Termination of Resuscitation, Part 3: Death Notification

The Angel of Grief, Photo courtesy of *AfEX from flickr
So, you and another ALS crew, along with fire department first responders have been trying valiantly, but unsuccessfully to resuscitate a 70 year old man who had witnessed arrest by the family. You are a medic and somewhat blessed to be working with another medic due to a call off. You are working with "Mark in the Dark", who is clueless on calls. So clueless he does the "Marky Mark Dance" of running around in a circle on bad calls. Mark though is still on the roster as he is wonderful with patients. He gets letters of thanks from patients he stabs 15 times for IVs that he never gets, but everyone else gets complaints from patients they did everything right on. You have been using Mark for CPR and to give periodic updates to the family. We have intubated the patient, done good CPR, gave all the resuscitation drugs the AHA wants us to give (but has yet to show great results)through an EJ and AC line and the rhythm remains in asystole. The FD first responders ask you if you want the stretcher. You calmly shake your head no, and give Mark the look. He knows what to do, and heads again to meet with the family. He's the perfect person for this task.

Death Notification
Death (Bengt Ekerot) from the film, The Seventh Seal, about...death's announcement
Alas, the end of the trilogy of death. In part 1 I gave an overview of TOR. In Part 2 I gave generally accepted guidelines and procedures for DOAs and TOR. In this Part, we assume TOR/DOA and the family must be notified of the death of their loved one.
As I stated in part 1, this is an area where EMS education and training are lacking, thus a reason why EMS providers don't like being the bearer of bad news of death and would rather refer this to the "professionals". But we are the professionals. This really should be our job.
Training in grief support is not taught well, if at all, in initial EMS certification programs, but when EMS providers attend grief support training programs, they are more inclined to be willing to confront the family and provide grief support (Smith and Feldman, 2004) only if they have the training. There are training programs like Death Notification Training by MADD (which I took), Griefstep and Coping with the Death of a Child, by the AHA, are available as continuing education. Others have great online slide presentations for death notification, such as GRIEV_ING Death Notification Protocol for interns by Dr. Hobgood, Expected Death: What does a paramedic do? byt SunnybrookOsler centre for prehospital care, and Death Notification for Paramedics by Greg Soto, just to name a couple. However core training in death education for EMS is substandard and not consistent. The minimum required training in this area is lacking. Here is another reason I advocate for a college degree being the minimum standards for EMTs and Paramedics, with a death education course being a requirement, such as Psychology of Death and Dying. There is much on the web designed for police officers, the traditional bearer of bad news, such as Bad News Bearers, by Moldovan (2009), Death Messenger, The Road Less Traveled and Death and Grieving from the PCLEC training manual.

Family response to field terminations

Many family members feel the deceased would rather have died at home than in a less than personal atmosphere of the hospital (Edwardson, Chiumento, and Davis, 2002). In fact, the family of transported patients felt less positive interactions with the EMS and ED staff and felt anxiety when rushing into an ED (Delbridge, Fosnocht, Garrison and Auble, 1993). However those who were surveyed after field termination by providers with grief support training (Schmidt and Harrahill, 1995) expressed very positive experiences.

The family, the neglected second patient
Photo courtesy of MiRea from flickr (Israeli Grief)

Once the resuscitation is over, or it is determined the patient is really not a patient but a dead body, the family now takes on the role of the patient in the eyes of EMS. This requires great compassion and concern for the cultural and religious practices and beliefs of the family (AHA, 2005). However, this should be considered from the beginning, when resuscitation begins, and maintained through the whole resuscitation. The family will remember this experience for the rest of their lives and a poor notification has proven to be associated with increased law suits. I remember back around 1990 an EMT spiked the IV bag for his medic, only it was premixed lidocaine for infusion, and the medic did not catch it. The patient died. The family chose not to sue because they thought the medics were just wonderful (and the patient was terminally ill). Doctors who have given the best care but worst death notifications often get hospitals sued, or stinging complaints.

In 2000, the American Heart Association ECC guidelines advocated keeping family present during the resuscitation (AHA, 2000). It is hard for EMS to exclude them when resuscitation is being attempted in the home of the patient with family present (Boyd, 2000). Often, it is tempting to ask family to leave the room or ask police to escort them out. Many EMS providers don’t like having family present s they can be disruptive, interfere with procedures and possibly faint. Others are worried about potential liability as family members may not like what they see, whether they understand it or not, and sue.
However, many family members wish to present and most, though loud, do not interfere and feel being at their loved one’s side is comforting and gives them an opportunity to say goodbye (Offord, 1998). Many also said it helped them with their bereavement process in coping with the loss of their loved one. Some family members may wish to leave the room while others may interfere but most feel closer to what is happening, and feel lonely in another room waiting for information (Soto, 2009). If family interfere with resuscitation efforts, then ask them to leave. Otherwise, ask family if they wish to be present. Some will, and some won’t, but they appreciate being asked. Professionalism and sensitivity need to be exhibited by the crew. Having the family present offers them a chance to help or be involved, lessening stress. Not only that, the family actually can help, by answering questions and clarifying the history of the present illness to even helping with CPR if they feel confident about it (Shaner and Eckle, 1997).

