Termination of Resuscitation Efforts

Purpose: Provide guidance to paramedics who wish to terminate resuscitation attempts of adult patients who experience non-traumatic cardiac arrest.

Medics should make every effort to resuscitate all patients who do not meet the criteria outlined in the Determination of Death Policy. However, studies show that rapid transport for in-hospital resuscitation after unsuccessful prehospital advanced cardiac life support rarely if ever results in survival to hospital discharge. Additionally, the risks associated with high-speed transport may outweigh the extremely small likelihood of benefit.

Field deaths not covered by this policy require assessment by a transporting paramedic and consultation with the base hospital physician for determination of death.

During the initial resuscitation effort, EMS personnel or appropriate fire/rescue personnel will inform the family of the progress of the resuscitative efforts and possible implementation of this policy. If any family member or responsible party objects to the termination of resuscitation efforts in the field, continue the resuscitation and the medics will transport the patient.

Terminating Resuscitation Efforts in the Field

The paramedic may terminate all resuscitation efforts of a presumed primary cardiac arrest after meeting ALL of the following criteria:

a. Patient is an adult (greater than 18 years of age)
b. Medics must

a. Document effective ventilation with a BVM (chest rise and fall, auscultation of breath sounds in four places, absence of gastric sounds) including capnography.
b. Establish patent IV or IO access.
c. Apply advanced life support measures throughout the initial resuscitation effort.
d. Sustain ALS measures

 

 

 

     i. for a minimum of 20 minutes regardless of the previous CPR time and the arrest interval.
        Time begins with paramedic initiation of ALS care (IV, advanced airway).
     ii. for a minimum of 30 minutes if the arrest occurred in the presence of EMS personnel.
e. EtCO2 reading less than 20 mm Hg while performing high-quality chest compressions
f. Consult with BioTel prior to terminating resuscitation efforts.

• Patient less than 18 years of age.
  
• If the patient is visibly pregnant
  
• The patient whose cardiac arrest MAY BE associated with hypothermia, drug overdose, toxicological exposures, airway obstruction, or electrocution.
  
• Patient is a victim at a crime scene or is in police custody.
  
• When the arrest has occurred in a crowded public setting, excluding patients in nursing homes or extended care facilities.
  
• Scene situations place EMS in jeopardy
  
• In a setting where the family will not accept the termination of resuscitative efforts in the field.
• Inability to communicate with family present at scene or in telephone contact due to language or cultural barrier. (This does not imply that medics must contact absent family members before making the decision. It only applies if contact with the family is already established.)
  
• The patient has persistent pulseless VF, VT, any narrow QRS complex, or any organized QRS complex at a rate of greater than or equal to 40
  
• The patient demonstrates any neurological signs
  
• If the patient has a return of spontaneous circulation (pulse) for even a brief period.

Once Death has been Determined

1. Immediately notify the appropriate law enforcement agency and remain on scene until they arrive.
   
2. Cover the body with a sheet or other suitable item.
   
3. Do not remove any property from the body or the scene for any purpose.
   
4. Leave all medical devices (i.e., endotracheal tube, IV, ECG pads, etc.) applied to the body in place.
   
5. The body is to be left at the scene with the appropriate law enforcement agency.

Dealing with the Family/Loved Ones

• The following guidelines will help prehospital personnel deal with family members or loved ones present on the scene:
  
• The moment resuscitative efforts stop for one person, EMS personnel acquire a new set of patients - the family and loved ones.
  
• Briefly describe the circumstances leading to the death. Go over the sequence of events that transpired. Avoid euphemisms such as he’s passed on, she is no longer with us, or he’s left us. Instead, use the words death, dying, or dead.
  
• Allow time for the shock to be absorbed. Make eye contact. Consider touching family members and sharing your feelings. Convey your feelings with a phrase such as You have my (our)sincere sympathy rather than I am (we are) sorry.
  
• Allow as much time as necessary for questions and discussion. Go over the events several times to make sure there is complete understanding and to facilitate further questions.
  
• Allow the family the opportunity to see their relative. If equipment is still connected, let the family know in advance.
  
• Know in advance what happens next and who will sign the death certificate. One of the survivors will surely ask, “What do we do next?” Be prepared with a proper answer.
  
• Return of spontaneous circulation for even a brief period is a positive prognostic sign and warrants consideration of transport to a hospital.

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