Termination of Resuscitative Efforts

Table of Contents

Aliases

Call the code

Patient Care Goals

  1. When there is no response to prehospital cardiac arrest treatment, it is acceptable and often preferable to cease futile resuscitation efforts in the field.
  2. In patients with cardiac arrest, prehospital resuscitation is initiated with the goal of returning spontaneous circulation before permanent neurologic damage occurs. In most situations, ALS providers are capable of performing an initial resuscitation that is equivalent to an in-hospital resuscitation attempt, and there is usually no additional benefit to emergency department resuscitation in most cases.
  3. CPR that is performed during patient packaging and transport is much less effective than CPR done at the scene. Additionally, EMS providers risk physical injury while attempting to perform CPR in a moving ambulance while unrestrained. In addition, continuing resuscitation in futile cases places other motorists and pedestrians at risk, increases the time that EMS crews are not available for another call, impedes emergency department care of other patients, and incurs unnecessary hospital charges. Lastly, return of spontaneous circulation is dependent on a focused, timely resuscitation. The patient in arrest should be treated as expeditiously as possible, including quality, uninterrupted CPR and timely defibrillation as indicated.
  4. When cardiac arrest resuscitation becomes futile, the patient’s family should become the focus of the EMS providers. Families need to be informed of what is being done, and transporting all cardiac arrest patients to the hospital is not supported by evidence and inconveniences the family by requiring a trip to the hospital where they must begin grieving in an unfamiliar setting. Most families understand the futility of the situation and are accepting of ceasing resuscitation efforts in the field.

Patient Presentation

Patient in cardiac arrest.

Inclusion Criteria

  1. Any cardiac arrest patient that has received resuscitation in the field but has not responded to treatment
  2. When resuscitation has begun and it is found that the patient has a DNR

Exclusion Criteria

Consider continuing resuscitation for patients in cardiac arrest associated with medical conditions that may have a better outcome despite prolonged resuscitation, including hypothermia (although under certain circumstances, direct medical oversight may order termination of resuscitation in these conditions)

Patient Management

Resuscitation may be terminated under the following circumstances:

  1. Non-traumatic arrest
    1. Patient is at least 18 years of age
    2. Patient is in cardiac arrest at the time of arrival of advanced life support
      1. No pulse
      2. No respirations
      3. No evidence of meaningful cardiac activity (e.g. asystole or wide complex PEA less than 60 BPM, no heart sounds)
    3. Advanced life support resuscitation is administered appropriate to the presenting and persistent cardiac rhythm
      1. Resuscitation may be terminated in asystole and slow wide complex PEA if there is no return of spontaneous circulation after 20 minutes in the absence of hypothermia and the ETCO2 is less than 20 mmHg
      2. Narrow complex PEA with a rate above 60 or refractory and recurrent ventricular fibrillation/ventricular tachycardia:
        1. Consider resuscitation for up to 40 minutes from the detection of cardiac arrest.
        2. Termination efforts may be ceased before 40 minutes based on factors including but not limited to ETCO2 less than 20 mmHg, age, co-morbidities, distance from, and resources available at the closest hospital. Termination before this timeframe should be done in consultation with direct medical oversight
    4. There is no return of spontaneous pulse and no evidence of neurological function (non-reactive pupils, no response to pain, no spontaneous movement)
    5. No evidence or suspicion of hypothermia
    6. All EMS personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate
    7. Consider direct medical oversight before termination of resuscitative efforts
  2. Traumatic arrest
    1. Patient is at least 18 years of age.
    2. Resuscitation efforts may be terminated in any blunt trauma patient who, based on thorough primary assessment, is found apneic, pulseless, and asystolic on an EKG or cardiac monitor upon arrival of emergency medical services at the scene
    3. Victims of penetrating trauma found apneic and pulseless by EMS should be rapidly assessed for the presence of other signs of life, such as pupillary reflexes, spontaneous movement, response to pain, and electrical activity on EKG
      1. Resuscitation may be terminated with direct medical oversight if these signs of life are absent
      2. If resuscitation is not terminated, transport is indicated
    4. Cardiopulmonary arrest patients in whom mechanism of injury does not correlate with clinical condition, suggesting a non-traumatic cause of arrest, should have standard ALS resuscitation initiated
    5. All EMS personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate
    6. Consider direct medical oversight before termination of resuscitative efforts

Assessment

  1. Pulse
  2. Respirations
  3. Neurologic status assessment [see Appendix VII; purposeful movement, pupillary response]
  4. Cardiac activity (including electrocardiography, cardiac auscultation and/or ultrasonography)
  5. Quantitative capnography

Treatment and Interventions

  1. Focus on continuous, quality CPR that is initiated as soon as possible
  2. Focus attention on the family and/or bystanders. Explain the rationale for termination
  3. Consider support for family members such as other family, friends, clergy, faith leaders, or chaplains
  4. For patients that are less than 18 yo, consultation with direct medical oversight is recommended

Notes – Termination of Resuscitative Efforts