6. Termination of Rescusitation Protocols

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

I always had a problem with it. The patient was dead. Everyone knew he was dead. He hadn’t been seen since the night before when he’d asked for a cool glass of water. They found him in the morning in his bed, still as can be. He wasn’t breathing and he had no pulse. He looked peacefully there, his head on the pillow, the half-drunk glass of water on the bed stand. He was eighty-nine years old with inoperable cancer. He’d refused hospitalization just two days before. The problem was while there was a little bit of rigor in his jaw, there was no lividity. The room was warm – how he liked it. The family knew he didn’t want any extra measures done to save his life, but they called us because they didn’t know what else to do.

How many times did this or similar scenes play out? The patient ripped from the bed, laid on the hard floor, compressions breaking the chest, tube down the throat, IV, drugs, strapped to a board, carried out of the house to the ambulance in the rain, raced lights and sirens to the hospital, only to be dismissively called dead on the stretcher on entry to the code room. And then later, unseen to us the family received bills for ambulance transport and for ED care.

Everyone was worked and everyone was transported unless they had a DNR bracelet or met the criteria of rigor mortis in the major joints with dependent lividity.

We finally instituted some changes in our system. Medics were encouraged to use their judgment and call medical control, explain a situation and get permission not to intervene. If they did work the code and the patient was asystole, we could work a patient for 20 minutes, and then cease the resuscitation at home, call the patient dead, remove the tube, lift the person back up, put them back in bed, pull the sheet up to the neck, and have the family come in to say goodbye.

For a number of years, we could presume the patient on our own, but then once we developed statewide guidelines on termination, in the interests of solidarity with the other regions, we agreed to require our medics to call a physician for permission to cease. I have never yet had a doctor disagree with my request to cease. I am somewhat bothered by the requirement that we have to initiate CPR until the doctor gives the final concurrence, although I suppose that protects us if the doctor were ever to say, no, I want you to work the patient and bring him in. It has happened to others.

Sometimes, I have the family come into the room while we were still doing CPR, and have them say goodbye before we stop. What a sight that can be. A family one by one saying good bye to the 100-year old aunt in the room where she has lived the last ten years of her life. The love you see, the things they say, the tenderness. “Auntie Mae, I’m going to look out for Junior, for you, you know that.” “Auntie Mae, I love you, I love you my whole life.” “You going to rest now, Auntie Mae, you going where the fields are green.” Sometimes, they just give a kiss, and whisper something into the ear. A husband says, we’ll be together again. Wait for me.

I have seen this scene play out a number of times and I have always considered myself privileged to be there to witness it.

We do all we can. The families know when a loved one’s time has come. Their spouce, or mother or father or sister or brother, grandparent, aunt or uncle, dies at home, surrounded with their love and thoughts in their last moments, with some kind of dignity.

The National Association of Emergency Medical Physicians has termination of resuscitation rules that have a 100% predictive value for determining death. A study done at Yale showed that 54% of cardiac arrests brought into their ED met national guidelines for being called at home. They were all declared dead in the ED.

I understand that sometimes there may be reasons to transport dead people and that every scene is different. But as the American Heart Association said in its 2005 Guidelines:
“Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable.”

Termination of Resuscitation Protocols is # 6 on my list of best treatment changes in the last 20 years.

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Here are our regional guidelines on termination on nontraumatic cardiac arrests:

TERMINATION OF RESUSCITATIVE EFFORTS (PARAMEDIC LEVEL ONLY):

NONTRAUMATIC CARDIAC ARREST

Discontinuation of CPR and ALS intervention may be implemented after contact with medical
direction if all of the following criteria have been met.
1. Patient must be least 18 years of age.
2. Patient is in cardiac arrest at the time of arrival of advanced life support, no pulse, no
respirations, and no heart sounds.
3. ACLS is administered for at least twenty (20) minutes, according to AHA/ACLS Guidelines
4. There is no return of spontaneous pulse and no evidence of neurological function (nonreactive pupils, no response to pain, no spontaneous movement).
5. Patient is asystolic in two (2) leads
6. No evidence or suspicion of any of the following: drug/toxin overdose, hypothermia,
active internal bleeding, preceding trauma.
7. All Paramedic personnel involved in the patient’s care agree that discontinuation of the
resuscitation is appropriate.

All seven items must be clearly documented in the ambulance patient care report
(PCR).

DMO should be established prior to termination of resuscitation in the field. The final decision to terminate resuscitative efforts should be a consensus between the on-scene paramedic and the DMO physician.

CONTACT DMO for confirmation of terminating resuscitation efforts.

If any of the above criteria are not met and there are special circumstances whereby
discontinuation of pre-hospital resuscitation is desired, contact DMO.

Logistical factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. Examples: Inability to extricate the patient, significant physical environmental barriers, unified family wishes with presence of a living will.

All patients who are found in ventricular fibrillation or whose rhythm changes to ventricular
fibrillation should in general have full resuscitation continued and be transported.

Patients who arrest after arrival of EMS should be transported.

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Here is a link to a blog post detailing a call where the decision to resucitate was complicated:

Here is a link to a survey on this issue I conducted a couple years back:

Here is a link to the NAEMP’s position paper.

TERMINATION OF RESUSCITATION OF NONTRAUMATIC CARDIOPULMONARY
ARREST: RESOURCE DOCUMENT FOR THE NATIONAL ASSOCIATION OF EMS
PHYSICIANS POSITION STATEMENT

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

1 Comment

  • Jess says:

    We are quite fortunate in the UK to have quite liberal rules on not starting resus. Techs and above can decide not to start in the present of rigor, PM staining or injuries incompatible with life. We can also not start if there has been no CPR in the last 15 minutes and the patient is asystolic (subject to certain exceptions). If we start, we do 20 minutes ALS then stop.

    Recently things have been liberalised further, we are now encouraged to look at the bigger picture and if we believe resus to be futile we can decide not to start. We are now dissuaded from conveying unless we get ROSC, and can terminate in PEA (or even VF/VT, though that would be rare). We hardly ever convey cardiac arrests now, conversely we are seeing a lot more ROSC.

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