Volume : 12, Issue : 10, October – 2025
Title:
NAVIGATING LIFE-OR-DEATH DECISIONS: A REVIEW OF PARAMEDIC DECISION-MAKING IN OUT-OF-HOSPITAL CARDIAC ARREST
Authors :
Mohammed Ali Dulaym Alanazi, Bader Mubarak G Alharbi, Alhemaidi Fudhail Alshammari , Mahmoud Hamoud S Algharbi , Ahmed Mohammed Abdullah Alhajji , Ahmed Fadhel Sabr Alanazi , Manaa Megbil Dboos Alanazi , Abdulwahid Hussain Ali Alatyaha
Abstract :
Out-of-hospital cardiac arrest (OHCA) is one of the most critical medical emergencies, where patient survival largely depends on the rapid and complex decisions made by paramedics. This review examines the multifactorial nature of paramedic decision-making in OHCA, highlighting the interplay between clinical guidelines, cognitive processes, ethical considerations, and system-level constraints. Decisions regarding the initiation, continuation, or termination of resuscitation, as well as choices on advanced interventions and transport strategies, are often made under extreme time pressure and uncertainty. Research indicates that while guidelines from organizations such as the American Heart Association (AHA) and the European Resuscitation Council (ERC) provide structured pathways, paramedics frequently rely on intuition, experience, and situational awareness to adapt care to unique circumstances. Human factors—including fatigue, stress, and cognitive overload—can influence judgment, while legal and ethical issues further complicate resuscitation choices. Emerging technologies, such as artificial intelligence–based predictive models and real-time feedback devices, present opportunities to support decision-making in the field. However, significant gaps remain in understanding the determinants of these critical decisions across diverse healthcare systems. This review underscores the need for enhanced training, ethical support frameworks, and integration of decision-support tools to improve both paramedic confidence and patient outcomes in OHCA.
Cite This Article:
Please cite this article in press Mohammed Ali Dulaym Alanazi et al., Navigating Life-Or-Death Decisions: A Review Of Paramedic Decision-Making In Out-Of-Hospital Cardiac Arrest, Indo Am. J. P. Sci, 2025; 12(10)
REFERENCES:
1. Anderson, N. E., Gott, M., & Slark, J. (2018). Paramedics’ experiences of providing end-of-life care to patients in the community. Journal of Palliative Medicine, 21(12), 1736–1741. https://doi.org/10.1089/jpm.2018.0135
2. Benger, J. R., Kirby, K., Black, S., Brett, S. J., Clout, M., Lazaroo, M. J., … & Nolan, J. P. (2018). Effect of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest (AIRWAYS-2). The Lancet, 392(10164), 1427–1437. https://doi.org/10.1016/S0140-6736(18)31471-1
3. Bossaert, L. L., Perkins, G. D., Askitopoulou, H., Raffay, V. I., Gale, C. P., Nolan, J. P., & Van de Voorde, P. (2015). Ethical guidelines for resuscitation. Resuscitation, 95, 302–311. https://doi.org/10.1016/j.resuscitation.2015.07.033
4. Carter, H., Thompson, J., Crampton, P., Roberts, M., & Brace-McDonnell, S. J. (2019). Cognitive overload in emergency medicine: Paramedic decision-making in the prehospital environment. Emergency Medicine Journal, 36(11), 642–647. https://doi.org/10.1136/emermed-2019-208509
5. Couper, K., Kimani, P. K., Abella, B. S., Chilwan, M., Craig, S., Drennan, I. R., … & Perkins, G. D. (2019). The effect of real-time feedback on the quality of cardiopulmonary resuscitation. Resuscitation, 138, 153–160. https://doi.org/10.1016/j.resuscitation.2019.03.037
6. Flowerdew, L., Brown, R., Vincent, C., & Woloshynowych, M. (2012). Identifying nontechnical skills associated with safety in emergency medicine. Annals of Emergency Medicine, 59(5), 384–391. https://doi.org/10.1016/j.annemergmed.2011.11.021
7. Gräsner, J. T., Lefering, R., Koster, R. W., Masterson, S., Böttiger, B. W., Herlitz, J., … & Wnent, J. (2021). EuReCa TWO: Epidemiology and system variability in out-of-hospital cardiac arrest across Europe. Resuscitation, 148, 218–226. https://doi.org/10.1016/j.resuscitation.2020.01.046
