This cohort study examines whether health-related quality of life 3 to 6 months after cardiac arrest is associated with long-term survival among adults who survived in-hospital or out-of-hospital cardiac arrest.,QuestionIs health-related quality of life (HRQOL) 3 to 6 months after cardiac arrest associated with long-term survival?FindingsIn this cohort study including 2000 survivors of in-hospital cardiac arrest and 1108 survivors of out-of-hospital cardiac arrest (OHCA), poorer HRQOL reported with the EuroQoL 5-dimension 5-level (EQ-5D-5L) tool questionnaire was associated with reduced long-term survival (assessed up to 7 years) in both cohorts, although uncertainty was higher among OHCA survivors.MeaningFindings suggest that HRQOL measured after cardiac arrest with the EQ-5D-5L may help identify survivors at risk of reduced long-term survival and inform follow-up care and rehabilitation; further research should confirm clinical utility.,ImportanceHealth-related quality of life (HRQOL) follow-up can increase knowledge of cardiac arrest outcomes from the patient's perspective. Whether HRQOL affects long-term survival is unknown.ObjectiveTo investigate whether HRQOL 3 to 6 months after cardiac arrest is associated with long-term survival.Design, Setting, and ParticipantsThis cohort study linked 5 national registers with nationwide coverage in Sweden across a 7-year period and included survivors of in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between January 1, 2014, and December 31, 2019, with follow-up through June 30, 2021. Participants were adults surviving at least 90 days after IHCA or OHCA who completed follow-up EuroQoL 5-dimension 5-level (EQ-5D-5L) tool questionnaires. Analyses were performed December 2 to 20, 2024.ExposuresEQ-5D-5L level sum score (LSS; sum of EQ-5D-5L dimensions, ranging from 5 [no problems] to 25 [extreme problems in all dimensions]), and the visual analog scale EQ VAS, 3 to 6 months after cardiac arrest.Main Outcome and MeasuresLong-term survival up to a maximum of 7 years among patients surviving IHCA and OHCA.ResultsIn total, 2000 survivors of IHCA (median [IQR] age, 73 [65-80] years, 66% male) and 1108 survivors of OHCA (median [IQR] age, 69 [59-75] years, 77% male) were included. There were 475 deaths among patients with IHCA and 132 deaths among patients with OHCA. For patients with IHCA, the LSS distribution was 394 (20%) for LSS 5, 1034 (52%) for LSS 6 to 10, and 572 (29%) for LSS 11 to 25. For patients with OHCA, the LSS distribution was 299 (27%) for LSS 5, 637 (58%) for LSS 6 to 10, and 168 (15%) for LSS 11 to 25. In the IHCA population, LSS 11 to 25 had higher hazard of death compared with LSS 5 (adjusted hazard ratio [AHR], 2.50 [95% CI, 1.82-3.43]), whereas LSS 6 to 10 did not (AHR, 1.21 [95% CI, 0.88-1.65]). In OHCA, no associations were found between LSS categories and long-term survival (LSS 11-25 vs LSS 5: AHR, 1.41 [95% CI, 0.83-2.42]; LSS 6-10 vs LSS 5: AHR, 0.88 [95% CI, 0.56-1.39]). In both IHCA and OHCA, spline modeling using LSS and EQ VAS as continuous variables showed significant increases in hazards of death with poorer HRQOL, although the estimates in the OHCA population showed greater uncertainty.Conclusions and RelevanceIn this cohort study of patients who survived beyond 90 days after IHCA or OHCA, poorer HRQOL reported with EQ-5D-5L scores 3 to 6 months after cardiac arrest was associated with reduced long-term survival in both groups, with greater uncertainty for OHCA estimates. HRQOL assessment may help guide follow-up care.

Aim: Self-reported cognitive function has been described as an important complement to performance-based measurements but has seldom been investigated in cardiac arrest (CA) survivors. Therefore, the aim was to describe self-reported cognitive function and its association with health status, psychological distress, and life satisfaction.

Methods: This study utilised data from the Swedish Register of Cardiopulmonary Resuscitation (2018–2021), registered 3–6 months post-CA. Cognitive function was assessed by a single question: “How do you experience your memory, concentration, and/or planning abilities today compared to before the cardiac arrest?”. Health status was measured using the EQ VAS, psychological distress with the Hospital Anxiety and Depression Scale, and overall life satisfaction with the Life Satisfaction checklist. Data were analysed using binary logistic regression.

