Table 3 Quotes identified in the medical records representing each theme

Autonomy

First electrocardiographic analysis shows asystole. It is noted that the patient does not wish for resuscitation to be initiated. For that reason, the treatment is terminated at [time]

We are informed of a verbal agreement between the patient and relatives of no resuscitation. This is not written on paper and thus resuscitation is continued

The patient wished to be discharged, [from the hospital] as he wanted to ‘die in his own nest’

Beneficence and non-maleficence

Old weak-looking man, diagnosed with non-specified kidney disease. Placed in an extended care home

He develops ventricular fibrillation in the ambulance. [We] withhold resuscitation because of advanced age, severe mental illness and the patient’s inability to take care of himself

The family discourages resuscitation, as the patient has been ill for some time now and was much weakened

Had Alzheimer's disease, prior history of illness unknown. Do-not-resuscitate wishes from the family and nursing staff

CPR is immediately initiated, at the paramedic’s arrival asystole despite CPR, it turns out that “no resuscitation” was determined in advance, death is declared at [time]

We find a folder in [the patient’s] house, this states loud and clear that the patient was in the terminal phase of a cancer disease!!! Therefore, the patient should not have been resuscitated, poor communication from the nursing staff

Justice and extraneous factors

There is a letter on no attempt at CPR. Not signed by a physician and the original text has been altered. [It] is not valid in the situation

At our arrival, the nurse is performing CPR. [The] family does not want the patient resuscitated. This wish cannot be granted, as there is not a written statement from the general practitioner. We initiate CPR. At the same time, [the family] calls the general practitioner, who asks me to terminate resuscitation, to which I have to say no to, as there, once again, does not exist a written statement regarding this

We retreat from the scene when the son gets infuriated. Police are on their way. Resuscitation has not been initiated at any time

Best practice examples

The patient has been in palliative care, has in-home nursing staff, who has a document that shows the patient does not wish for resuscitation to be initiated. The husband clearly expresses that the patient did not want resuscitation in case of cardiac or respiratory arrest. The physician at the emergency dispatch centre is contacted and agrees to withhold resuscitation based on the medical history and the patients’ wishes

Resuscitation attempt and the potential subsequent treatment will be with no chance of survival, and in agreement with the patient’s wishes, resuscitation will not be attempted