Mike Smith, brought up a good point by having the family present. It lessens the shock of the final notification. The bad news can be delivered in two or three chunks. Start off notifying the family the patient is not doing well but all that can be done is being done. Later, notify the family of what is being done but that it looks grim as the patient is not breathing or does not have a pulse. A third update can be made and that at this point, it does not appear there will be a positive outcome. Finally, when it is time to stop, approach the family and tell them the patient is dead, and all that could have done was done. They will know this as they have been getting the updates and they become a little more prepared for the bad news. This process prevents delaying of the final blow and allows for the EMS provider to size up the family (Smith, 2008). Ensure no medical jargon is used unless the whole family works in health care.

The final blow

Continue efforts while you send someone to speak to the family, and get their consent to cease efforts. Then notify medical command and get authorization to TOR. Ensure the friendliest member of the crew who has been updating the family, or the crew leader, possibly with another member, should make the notification. If you are that person, take off your gloves, tuck in your shirt and wipe sweat from your face. Join the family and make an introduction, but direct yourself to the spouse, parent or paramour. Shake hands and ideally, ask to sit down with the family and have an attentive posture at eye level, trying not to stare, leaning forward with hands on knees (Hobgood, 2005). State despite all possible efforts, the patient has died. Steer clear of trying to use euphemisms or softer terms for death. The family will usually want it straight and quick. It may also be helpful to give an overview again of the procedures that were done to save their loved one (Meoli M, 1993). It is important to not show distance from the patient as we normally do, but use the patient's name when addressing the family.

Grief support

It is important to be empathetic with the family. They will experience a variety of emotions such as:

  • Crying or wailing

  • Anger, antagonism or hostility

  • Numb, blank or even complete collapse

  • Incomprehension or inability to concentrate

  • Blaming or the reverse, guilt

  • Denial or disbelief

  • Fear or hysteria

  • Prayer

  • Sense of being lost

They should be encouraged to show their emotions. A variety of emotions can be expected, from silence to loud weeping and the providers should not be judgmental. The EMS provider should give the family time to reflect or react. Let them express themselves, letting them know they are heard by using one or two of their key words or paraphrase what they ask or say. You will not have to speak too much. Just sitting and listening is enough.

Photo courtesy of www.mentalhelp.net

Express sympathy and concern, and use phrases that express your feelings and acknowledgement of their loss, such as:

  • "I am sorry for your loss"

  • "I see that it is difficult to accept the loss of..."

  • "I can't imagine how difficult this is for you"

  • "I know this is very painful for you"

  • "It must be hard to accept"

  • "It's harder than most people think"

  • "You must have been very close to him/her"

  • "It is normal for you to react as you are"

  • "How can I help"

A provider should not be expected to know what magical things to say, but could just say “I am sorry. I don’t know what to say”. Be aware of your responses as they can reflect withdrawn or distant, antagonism or defensive to family reactions, indifference or being unflappable, too clinical, fear or even being curt. Ensure you express empathy, understanding, sorrow and concern but don't feel you have to keep talking-just being there is usually sufficient.

Photo courtesy of http://www.saveourparamedics.com/

Be careful to avoid these phrases:

  • His/her death was for the best

  • I know how you feel. My ? died last year

  • We all have to deal with loss

  • At least he/she died in their sleep

  • Religious cliches, such as he/she is in a better place

  • You should not feel that way

  • Aren't you lucky that at least...

  • Snap out of it! Get a hold of your self!

  • You must focus on your precious moments

  • You at least have another child or ...

Touching is alright, but let the family members express the cue for that. If they want to hug you, let them but don't initiate it.

Photo courtesy of articles.mercola.com

Assist with logistics

Offer drinks such as making them tea or coffee or just getting them water (Meoli, 1993). Ask if there is additional family or friends, and especially clergy who they may want called. The family needs to know what the formal death notification procedures are in relation to the coroner and PCP and even the police, if necessary. They will need to be told EMS will need past medical history and medications and will contact the patient’s PCP to see if the PCP will sign a death certificate. The coroner will also need notified and the family should be told of an impending autopsy if warranted, or ask them if they want one done. The funeral home will need to be called if the deceased is not getting an autopsy, and the crew should offer to do this for the family. Try to be open with cultural diversity in regard to assisting with family and even positioning of the body.

Care of the body

While a crew member is conferring with the family, the body needs prepared and the family will need to be told of what to expect as far as ET tube and IVs. If the body will go with the funeral home, the tubes and catheters should be pulled and the mess of resuscitation cleaned up, and the body placed in bed if possible. A sheet should be put over the patient, but the family should be asked if they want the head exposed, as most do. The family should not be discouraged from touching or talking to the deceased, but rather encouraged unless it is a crime scene (Leash, 1996).

Autopsy case

If it is an autopsy case, especially of a child, the family may or may not be cooperative. This takes a lot of empathy and great skill in explaining the legal issues and why an autopsy needs done. They need to be told an ambulance crew or police officer needs to be present until the coroner arrives, and why scene preservation is important, if required.