Results: Among 4026 identified survivors, 1254 fulfilled the inclusion criteria. The mean age was 65.9 years (SD = 13.4) and 31.7% were female. Self-reported cognitive function among survivors was reported as: ‘Much worse’ by 3.1%, ‘Worse’ by 23.8%, ‘Unchanged’ by 68.3%, ‘Better’ by 3.3%, and ‘Much better’ by 1.5%. Declined cognitive function was associated with lower health status (OR = 2.76, 95% CI = 2.09–3.64), symptoms of anxiety (OR = 3.84, 95% CI = 2.80–5.24) and depression (OR = 4.52, 95% CI = 3.22–6.32), and being dissatisfied with overall life (OR = 2.74, 95% CI = 2.11–3.54). These associations remained significant after age, sex, place of CA, aetiology, initial rhythm, initial witnessed status, and cerebral performance were controlled.

Conclusions: Survivors experiencing declined cognitive function post-CA are at a higher risk of poorer health status, increased psychological distress, and reduced life satisfaction, and these risks should be acknowledged by healthcare professionals.

Clinical Ethics Support (CES) includes various forms of systematic support to deal with ethical challenges in healthcare and case-based CES (C-CES) is used for CES in particular cases. The aim was to describe and normatively discuss organizational and methodological aspects of C-CES used in Swedish healthcare. A mixed-methods approach was used. A descriptive survey was answered regardingeight organizations on hospital, regional and national level, with large variations in the number of conducted C-CES activities. Data were compiled and frequencies calculated. Based on the survey results, normative questions were formulated. Six participants, with expertise of C-CES, participated in a normative group discussion. Field notes and transcribed data were analysed qualitatively. The top ranked goalof C-CES was “Supporting decision making”. Mainly prospective cases were used and C-CES was carried out as un-planned and pre-planned sessions. The normative results showed the importance of avoiding making C-CES unattractive to clinicians, for instance by keeping the time frame. The professional backgrounds of C-CES leaders varied greatly and arguments were provided for the facilitating role andthat C-CES leaders ought not facilitate where they have been clinically engaged. Identified challenges included variations in uptake of C-CES activities that don not mirror the ethical challenges of the context. The unfair uptake of C-CES can be compared with the uptake in Norway where there are legal requirements for CES. In this study patients and families were not reported to request or attend C-CES. Thus, further research and interventions are needed to ensure their representation in Swedish C-CES.

Background: Shared decision-­ making aims to ensure that healthcare professionals and patients jointly make decisions regarding the patient's care. However, professionals often find it challenging to implement shared decision-­ making with older patients who have cognitive impairments or diminished decision-­making capacity. Research indicates a significant gap in the understanding of how decision-­ making processes unfold in prehospital settings.

Aim: The objective of this scoping review was to explore how decision-­making involving older patients in acute prehospital situations is characterized.

Design and Method: This scoping review is based on the Joanna Briggs Institute's guidelines for scoping reviews and is reportedusing the Preferred Reporting Items for Systematic Reviews and Meta-­Analyses extension for Scoping Review (PRISMA-­ScR).

Data Sources: CINAHL, PubMed, Scopus, PsychINFO and Web of Science were searched to identify relevant studies published between the years 2000 and 2024.

Results: The results are based on 26 studies and indicate that decision-­making among older patients is a conditional process,characterised by collaborative support involving the patient, significant others and healthcare professionals. Barriers to this process include hierarchical dynamics, fear of reprisals and uncertainty regarding the risk–benefit ratio. Factors that support decision-­making include situationally relevant competence, organisational resources and the presence of specific symptoms and signs.

Conclusion: Shared decision-­making with older patients in acute prehospital settings is conditional, often resulting in decisions being made primarily by healthcare professionals. There is considerable room for improvement in how this process is systematically approached. A structured approach is needed—one that assesses the older patient's decision-­ making capacity, considers the perspectives of family members, and incorporates input from individuals who know the patient well, all while minimizing hierarchical barriers.

Background: Ambulance clinicians regularly encounter medical, caring, existential and ethical challenges. Meeting patients with complex medical presentations underscore the need for holistic decision-making and actions as ambulance clinicians struggle to strike a balance between addressing medical and caring needs.

Aim: This study aimed to explore action alternatives considered and discussed during ethics case reflections in response to care-related challenges in ambulance services.

Research design: A qualitative descriptive study design was applied. Data were analyzed using conventional and summative content analysis.

Participants and research context: Ethics case reflections were performed with 14 groups comprising a total of 78 ambulance clinicians. Prior to the reflections, a video depicting the encounter between two ambulance clinicians and an older patient and his spouse was viewed.

