INTRODUCTION: Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. METHODS: A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. RESULTS: Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). CONCLUSIONS: The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.

Akureyri Hospital and University of Akureyri Akureyri Iceland

Department of Anaesthesiology and Intensive Therapy Medical University of Gdansk Gdansk Poland

Department of Anaesthesiology and Intensive Therapy Semmelweis University Budapest Hungary

Department of Anaesthesiology University Medical Centre Göttingen Göttingen Germany

Department of Anesthesiology Amsterdam UMC University of Amsterdam Amsterdam the Netherlands

Department of Anesthesiology and Critical Care Medicine University Hospital Innsbruck Austria

Department of Anesthesiology and Intensive Care East Slovak Institute of Oncology Košice Slovakia

Department of Anesthesiology and Intensive Care Stavanger University Hospital The Regional Centre for Emergency Medical Research and Development Department of Clinical Medicine University of Bergen Norway

Department of Applied Mathematics Computer Science and Statistics Faculty of Sciences Ghent University Ghent Belgium; Department of Medical Statistics London School of Hygiene and Tropical Medicine London United Kingdom

Department of Emergency Medicine Antwerp University Hospital Antwerp Belgium

Department of Emergency Medicine Cork University Hospital Cork Republic of Ireland

Department of Emergency Medicine Ghent University Hospital Ghent Belgium

Department of Emergency Medicine Musgrove Park Hospital Taunton and Somerset NHS Foundation Trust Taunton United Kingdom

Department of Emergency Medicine Rouen University Hospital Rouen France

Department of Geriatric Medicine Ghent University Hospital Ghent Belgium

Department of Intensive Care Medicine Ghent University Hospital Ghent Belgium

Department of Medical Sciences Örebro University and Department of Clinical Research and Education Karolinska Institute Stockholm Sweden

Emergency Department Shaare Zedek Medical Center Jerusalem Israel

Emergency Medical Services of the Hradec Kralove Region and University Hospital Hradec Kralove Czech Republic

Emergency Medicine and Services Helsinki University Hospital Helsinki Finland

European University Nicosia Cyprus Hellenic Society of Cardiopulmonary Resuscitation Athens Greece

Faculty of Medicine and Health Sciences Ghent University Ghent Belgium

Harvard Medical School Department of Emergency Medicine and Department of Anesthesia Critical Care and Pain Medicine Division of Critical Care Beth Israel Deaconess Medical Center USA

Hospital General Universitario Reina Sofia Murcia Spain

Municipal Institute for Emergency Medicine Novi Sad Serbia

Nicosia General Hospital Nicosia Cyprus

Pontificia Universidad Católica de Chile Santiago Chile

Teikyo University School of Medicine Tokyo Japan

University of Medicine and Pharmacy Gr T Popa and Emergency County Hospital Sf Spiridon Iasi Romania

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Ethik der Reanimation und Entscheidungen am Lebensende: Leitlinien des European Resuscitation Council 2021