Photo courtesy of The Pittsburgh Post Gazette


Most EMS crews do not want to stay longer than they should and the family need time to themselves, but must ensure they family has no other questions or requests before leaving. They should approach the family and state they will be leaving and ask if there is anything else that can be done. Have brochures or business cards for the local victim/crisis services and offer one to the family if they wish grief counsling. Usually a single family member may not want left alone until more family or friends arrive. Providers should ensure to offer condolences to all family and friends present, showing sincerity, and then say good bye.

No discussion of grief can go without listing The 5 Stages of Death by Dr. Kubler-Ross

Your own personal mental fitness

Photo courtesy of www.theprovince.com
Experiencing deaths and providing death notifications are often trying to EMS providers, especially to those with limited experience with DOA and cardiac arrest calls. You need to realize this can be a stressful event. Even experienced providers sometimes experience a call that stresses them out (Overweg, 2007). I know a great medic who quit EMS after almost 20 years after helping to recover the bodies of a family wiped out in a house fire. Specific events of the call were most stressful to him. Now he teaches EMS. Just making a death notification is stressful enough. I am not a strong advocate in CISD though I did take the provider training, but I do strongly endorse talking about it with your spouse or paramour and your coworkers. Sometimes CISD may be the answer, or consider professional support if you cannot get over the call.


EMS providers find dealing with death a stressful situation but routine exposure desensitizes them. However, EMS providers are often uncomfortable with interacting with grieving family and friends and death notification as it is physically and emotionally exhausting. The crew must expect to “express the right words, anticipate and understand family emotions, and respond with empathy.” They don’t want to leave a wrong impression of being callous, thoughtless and insensitive(Page, 2008). Added death notification training or death education is necessary for EMS providers and will help alleviate any discomfort they may have in this important role. I suggest if you have not attended similar training, take advantage of it when it is offered in your region. Contact MADD about doing a training program. And remember to always keep in mind your own mental well being as these are stressful roles.

Photo by Shawn Raecke, at Health.idahostatesman.com


American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bereavement. In: Resuscitation Council UK Advanced Life Support Course Manual; 1998

Boyd R., (2000) Witnessed resuscitation by relatives, Resuscitation. 2000 Feb;43(3):171-6.

Delbridge T, Fosnocht D, Garrison H, Auble T., (1996), Field Termination of Unsuccessful Out-of-Hospital Cardiac Arrest Resuscitation: Acceptance by Family Members, Annals of Emergency Medicine Volume 27, Issue 5, May 1996, Pages 649-654

Edwardsen EA, Chiumento S, Davis E., (2002), Family perspective of medical care and grief support after field termination by emergency medical services personnel: a preliminary report, Prehospital Emergency Care. 2002 Oct-Dec;6(4):440-4.

Grief Support Institute, (1998) Say the Right Thing: EMS Death Notification and Grief Support Guidelines

Hobgood, Cherri, (2005), "Delivering the News With Compassion: The GRIEV_ING Death Notification Protocol", Trainers Manual.

Iserson KV. (2000) Notifying survivors about sudden, unexpected deaths. Western Journal of Medicine 2000; 173: 261–265.

Leash RM., (1996) Death notification: practical guidelines for health care professionals, Critical Care Nursing Quarterly. 1996 May;19 (1):21-34.

Meoli M., Supporting the bereaved. Field notification of death, JEMS. 1993 Dec;18(12):39-46.

Moldovan, Emil, (2009), "
The Bad News Bearers: The Most Difficult Assignment in Law Enforcement", http://www.csa.com/

Offord RJ.. (1998) Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation? Intensive Critical Care Nursing. 1998; 14: 288–293

Overweg, Cynthia, (2007), "Saving Lives Sometimes Trigger Crises", Ventura County Star
Placer County Law Enforcement Chaplaincy, "
Death and Grieving", Training Manual, Chapter 6

Page, Douglas, (2008),
Death notification: Breaking the bad news: Why does so little training exist for the most grim job in law enforcement?, Officer.com, March

Schmidt TA, Harrahill MA., (1995), Family response to out-of-hospital death, Academy of Emergency Medicine. 1995 Jun; 2(6):513-8.

Smith L, Feldman, R (2004),
THE EFFECT OF TWO DEATH EDUCATION PROGRAMS ON EMERGENCY MEDICAL TECHNICIANS, Prehospital Emergency Care, January / March 2006 Volume 10 / Number 1

Smith L, Feldman R, (2005),
Survey of EMTs’ Attitudes towards Death, Prehsospital and Disaster Medicine, May-June

Smith, Mike, (2008)
Recognizing and Managing Futility: Take a proactive approach with tragic events, EMS Magazine, May 2008 Issue

Smith, T., (2009),
Emergency Medical Technicians, Encyclopedia of Death and Dying.

Soto, Greg, Cooke, David,
Death Notification for Paramedics, TOR Study Group Presentation

Happy Holidays

I hope everyone had a delightful Thanksgiving day or Turkey Day if you are a part of my family. You may have noticed that some of the other authors have been filling my voids with some excellent posts. We have quite a few consistent readers, and I hope that this blog has become a reliable educational resource. As always, I am overly busy, but I plan on writing a lot more than I have recently. The ECG tutorial will continue, I promise.

In the meantime please read below to get a taste of another topic I plan on discussing. Improved stroke care is one of my few passions, and something that we can do quite a bit about. The major treatment that we can provide is expeditious transport to an appropriate facility. As easy as that sounds, it is overlooked so often.