Ethical considerations: The principles of the Declaration of Helsinki were applied throughout the research process, and an advisory statement was obtained from the Swedish Ethical Review Authority (No. 2019-02127 and 2021-03490).

Findings: The ethics case reflections generated a variety and breadth of action alternatives to manage challenges in caring, suggesting that this format is suitable for discussing ethical issues in clinical cases that depart from standard medical emergencies. Furthermore, the breadth of the results reveals the wide professional discretion afforded to ambulance clinicians and suggest the presence of tacit competences embedded in professional practice.

Conclusions: Ethics case reflection has a potential to enhance ambulance clinicians’ ethical decision-making by deepening reflections about patient autonomy as well as highlighting the potential for a caring approach and promoting holistic care. By generating a breadth of specific action alternatives, many possible ways forward even in situations with complex care-related challenges are illustrated. Further investigation regarding the role of ethics case reflections to articulate implicit attitudes and tacit competencies is warranted.

Ethical issues are inherent in clinical encounters and only a small number of difficult ethical issues ever reach clinical ethics support services. Within the discipline of surgery, empirical research on ethical issues in daily care is sparse. Aiming to understand more about dealing with inherent ethical issues in vascular surgery, we explored elements of moral reasoning during vascular surgeons’ discussions of clinical management during case conferences.

Data comprised observations, field notes and audio recordings of seven case conferences as well as interviews with 21 vascular surgeons at three Swedish university hospitals. The data was analyzed with systematic text condensation.

The moral reasoning on the vascular case conferences implied the jointly anchoring of norms for a responsible balance between risk and benefit. The process implied the narrating of vascular suffering and general health, deliberating benefits by scrutinizing the clinical details, and assembling these in a reasonable proposal for further care of the patient. Additionally, the case conference signified amplifying perceptions and promoting transparency, promoting professional and moral learning, as well as supporting complex decision-making.

The process of moral reasoning on the case conferences highlights the dual authority between the team’s deliberations of surgical care and the authority from the surgeons’ clinical encounter with the patient. In the process of moral reasoning, clinical, ethical and existential issues are embodied, and this complexity demands conditions for deliberating the framing of patients’ care by providing clinical ethical support that is targeted and relevant to the ethical challenges faced by vascular surgeons. 

Aim: To illuminate from the perspective of nurses in ambulance services the experiences of using a web-based advisory decision support system to assess care needs and refer patients.

Design: Inductive and descriptive approaches.

Method: Thirteen semi-structured interviews were conducted in the spring of 2020. The data were analysed through the reflexive thematic analysis.

Results: The Swedish web-based advisory decision support system (ADSS) was found to strengthen nurses' feelings of security when they assess patients' care needs, promote their competence and professional pride, and help them manage stress. However, the system also generated difficulties for nurses to adjust to the dynamic ambulance team and revealed a discrepancy between their professional roles and responsibilities to refer patients and provide self-care advice. The nurses thought that the support system facilitated their increased participation and helped them understand patients and significant others by offering transparency in assessment and decision making. Thus, the support system provides nurses with an opportunity to strengthen patients' independence through information and education. However, in the care relationship, nurses worked to overcome patients' expectations.

Conclusion: Nurses using the ADSS increased their security while performing assessments and referrals and found new opportunities to provide information and promote understanding of their decisions. However, nursing care values can be threatened when new support systems are introduced, especially as ambulance services become increasingly protocol-driven.

Implications for Profession and/or Patient Care: These findings have implications for nurses' work environments and help them maintain consistency in making medical assessments and in providing equivalent self-care advice when referring patients to the different levels of care. The findings will also impact researchers and policymakers who formulate decision support systems.

Reporting Method: Consolidated criteria for reporting qualitative research (COREQ).

Patient or Public Contribution: None.

Background 

In Sweden, most out-of-hospital cardiac arrests (OHCAs) occur in private residences and nursing homes. Although studies suggest that nursing home staff appear hesitant to start cardiopulmonary resuscitation (CPR) before ambulance staff arrive, it is unknown whether treatment and outcomes among those who suffer OHCA in nursing homes differ from private residences. The aim of the study was to describe OHCA occurrence, treatment, and 30-day survival in people aged 65 years or older in Swedish nursing homes, in comparison with private residences.

Methods 

This retrospective registry study utilized data from the Swedish Register of Cardiopulmonary Resuscitation from 1992 to 2022. The study included 59 459 OHCAs. Data were analyzed using descriptive and inferential statistics, complemented with generalized linear models.

