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What factors affect paramedic decision-making when deciding to commence or withhold resuscitation attempts in the absence of a DNACPR? A literature review

Posted on 19th June 2020 by

Evidence Reviews

During the final year of their Paramedic Science (BSc Hons) course at Oxford Brookes University, students carry out a literature review and critical appraisal of a topic relevant to their future practice.  This blog presents the abstract of a literature review on ‘factors that affect paramedic decision-making when deciding to commence or withhold resuscitation attempts in the absence of a DNACPR’. Other Paramedic topic blogs can be found here.


The factors that influence paramedic decision-making on commencing or withholding resuscitation are not well understood.


To gain an understanding of the factors that affect paramedic decisions to commence or withhold resuscitation attempts in out-of-hospital cardiac arrest in the absence of a ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) order and use translational research to apply learnings from in-hospital settings and other countries.


A comprehensive review of the existing literature around the subject using systematic principles, a PICOT tool for question formation, an adapted critical appraisal tool and QSR International’s NVivo qualitative analysis software for thematic analysis.


Five papers were identified as being appropriate for inclusion. Thematic analysis resulted in three core themes and nine sub themes emerging:

i) Gathering of information: pre-arrival information gathering, immediate on scene impressions, and the wishes of the family.

ii) The clinician and the crew: clinician experience informing decision-making, clinician background and values, crew disagreement

iii) The unique challenges of prehospital decision-making: initiating resuscitation in the absence of a clear directive, acting in the patient’s best interest and the context of the arrest.

This review identified the ethical dilemmas of commencing resuscitation as a default in the absence of any clear directive.


Paramedic decision-making is individualistic and is influenced by both internal and external factors such as the experience, cultural background and beliefs of the clinician, as well as the setting, context of the cardiac arrest and the patient’s family input. The unique circumstances of each out of hospital cardiac arrest (OHCA) means that paramedics must rely on their skills of information gathering and processing in order to make a time critical decision.

Recommendations following this review are, firstly, to regularly train paramedics by using high-fidelity simulation with actors and immersive environments. This would enable trainees to experience the pressure of critical decision-making in a safe environment. Secondly, greater awareness of the human factors which affect performance and specific training in this area will enhance all areas of paramedic practice. Thirdly, due to the impact of culture and background on decision-making, conduct further research examining a wider international sample. Finally, improve the uniformity and consistency in the application and communication of DNACPR decisions to prevent harm through inappropriate resuscitation attempts.

References (pdf)


John Gladwell

Newly Qualified Paramedic with South Central Ambulance Service NHS Foundation Trust with a background in volunteer Search and Rescue. Oxford Brookes University BSc Paramedic Science 2017-2020, OBU ParaSoc Treasurer and CPD organiser. Interests in remote and wilderness medicine, human factors and staff wellbeing. View more posts from John

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