• Heidi Kangasniemi, Piritta Setälä, Heini Huhtala, Antti Kämäräinen, Ilkka Virkkunen, Joonas Tirkkonen, Arvi Yli-Hankala, and Sanna Hoppu.
• Research and Development Unit, FinnHEMS Ltd, WTC Helsinki Airport, Lentäjäntie 3, 01530, Vantaa, Finland. Heidi.kangasniemi@tuni.fi.
• Scand J Trauma Resus. 2019 Oct 2; 27 (1): 89.

BackgroundMaking ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes.MethodsA nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048).ResultsFifty-nine (88%) physicians responded. Their median age was 43 (IQR 38-47) and median medical working experience was 15 (IQR 10-20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes.ConclusionMaking limitation of care orders is an important but often invisible part of a HEMS physician's work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient's best interests.

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