehospital life-and-death decision-making in the patient's medical records is required. We suggest that a template be implemented in the prehospital medical records describing the basis for any ethical decisions. This template should contain information regarding the persons involved in the deliberations and notes on ethical considerations. The documentation should include considerations concerning the patient's end-of-life wishes, the estimations of the quality of life before and after the incident, and a summary of other ethical concerns taken into account, such as the integrity of the patient and frame of mind of relatives.
authors.affiliation: Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine V, Odense University Hospital, Odense, Denmark. Soeren.mikkelsen@rsyd.dk.|Department of Clinical Research, University of Southern Denmark, Odense, Denmark. Soeren.mikkelsen@rsyd.dk.
authors.forename: Søren
authors.identifier: http://orcid.org/0000-0002-5187-7027
authors.initials: S
authors.lastname: Mikkelsen
authors.affiliation: Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark.
authors.forename: Caroline
authors.initials: C
authors.lastname: Schaffalitzky de Muckadell
authors.affiliation: Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark.
authors.forename: Lars Grassmé
authors.initials: LG
authors.lastname: Binderup
authors.affiliation: Field of Prehospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, NO-4036, Stavanger, Norway.|Norwegian Air Ambulance Foundation, Holterveien 24, NO-1441, Drøbak, Norway.
authors.forename: Hans Morten
authors.initials: HM
authors.lastname: Lossius
authors.affiliation: Department of Clinical Research, University of Southern Denmark, Odense, Denmark.|Department of Anaesthesiology and Intensive Care Medicine V, Odense University Hospital, Odense, Denmark.
authors.forename: Palle
authors.initials: P
authors.lastname: Toft
authors.affiliation: Department of Clinical Research, University of Southern Denmark, Odense, Denmark.|Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.
authors.forename: Annmarie Touborg
authors.initials: AT
authors.lastname: Lassen
mesh_terms: D016887:Cardiopulmonary Resuscitation; D003718:Denmark; D004632:Emergency Medical Services; D006323:Heart Arrest / Q000628:therapy*; D006801:Humans; D008485:Medical Audit; D012189:Retrospective Studies; D028761:Withholding Treatment / Q000941:ethics*