Pubmed [Link]
PURPOSE OF REVIEW: Tissue-type plasminogen activator is the only pharmacological treatment approved for acute ischemic strokes but is administered to less than 5% of the patients. Excessive prehospital and in-hospital delays and lack of stroke center coverage are major issues that negatively impact stroke care. New strategies are being developed and evaluated to increase the number of tissue-type plasminogen activator-treated patients. RECENT FINDINGS: Factors that limit rapid access to acute stroke care are discussed, including those influencing time intervals from stroke onset to hospital admission. We also describe strategies that hold promise to reduce prehospital delays and increase access to acute stroke treatment. SUMMARY: The shortening of prehospital delays requires education of patients and health professionals and optimization of transport strategies. Future developments may include video conferencing offering telestroke expertise, strategies (i.e. therapeutic interventions) that might help to treat acute stroke patients with tissue-type plasminogen activator, and prehospital selection of candidates for endovascular therapies.

Thanks for stopping by,

Adam Thompson

Termination of Resuscitation, Part 2

Photo courtesy of Unity VFD, Pa.

You are a medic student currently volunteering for a fire department but work as an EMT. You are on the computer at the fire station studying for class when you get a call for a single vehicle MVC with unknown injuries. You and another EMT, Bill, who is more experienced than you, as well as a first responder, Rick jump in the SUV/QRV and respond. An ALS ambulance is enroute from the same service you work at, with a 15 minute ETA. This will be exciting, you think. You are driving, pulse racing and anxious, palms sweating, thinking of how you will handle the call, listening to PD on the scanner regarding the call. The car was found by passers-by; unknown time of accident. You look in the rear view mirror and notice Rick is looking pretty anxious. You look over at Bill, who is sitting calmly, pulling a piece of chewing gum from a wrapper. He offers you a piece and while you take one, he states, “The patient will either be DOA or GOA.” He then listens to the PD on the radio say they found the patient next to a tree and appears to be unresponsive. Then they say is appears DOA. Bill looks at you, raises his eyebrows, and says, “see; told you.”

You arrive to the flashing red and blue lights of PD and see a car crumpled off the road and about 15 feet in the tree line, a cop frantically waving a flashlight. You stop briefly to look at the car to get an idea of MOI, and then jog over to the cop, standing over a crumpled young man in his early 20s if that. Though there is poor lighting, it appears obvious there is no circulation. There is a lot of blood around him and blood on the tree. It appears he may have been unrestrained, ejected and took a header into the tree. Rick, holding the jump bag, is standing next to you with a look of shock. The patient has an obvious head injury, but not incompatible with life. You reach down and feel for a pulse, The skin temperature is close to the cool ambient temperature of the night. You tell Rick to retrieve the AED while Bill walks over after doing a scene survey for other patients. He is sure there aren’t any. He asks you what is going on and you tell him you have a traumatic arrest. He looks at the car, and then to Rick running back with the AED, then shakes his head, and calmly gets on the radio to cancel the ALS. As Rick runs up with the AED, out of breath, Bill tells him it won’t be necessary.

Photo credit www.consumershero.com

What is Bill thinking? He is an officer in the fire department and has 10 years on you as an EMT though he doesn’t work for an ambulance service full time like you do and most of all, he is not in Paramedic school like you are. Should you disagree with him? You are also surprised to hear the ALS service downgrade their response but head to the scene regardless due to their short ETA. Nosy? Anyway, is Bill right? Can he, as a BLS provider, make a decision to withhold resuscitation? There was no dependant levidity, no rigor mortis or obvious injury incompatible with life. He is just a fireman. Can he be right?

Photo courtesy, injuryboard.com

In this section, I will be discussing DOA and TOR guidelines and procedures. I am one who shies away from protocols as they keep you from thinking, but they also help protect you from liability if you follow them. Protocols do not always fit every situation and do not have to be followed to the letter, but medical command is necessary when you feel you need to deviate from them. Every state and province is different, review your regional protocols after reading what I say hear. Though I will be presenting generally accepted guidelines, many regions are still unique in their protocols. Let’s start with DOA procedures.

Photo courtesy of the NY Daily News

The manner of death, place of death, and local legal procedures dictate the type of procedures to be followed. For example, a murder victim will be handled by the police. Your role will simply be to determine if the patient really is dead or if resuscitation efforts will be useful. If the victim is a terminally ill patient who died with family and hospice nurse present, chances are, your locality puts most of the responsibility on the shoulders of EMS. A death at a home will involve family consoling and involve more reporting procedures than say, an MVC where all you will do is confirm death and go back in service.

Criteria, known as “medical futility criteria” were developed for EMS to prevent withhold or withdraw resuscitation efforts in hopeless situations where there is little chance, if any in complete resuscitation of the patient. These criteria included appropriate duration of resuscitation efforts and recommended procedures for on-scene pronouncement of death (Pepe, et al, 2001). Today, professional guidelines exist for EMS for basic and advanced providers (Bailey, et al, 2000), and they appear to be effective (Kamarainen et al, 2007).