Results 

The number of OHCAs was 56 379 in private residences and 3 080 in nursing homes. While the occurrence of OHCA increased in private residences it remained stable in nursing homes. The overall survival rate in people suffering OHCA in living facilities was 4.4% during the 31-year study period. There was an advantage of 1.0% in 30-days survival for private residences in the unadjusted analyses (p < 0.001), while the adjusted longitudinal model displayed a positive trend in annual survival odds in both private residences (5.6%) and in nursing homes (3.5%), with no difference between the groups (p = 0.207).

Conclusions 

In this registry study, 30-day survival in nursing homes and private residences was similar and improved in both settings. These findings suggest that the location of OHCA is not the primary determinant of survival. Resuscitation decisions should be guided by careful consideration of the patient’s medical condition, frailty, andpersonal preferences. Future initiatives might include strengthening emergency preparedness in nursing homes while supporting ethically justified and patient-centred shared decision-making.

Purpose: With aging, the risk of requiring emergency care increases. Elderly patients who need Emergency Medical Services (EMS) are often vulnerable and dependent, especially when their decision-making ability is reduced, which may intensify the risk of important ethical values being violated. Studies about paramedics’ views on elderly people’s self-determination within EMS settings are scarce. The aim of this study was to explore the attitudes and perceptions of paramedics in a US context regarding self-determination in elderly patients who need emergency care provided by EMS.

Design/methodology/approach: The study had an exploratory design, and data were collected using a Delphi technique. A panel of experts consisting of US paramedics was recruited to answer a questionnaire sent out in three rounds. The questionnaire comprised 108 items, derived from a Swedish study on the same topic, rated with a five-point Likert scale ranging from agree to disagree with a predetermined consensus level of 70%.

Findings: In total 21 experts agreed to participate, 15 completed all three rounds, leaving a total response rate of 71%. Finally, 87 out of 108 items reached consensus, of which 60 were “agree” and 27 were “disagree.”

Originality/value: The paramedic–patient relationship is a core in assessing and handling ethical challenges within an advanced practice influenced by the paramedics’ educational level and/or the patient’s physical/mental status. Within a “find it fix it” modus operandi, there is a need to increase paramedics’ competence in understanding and handling advanced ethical challenges in relation to ethical values such as autonomy and self-determination in elderly patients.

Background 

Decision-making regarding treatment limitations such as “Do not attempt resuscitation” (DNAR) orders for older patients has been found deficient. Patients ≥ 80 years with substantial comorbidity have little chance of surviving cardiac arrest, thus require thorough risk classification focusing on comorbidity and frailty. This study aimedto explore the degree of frailty, comorbidity and treatment limitations in patients ≥ 80 years in various forms of care. Additionally, the study examined the extent to which patients and/or relatives participated in these decisions.

Methods 

Descriptive, quantitative cross-sectional design. Medical records of 500 patients ≥ 80 years were reviewed: 100 medical, 100 orthopaedic and 100 surgical in-patients, in addition to 100 patients in Home Health Services (HHS) and 100 patients in Municipal Short-Term Care (MSTC). Comorbidity was classified and categorized using the Age-combined Charlson Comorbidity Index (ACCI). Frailty was assessed using the Clinical Frailty Scale (CFS). DNAR decisions as well as other treatment and care limitations were compiled. Patients’ and relatives’ participation in discussions and information about treatment limitations was also examined.

Results 

Of the 500 patients, 48% had a moderate (5–7 points) and 50% a severe burden (≥ 8 points) of ACCI, while 91% were rated as frail (CFS ≥ 5). In total, 176/500 (35%) had valid DNAR-decisions. Both age ≥ 90 years (OR 4.07, 95% CI 2.56–6.37) and CFS ≥ 5 (OR 16.13, 95% CI 4.54–103.40) was significantly associated with a DNAR-decision,while ACCI ≥ 8 was not. Less than a third (29%) of patients with a DNAR-decision had been informed by a physician. For those without a DNAR-decision, there was no documentation of discussions regarding their wish for full cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Of all 500 patients, 14% had a discussion with aphysician about CPR.

Conclusion 

Fewer treatment limitations than expected were documented for older, frail patients with moderate or severe comorbidity. Considerable deficiencies were found regarding decision-making and actively reviewing and confirming DNAR-decisions, showing a gap between medical-ethical guidelines and their application in practice. Improved adherence to medical-ethical guidelines would strengthen patients’ legal rights and their opportunity for shared decision-making.