Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians' intention to leave the job : Results from a cross-sectional survey in 288 centres across 24 countries

Introduction: Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians. Methods: A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals. Results: Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23-1.67]), experiencing associated moral distress (1.44 [1.24 -1.66]) and who were between 30-44 years old (1.53 [1.21-1.92] compared to Conclusion: Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job.Peer reviewe

Cardiopulmonary Resuscitation in Adults Over 80 : Outcome and the Perception of Appropriateness by Clinicians

OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts.Peer reviewe

Dual disseminated infection with Nocardia farcinica and Mucor in a patient with systemic lupus erythematosus : a case report

INTRODUCTION: Infections remain a major cause of morbidity and mortality in immunocompromised patients and require early diagnosis and treatment. However, correct diagnosis and treatment are often delayed by a multitude of factors. We report what we believe to be the first case of a combined disseminated infection with Nocardia and Mucor in a patient with systemic lupus erythematosus. CASE PRESENTATION: A 74-year-old Caucasian woman with systemic lupus erythematosus presented with recurrent pneumonia. Despite empirical treatment with antibiotics, her condition gradually deteriorated. Microbiological sampling by thoracoscopy revealed the presence of Nocardia. Despite the institution of therapy for disseminated nocardiosis, she died of multi-organ failure. A post-mortem investigation confirmed nocardiosis, but showed concomitant disseminated mucormycosis infection as well. CONCLUSION: Members of the bacterial genus Nocardia and the fungal genus Mucor are ubiquitous in the environment, have the ability to spread to virtually any organ, and are remarkably resistant to appropriate therapy. Both pathogens can mimic other pathologies both on clinical and radiological investigations. Invasive sampling procedures are often needed to prove their presence. Establishing a timely, correct diagnosis and a specific treatment is essential for patient survival

Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services : The REAPPROPRIATE international, multi-centre, cross sectional survey

Introduction: Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. Methods: A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. Results: Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P 79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P 79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P <0.0001). Conclusions: The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.Peer reviewe

Corrigendum to “European Resuscitation Council Guidelines 2021: Executive summary” [Resuscitation (2021) 1–60] (Resuscitation (2021) 161 (1–60), (S0300957221000551), (10.1016/j.resuscitation.2021.02.003))

The authors regret that the list of the ERC 2021 Guidelines Collaborators which were included in Appendix A was incomplete. The complete list of collaborators is provided below: [Table presented] The authors would like to apologise for any inconvenience caused

European Resuscitation Council Guidelines 2021: Executive summary

Perkins GD, Gräsner J-T, Semeraro F, et al. European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation. 2021;161:1-60.Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education