Patients found dead on arrival (DOA) are much the same as TOR only instead of ceasing life support, it is simply withheld. An assessment needs accomplished as well as a decision made as whether or not to attempt resuscitation efforts and notification procedures are almost exactly the. same, often including interactions with family. Resuscitation should be withheld if obvious signs of death, are present, such as:
· Decomposition
· Rigor mortis
· Dependent livitity
· Submersion greater than 1 hour, regardless of temperature

  • ...and injuries incompatible with life such as incineration and decapitation/transection

Photo courtesy connect.jems.com

For trauma patients, we need to look at the mechanism and type of injury. Generally blunt injuries are not candidates for resuscitation, regardless of rhythm, while penetrating injuries could be resuscitated as long as the injury is not inconsistent with life (Pepe, et al, 2001), however many regions don’t include this in their DOA protocols. An unwitnessed traumatic arrest should not be resuscitated nor should a traumatic arrest in entrapped patient with severe injury that is not compatible with life. Obviously an MCI where seriously ill patients outnumber EMS personnel is another situation where cardiac arrest should not be attempted, except in cases of multiple patients of lightning strikes, unless they meet the other criteria above.
There are a couple of exceptions. Pregnant women who arrest after trauma, and the arrest was witnessed by EMS providers, should be resuscitated and transported to closest receiving facility for the benefit of the fetus. Hypothermia is another exception, and remember these patients can be stiff. But if the body temperature is the same as the ambient temperature and there are other signs of death, or the body tissue or chest wall is frozen solid, resuscitation should not be attempted.

So can BLS providers determine whether cardiac arrest victims should or not be resuscitated? Though some states may not allow it, the general consensus in the literature and most state protocols is YES. If the victim meets the criteria listed above, ALS can be cancelled. Of course, if there is any doubt, err on the side of the patient, start resuscitation efforts and call medic command. Medic command may order termination of efforts.
What about ALS providers? Experts agree attempts at resuscitation should not be attempted on an asystole patient with unwitnessed non-trauma cardiac arrest or a penetrating injury, but many regions, like my state of Pa., does not include these in their protocols, though it is common practice here to not resuscitate them. A little bit of critical thinking and decision making is required, and the help of medical command consult, who often agree with medic decisions to not attempt resuscitation in these cases.

Photo courtesy of stevespak.com

DNR Orders

Another reason to withhold resuscitation and or terminate it is when family produces a valid out of hospital DNR or advanced directives, or official DNR bracelet or necklace is found on the patient. We all know about DNRs and why we should honor them. Not honoring them is violating their consent, though they are now dead. However, what do we do if the family cannot produce the official copy but insists one is present? Start resuscitation, get a SAMPLE history, and call medical command for instructions. As an ALS provider, if the pt is terminally ill and the pt is in asystole, the pt. will not be a candidate for resuscitation but medic command must be contacted if protocols are gray in this area. Chances are, command will agree to withhold resuscitation.

What if the patient, moments before arresting, decides to waive the DNR, or the patient’s surrogate wants to override it? Then in this situation, resuscitation should NOT be withheld. Consultation with medical command should be made, but will usually decide in favor of the surrogate unless the official capacity of the surrogate is in question. What if bystanders or first responders are doing CPR when you arrive? Continue CPR, call medical command and get approval for TOR. Many states don’t recommend command consultation in this instance.

Photo courtesy of Cityhigh.org; Dory Sanders, City High intern with coroner's office

Now that the patient is determined not to be a candidate for resuscitation, what else needs done? Again, it depends on the situation. At a crime scene, your only responsibility is to determine the patient is DOA. You need to preserve the scene as much as possible, leave and go back in service and the police will handle the rest. An MVC is much the same, only you may be tasked with notifying the coroner, though the police usually do this. At a residence, things are different. You will most likely have to get a SAMPLE history and then call the patient’s family MD to ask if he or she will sign the death certificate. Jurisdictions differ in this procedure. If the MD is willing to sign it, your next call will be the coroner. If the MD will not sign the death certificate, death is suspicious or family requests it, the coroner’s office will have to send out their staff to retrieve the body. Again, these actions differ with local. If someone from the coroner’s office is coming for the patient, someone has to wait with the body. Legally it a police responsibility, but the EMS usually do this out of courtesy to keep PD back in service and since the EMS handle the call from the beginning anyway. This unfortunately keeps a truck out of service, but this is opportune for a supervisor or BLS QRV person to free up the ambulance.

Termination of Resuscitation Procedures

As I stated in part 1, it is unethical now to transport cardiac arrest patients and adds to UNNECESSARY risk to EMS crews transporting them as they are unrestrained in the back and the ambulance going lights and sirens is at risk for MVC. The on scene care will be not much different than that performed in the ED, and there is usually no additional benefit to transporting the patient to the ED. Besides, CPR performed during patient packaging and transport is much less effective than CPR done on scene, though this can be alleviated with automatic CPR machines, though these are expensive and not consistently used in the US.