8. Greif, R., Lockey, A., Conaghan, P., Lippert, A., De Vries, W., Monsieurs, K. G., … & Olasveengen, T. M. (2021). European Resuscitation Council Guidelines 2021: Education, implementation, and teams. Resuscitation, 161, 388–407. https://doi.org/10.1016/j.resuscitation.2021.02.017
9. Hunziker, S., Johansson, A. C., Tschan, F., Semmer, N. K., Rock, L., Howell, M. D., & Marsch, S. (2011). Teamwork and leadership in cardiopulmonary resuscitation. Journal of the American College of Cardiology, 57(24), 2381–2388. https://doi.org/10.1016/j.jacc.2011.03.017
10. Klein, G. (2008). Naturalistic decision making. Human Factors, 50(3), 456–460. https://doi.org/10.1518/001872008X288385
11. Metelmann, B., Metelmann, C., Schuffert, L., Hahnenkamp, K., & Hinkelbein, J. (2019). Telemedicine in prehospital emergency care: A randomized controlled trial. PLoS ONE, 14(9), e0223158. https://doi.org/10.1371/journal.pone.0223158
12. Morrison, L. J., Visentin, L. M., Kiss, A., Theriault, R., Eby, D., Vermeulen, M., & Sherbino, J. (2006). Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New England Journal of Medicine, 355(5), 478–487. https://doi.org/10.1056/NEJMoa052620
13. Nakahara, S., Tomio, J., Ichikawa, M., Nakamura, F., Nishida, M., & Morimura, N. (2022). Predictive modeling of out-of-hospital cardiac arrest outcomes using artificial intelligence. Resuscitation, 170, 193–201. https://doi.org/10.1016/j.resuscitation.2021.10.017
14. Nichol, G., Lerner, E. B., O’Connor, R. E., Sayre, M. R., Reynolds, J. C., van Diepen, S., & Aufderheide, T. P. (2020). Ethical and legal considerations in termination of resuscitation. Circulation, 142(16_suppl_2), S345–S358. https://doi.org/10.1161/CIR.0000000000000910
15. Pang, P. S., Callaway, C. W., & Einav, S. (2022). The role of team dynamics in prehospital cardiac arrest resuscitation. Current Opinion in Critical Care, 28(3), 227–234. https://doi.org/10.1097/MCC.0000000000000938
16. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., … & Kudenchuk, P. J. (2020). 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_suppl_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000918
17. Perkins, G. D., Ji, C., Deakin, C. D., Quinn, T., Nolan, J. P., Lall, R., … & PARAMEDIC2 Collaborators. (2018). A randomized trial of epinephrine in out-of-hospital cardiac arrest. New England Journal of Medicine, 379(8), 711–721. https://doi.org/10.1056/NEJMoa1806842
18. Rubertsson, S., Lindgren, E., Smekal, D., Östlund, O., Silfverstolpe, J., Lichtveld, R. A., … & Hollenberg, J. (2014). Mechanical chest compressions and simultaneous defibrillation vs. conventional CPR in out-of-hospital cardiac arrest: The LINC randomized trial. JAMA, 311(1), 53–61. https://doi.org/10.1001/jama.2013.282538
19. Schmidbauer, W., Aichinger, G., Strobl, H., Schriefl, C., Steinlechner, B., Laggner, A. N., & Prause, G. (2019). Decision-making in prehospital cardiac arrest management: A qualitative study of paramedics’ perspectives. BMC Emergency Medicine, 19(1), 23. https://doi.org/10.1186/s12873-019-0248-7
20. Sinden, J. D., MacKenzie, R. K., & Sekhon, R. K. (2013). Fatigue and cognitive impairment in paramedics: Implications for decision-making in emergencies. Prehospital and Disaster Medicine, 28(2), 135–140. https://doi.org/10.1017/S1049023X13000054
21. Skrifvars, M. B., Castren, M., & Nurmi, J. (2020). The influence of prehospital factors on survival after OHCA. Critical Care, 24, 489. https://doi.org/10.1186/s13054-020-03257-5
22. Soar, J., Böttiger, B. W., Carli, P., Couper, K., Deakin, C. D., Djärv, T., … & Nolan, J. P. (2021). European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation, 161, 115–151. https://doi.org/10.1016/j.resuscitation.2021.02.010
23. Wang, H. E., Schmicker, R. H., Daya, M. R., Stephens, S. W., Idris, A. H., Carlson, J. N., … & PART Investigators. (2018). Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest (PART trial). JAMA, 320(8), 769–778. https://doi.org/10.1001/jama.2018.11443