Managing Death in the Field: Prehospital End-of-Life Care.

Context: Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected.

Objectives: The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care.

Methods: This exploratory study used mixed methods in a sequential nondominant two-stage convergent quantitative and qualitative design. Phase I involved the collection of survey data. Phase II involved in-person semistructured interviews.

Results: Surveys were completed by 239 participants, and 50 follow-up interviews were conducted. Survey data suggested that 73.7% felt confident when there was a DNR order and they did not initiate resuscitation, and 58.2% felt confident working through family disagreement when cardiopulmonary resuscitation was requested but there was a DNR; 66.1% felt confident explaining the dying process when death was imminent, and 55.7% felt comfortable telling a family that a patient was dying. Four themes emerged: changing standards of care; eliminating false hope; transitioning care from patient to family; and transferring care after death.

Conclusion: Prehospital providers provide support and care when they tell families that someone has died. Being able to comfort and be present with acute grief on scene is an important and evolving role for prehospital providers who manage death in the field.