Since the late 90s, most EMS services have protocols to terminate resuscitation efforts in the field and surveys show most medics seem comfortable with the concept. Yet, I still see EMS providers transporting cardiac arrest patients. I have tried to find data on those arrest patients that are transported as opposed to those that get resuscitation efforts and subsequent pronouncement, but data is almost nonexistent (Morrison, et al, 2008). When I ask EMS providers who continue to transport cardiac arrest patients why they do it, I am given a variety of answers that boil down to lack of confidence in notifying the family and consoling them, lack of confidence in deciding when to cease life saving efforts, and not wanting to take time out on scene helping the family or waiting for a coroner (thought this time is not much longer than transport, report, clean-up and restocking).

Photo courtesy of camperman999 from flicker

Though this is generally an ALS concept, the option is available to BLS as well. For instance many protocols recommend that after 3 “no shock advised” messages on an AED and ETA to hospital or ALS is >15 minutes, contact medical command for termination. The same holds true for traumatic arrests where bystanders or first responders started CPR. EMTs can call medical command to request termination. Of course all the factors regarding the arrest and MOI will have to be obtained and relayed to medical command to aid in the decision to terminate. As stated above, BLS can terminate when official DNR documentation is presented.

For ALS, most guidelines recommend medics consulting medical command for TOR if there is no positive response to approximately 20 minutes of ALS care including ventilation with advanced airway, good vascular access and several rounds of resuscitation drugs. In remote or wilderness situations, when medical command cannot be contacted, medics can terminate on their own if there is no ROSC after 30 minutes (hypothermia excluded), transport to an ED will take longer than 30 minutes or the providers are too exhausted to continue.

Photo courtesy of CBC news; Paramedics should make call on resuscitation for cardiac arrest

Though these are not absolute, the following conditions should be CONSIDERED as exclusions to TOR:
· Drug OD
· Electrocution or lightning strike
· Hypothermia
· Near-drowning
· Pediatrics (Data obtained by Hickey, Cohen, Stausbaugh, and Dietrich (1995) showed peds still arrest when arriving in ED usually don't survive, either)
· Public place
· Environment where bystanders do not accept the idea of TOR

Photo courtesy of mr walker from flickr; two ODs here, one an arrest but assumed to be resuscitated by St. John's Ambulance crew

The procedures are to ensure the patient is in fact dead with no breathing, no femoral and carotid pulses, and asystole or idioventricular rhythm less than 10-60 on the monitor. Efforts must continue until command gives the order to terminate. This requirement may differ in various regions. From this point on, the procedures are much the same as for a DOA.

  • Document the time of death at the time of TOR.

  • If a crime scene, leave tube and catheters in place, keep away and preserve the scene and hand over to police (who should have been called as soon as a crime scene was recognized

  • Inform family and friends who are present and provide grief consoling and don’t leave until family has adequate support

  • Notify the PCP and ask if willing to sign death certificate

  • Contact coroner (if an autopsy will be performed, leave all resuscitation adjuncts in place, leave patient in position

  • If no autopsy, place patient in position that appears comfortable and clean up debris from the resuscitation

  • Assist the family calling other family, friends, clergy and funeral director

  • Consider calling the local organ donation program as many arrest victims can donate corneas, skin grafts or bone grafts.

  • Sometimes the EMS will transport bodies as a service to aid the local coroner or funeral director. I have been tipped well for doing these, however, EMS is not designed for body transport as it is counter to original role of EMS and keeps a vehicle out of service
  • Proper documentation-some services and regions have forms for DOAs and TORs

Obviously, for a system like this to be in place, the service medical director needs involved and agrees with the program. Most do EMS agencies should have policies in place, especially concerning transporting bodies if the resuscitation is terminated in an ambulance and contacts such as where the body will be transported. Rapport with nursing homes is important as many expect the medics to transport their cardiac arrest patients out of their facility and may not understand when the medics terminate and leave the body. EMS staff need grief counseling training as well for family and friends of the deceased. I will discuss this in part 3.

How many of you have TOR policies? How many of you follow them? For those of you who do, what do you find the hardest part? Do any of you transport dead bodies to anywhere other than a hospital?

References sited:

American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bailey ED, Wydro GC, Cone DC. (2000), Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee, Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5.

Commonwealth of Massachusetts, OEMS, (2009) Appendix C: Cessation of Resuscitation

Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. (1995)"Pediatric patients requiring CPR in the prehospital setting.", Annals in Emergency Medicine 1995 Apr;25(4):495-501.

Kämäräinen A, Virkkunen I, Yli-Hankala A, Silfvast T., (2007), Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland, Resuscitation. 2007 Nov;75(2):235-43. Epub 2007 Jun 5.

Morrison LJ, Bigham BL, Kiss A, Verbeek PR., (2008) Termination of resuscitation: a guide to interpreting the literature. Resuscitation. Dec;79(3):387-90. Epub 2008 Sep 20.
Morrison LJ, Visentin LM, Vermeulen M, Kiss A, Theriault R, Eby D, Sherbino J, Verbeek R., Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest, ResuscitationVolume 74, Issue 1, July 2007, Pages 150-157

Pennsylvania Statewide Advanced Life Support Protocols, (2008) Termination Of Resuscitation, 3091-1 thru 3091-2

Pennyslvania Statewide Basic Life Support Protocols, (2008), Dead on Arrival, 322-1, Out-of-hospital Do Not Resuscitate, 324-1, Cardiac Arrest-General, 331-1 thru 331-3, Cardiac arrest-Traumatic, 332-1

Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton DM, Griswell JK, Blackwell T, Dunford J; Turtle Creek Conference II., (2001) Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death, Prehosp Emerg Care. 2001 Jan-Mar; 5(1):79-87.

