Withholding or terminating resuscitation in the prehospital context: A focus group study exploring paramedic preparation and support for resuscitation decision-making and patient death

Mrs Natalie Anderson1,2, Professor Merryn Gott1, Dr Julia Slark1

1School of Nursing, University Of Auckland , Auckland, New Zealand, 2Auckland Emergency Department, ADHB, Auckland, New Zealand

Background: Internationally, many emergency medical services authorise paramedics to withhold or terminate resuscitation in accordance with clinical guidelines.  Research suggests that the decision to terminate or withhold resuscitation is often a challenging one. Even in the context of extremely poor prognosis, ambulance personnel who lack confidence or feel uncomfortable with terminating or withholding resuscitation are likely to ‘default’ to commencing or continuing resuscitation until more senior back-up arrives.

Aim: To identify existing preparation and support mechanisms for New Zealand paramedics making decisions to withhold or terminate resuscitation and manage patient death.

Methods:  Focus groups were held with senior ambulance personnel currently working in clinical support or peer support roles across New Zealand.  A thematic analysis of transcribed data was then undertaken. A scoping review also provided an overview of international literature addressing this question.

Results: Paramedics need sufficient confidence in their ability to competently manage the resulting scene of a death, including post-mortem care, providing death notification to the bereaved, managing personal responses and supporting crew and bystanders. There is limited classroom or simulation-based training in this area. On-road clinical experience with supportive mentoring and opportunities for reflective practice are key.

Conclusion: Preparation and support for paramedic resuscitation decision-making is an under-researched area. Education interventions tend to focus on discrete skills such as death verification and death notification. There is, however, increasing inclusion of stress and coping strategies in paramedic training, and acknowledgement of the importance of both formal and informal mentoring and support.


Natalie Anderson is a Professional Teaching Fellow and currently-practising emergency nurse, with clinical experience in prehospital, intensive care and emergency department settings.  Her dual-discipline academic background in nursing and health psychology has led to a research interest in the behaviour and experiences of health professionals when faced with challenging clinical, ethical or emotional situations. Natalie’s PhD explores  the experience of New Zealand paramedics, tasked with deciding when to start, continue, withhold or terminate resuscitation attempts.