Alarik Lovisa, Nelson Maja, Terling Lovisa, Thoren Anna, Djärv Therese
Emergency Department, Södertälje Hospital, Stockholm, Sweden.
Emergency Department, Karolinska University Hospital, Stockholm, Sweden.
Resuscitation. 2025 May;210:110572. doi: 10.1016/j.resuscitation.2025.110572. Epub 2025 Mar 7.
In the event of an in-hospital cardiac arrest (IHCA), the fundamental principle is to initiate Cardiopulmonary Resuscitation (CPR). Lately, decisions on Do-not-attempt CPR (DNACPR) have received increasing attention which might affect the perception of medical staff in initiation of resuscitation.
To investigate to which extent medical staff hesitate to initiate CPR when arriving at an IHCA and to explore the factors influencing their hesitation.
Nationwide cohort study based on data from the Swedish Registry of Cardiopulmonary Resuscitation between the years 2007-2023 including all IHCAs aged 18 and over. Hesitation was defined based on answers on the variable "Expression of hesitation to start CPR", it was categorized into either Hesitation (Yes) or Non-hesitation (no/unknown/left blank). Additional free text comments regarding the grounds for the hesitation was evaluated with an inductive qualitative content analysis. Hesitation ratio was calculated as the quote per variable.
Among 36 471 patients with IHCA, the hesitation ratio was 8% (n = 2757). The patients mean age was 79 years in the hesitation group compared to 72 in the non-hesitation group (p-value < 0.01). Hesitation ratio was higher in patients admitted to general wards than in patients admitted to intensive care units (11% vs. 3%, p-value < 0.01). A hesitation ratio over 10% was found for; age, ongoing myocardial infarction, general ward, non-ECG-surveillance and unwitnessed. Grounds for the hesitations were most commonly due to a prior DNACPR order or a wish from the staff to have such, some related to age or comorbidity but none related to frailty.
Hesitation to initiate CPR in IHCA occur, particularly among older patients admitted in general wards. Hesitation relates to lack of resuscitation decisions or staff expressing an opinion that a DNACPR decision should have been made prior to the IHCA. This suggests that the routine around discussions and decisions of DNACPR orders could be improved.