Termination of Resuscitation by EMS, Part 1

This will again, be a 3 part series, in addressing issues on DOAs and termination of resuscitation (TOR). Part 1 will cover the theory of these issues, Part 2 will cover the actual guidelines and procedures for DOAs and TOR, and Part 3 will cover some basic death notification and grief support procedures. I can assure you I will not space these out as I did with my last posts, Sick Kid.

Photo courtesy of Las Vegas Review-Journal

Recently I was the assisting Paramedic for a neighboring service on a cardiac arrest call. Immediately after determining the patient was in a possible witnessed cardiac arrest, CPR was started and the monitored showed asystole. Within a couple of minutes, before IV access was obtained or intubation attempted the medic started shouting, “let’s load and go!” I looked at my partner dumbfounded, and asked the medic if he was sure he did not want to try for ROSC and consider TOR later. It was his call and he said his service transports all arrests. Of course I had to approach their supervisors, and they denied that claim. Recently, at a PALS class, all the medics in their class stated they transport all arrests except the obvious DOAs. Again, I was dumbfounded, so I thought I would discuss this issue here.

Photo Courtesy of www.life-save.org

Responding to cardiac arrest calls is a common practice and until the late 90s, there was no choice but to transport all the patients to the hospital, interacting with family only to illicit a medical history, and leaving death notification and grief consoling to hospital “professionals”. Since the late 90s, especially the release of the 1995 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (AHA, 1995) many experts in emergency medicine, started to question the efficacy of this practice and since then, EMS has been slowly adopting the practice of terminating of resuscitation (TOR) efforts (AHA, 2005,Grudzen, C: 2006).

In fact, now it is no longer acceptable to transport cardiac arrest patients to the hospital (Grudzen, 2006). It is considered unethical for many reasons (AHA, 2000): It ties up a needed bed in an overcrowded ED; it ties up needed members in the ED who must continue the resuscitation; it incurs unnecessary hospital charges; it increases time that EMS crews are not available for another call; it gives the family a false sense of hope and causes them much inconvenience in coming to a crowded ER out of touch with their loved one. It can also be dangerous for the family driving to the hospital in a stressed state of mind (Dick, 2007), and most importantly, dangerous to the public and EMS crew travelling to a hospital lights and sirens with attendants providing resuscitation efforts in the back, unrestrained.

This, courtesy of San Diego EMS at Flikr, is story of an ambulance who was transporting a cardiac arrest patient.

This left us in an uncomfortable situation of going counter to the social expectations to try and save everyone, and going against their altruistic nature. EMS providers also find themselves having to take on the added responsibility of deciding when to cease resuscitation efforts and most importantly, to notify the family of the death and console them. Though EMS providers have useful defense mechanisms when confronting dead patients, they seem to often lack the confidence in helping families at the moment of death as they see it as problematic, stressful, and uncomfortable. (Smith, 2009)
Courtesy of stevspak.com

Many EMS providers, knowing the futility of continuing resuscitation efforts, but feeling obligated to transport, practice the inappropriate “slow-code”, giving half-hearted attempts at CPR to just appear to an unknowing public that that efforts are being made, when in fact, they are not. This can damage the ethical integrity of healthcare providers and undermine the healthcare provider-patient relationship (AHA, 2005).

Courtesy of the Boston Globe. This is photo is not to imply this crew performed a "slow code".
Withholding Resuscitation
Withholding resuscitation efforts is not much different than terminating efforts. An assessment needs completed and a decision needs made to resuscitate. Notification procedures are the same and most of all, ALS does not need called, contrary to popular belief. If obvious signs of death are present (and I will get into those in part 2), the EMT can make a decision not to resuscitate. Other than the obvious signs of death, we need to consider the others that should not be candidates for resuscitation. There are others that should not be resuscitated as well, and I will get into that in more detail in part 2.

Courtesy of gayaruangkepelbagaim.wordpress.com

The AHA in their 1995, 2000, and 2005 ECC guidelines have addressed how futile it is to initiate extraordinary measures on terminal ill patients. We must ask ourselves are we are really saving a life or prolonging a death, especially when the patient is most likely to result in a persistent vegetative state. However, without guidelines to address terminally ill patients, DNR orders and advanced directives, EMS providers are legally forced to start resuscitation efforts, putting them in an ethical dilemma (Guru, Verbeek, Morrison, 1999). Most states and provinces have adopted protocols that allow providers to honor valid DNR orders or advanced directives without consulting medical oversight. If a patient has a DNR or advanced directive, why would you get a call at their residence or nursing facility? Meischke, et al, (2009) point out many people call EMS for DNR patients for a myriad of reasons, i.e., believing it is required by law, confusion on what to do and to confirm death. This gives EMS the responsibility of being an educator to the public as well as acting as a liaison in reporting and consoler for the family.

