Determination of Death/Withholding Resuscitative Efforts

Table of Contents

Aliases

None noted

Patient Care Goals

All clinically dead patients will receive all available resuscitative efforts including cardiopulmonary resuscitation (CPR) unless contraindicated by one of the exceptions defined below.

Patient Presentation

A clinically dead patient is defined as any unresponsive patient found without respirations and without a palpable carotid pulse.

Inclusion/Exclusion Criteria:

  1. Resuscitation should be started on all patients who are found apneic and pulseless unless the following conditions exist (does not apply to victims of lightning strikes, drowning, or hypothermia):
    1. Medical cause or traumatic injury or body condition clearly indicating biological death (irreversible brain death), limited to:
      1. Nontraumatic arrest with obvious signs of death including dependent lividity or rigor mortis
      2. In blunt and penetrating trauma, if the patient is apneic, pulseless, and without other signs of life upon EMS arrival including, but not limited to spontaneous movement, EKG activity, or pupillary response
      3. Injuries incompatible with life (such as massive crush injury, complete exsanguination, severe displacement of brain matter)
      4. Decapitation: the complete severing of the head from the remainder of the patient’s body
      5. Decomposition or putrefaction: the skin is bloated or ruptured, with or without soft tissue sloughed off. The presence of at least one of these signs indicated death occurred at least 24 hours previously
      6. Transection of the torso: the body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed
      7. Incineration: 90% of body surface area with full thickness burns as exhibited by ash rather than clothing and complete absence of body hair with charred skin

OR

  1. A valid DNR order (form, card, bracelet), when it:
    1. Conforms to the state specifications for color and construction
    2. Is intact: it has not been cut, broken or shows signs of being repaired
    3. Displays the patient’s name and the physician’s name

Patient Management

Assessment

Assess for dependent lividity with rigor mortis and/or other inclusion criteria

Treatment and Interventions

  1. If all the components above are confirmed, no CPR is required
  2. If CPR has been initiated but all the components above have been subsequently confirmed, CPR may be discontinued and direct medical oversight contacted as needed
  3. If any of the findings are different than those described above, clinical death is not confirmed and resuscitative measures should be immediately initiated or continued. The Termination of Resuscitative Efforts guideline should then be implemented
  4. Do Not Resuscitate order (DNR/MOLST/POLST) with signs of life:
    1. If there is a DNR bracelet or DNR transfer form and there are signs of life (pulse and respirations), provide standard appropriate treatment under existing protocols matching the patient’s condition
    2. To request permission to withhold treatment under these conditions for any reason obtain direct medical oversight
    3. If there is documentation of a Do Not Intubate (DNI/MOLST/POLST) advanced directive, obtain direct medical oversight
    4. If for any reason an intervention that is prohibited by an advanced directive is being considered, direct medical oversight should be obtained

Notes – Determination of Death/Withholding Resuscitative Efforts