Photo courtesy of www.coopaleworks.com

Termination of Resuscitation (TOR) guidelines

Criteria, known as “medical futility criteria” were developed for EMS to prevent withhold or withdraw resuscitation efforts in hopeless situations where there is little chance, if any in complete resuscitation of the patient. These criteria included appropriate duration of resuscitation efforts and recommended procedures for on-scene pronouncement of death (Pepe, et al, 2001). Today, professional guidelines exist for EMS for basic and advanced providers (Bailey, et al, 2000), and they appear to be effective (Kamarainen et al, 2007).

Photo courtesy of www.finda.com. This photo is the Australian ambulance crew after they pronounced the drowning victim after an hour of resuscitation efforts at Cabarita beach.

Provider confidence in TOR guidelines

Morrison, et al, 2007, showed that most EMS providers surveyed were comfortable with TOR guidelines. One survey found most EMS services have protocols that allow for TOR yet only 19% of them had “written policies concerning on-scene family grief counseling.” This helps explain why EMS providers are reluctant with TOR. It is not the concept of pronouncement that is uncomfortable but spending time consoling family.

TOR and Pediatric Arrests

Photo courtesy of Michael Ging at photo.net

A Pediatric cardiac arrest often illicit a variety of responses from EMS providers and often poses a more stressful situation than the more common adult arrest. Providers tend to give the children the benefit of the doubt and resuscitate or transport all children regardless if the death is obvious no matter if it is unethical or not. Children differ from adults as to the cause of cardiopulmonary arrest (Young and seidel, 1999) as SIDS, trauma, airway compromise and drowning are the common causes in that order (Kuisma, Suominen, Korpela, 1995). Though SIDS children are never resuscitated (Smith, Kaji, Young, Guasche, 2005), the other causes of pediatric arrest often lead to better resuscitation rates compared to adults, though still poor (Donoghue, et al, 2005). This means that EMS providers are able to recognize pediatric arrests statistically more salvageable (Topijian, Nadkarni, Berg, 2009). Therefore, they are very uncomfortable with terminating resuscitation efforts in children (Hall, et al, 2004).

Despite the absolute negative outcomes of SIDS patients, there is debate on whether resuscitation should be started on them or not. Most EMS experts agree now it should be withheld (Dick, 2007, Smith, et al, 2005). Regardless, the police need notified and an autopsy needs done, because though Paramedics can easily identify SIDS cases, they show lack of ability to identify child abuse cases (Graham, Olson, Sapien, Tanberg, Sklar, 1997). In most cases involving a pediatric death, whether DOA or TOR, strong grief support needs to be provided to the family, and this falls on the shoulders of the EMS providers.

Family grief support
AP photo in Daily News, Mail.online

According to a survey done by Smith (2005), about half of EMS providers felt that their role should include notifying the family of the death, but “three-quarters reported they had not been trained adequately to make a death notification.” She and Feldman (2004) evaluated the change in behavior of EMS providers following death education training were more confident and planned to change their behavior at the scene of death. There are many training programs offered to EMS. However, there is no standardized or required grief support training for EMS, and it is severely deficient in initial EMS training. Cudos should go out to the AHA for including death notification in their 2000 Guidelines PALS video. Since most ALS providers need PALS training, their only grief support training was provided in this video. Still, death notification and grief support training is not consistent and lacking.

In part 2, I will discuss the procedures and guidelines for DOAs and TOR. I know protocols vary among states and provinces, but they are based upon well established guidelines and usually do not vary by much. Do you have protocols in your region for DOAs and TOR and some reasons for the guidelines? I am sure you do. How well do you know them?

American Heart Association (AHA), (1995), 1995 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Ethical Issues, Circulation.
American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bossaert L, Van Hoeyweghen R. (1989), Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest, The Cerebral Resuscitation Study Group, Resuscitation. 1989;17 Suppl:S55-69; discussion S199-206.

Dick, Thom, (2007) Dark side of the world's greatest job, EMS Magazine, April 2007 issue.

Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG; CanAm Pediatric Cardiac Arrest Investigators. (2005) Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge, Ann Emerg Med. 2005 Dec;46(6):512-22. Epub 2005 Aug 8.
Disaster Medicine, 21(6):445–450.

Jaslow D, Barbera J, Johnson E, Moore W, (2008), Termination of Nontraumatic Cardiac Arrest

Resuscitative Efforts in the Field: A National Survey, Academic Emergency Medicine Volume 4 Issue 9, Pages 904 – 907 Published Online: 29 Sep 2008

Morrison LJ, Bigham BL, Kiss A, Verbeek PR., (2008) Termination of resuscitation: a guide to interpreting the literature. Resuscitation. Dec;79(3):387-90. Epub 2008 Sep 20.
Morrison LJ, Visentin LM, Vermeulen M, Kiss A, Theriault R, Eby D, Sherbino J, Verbeek R., Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest,
ResuscitationVolume 74, Issue 1, July 2007, Pages 150-157

Smith, T., (2009), Emergency Medical Technicians, Encyclopedia of Death and Dying.

Smith L, Feldman, R (2004), THE EFFECT OF TWO DEATH EDUCATION PROGRAMS ON EMERGENCY MEDICAL TECHNICIANS, Prehospital Emergency Care, January / March 2006 Volume 10 / Number 1

Topjian AA, Nadkarni VM, Berg RA.,(2009) Cardiopulmonary resuscitation in children, Current Opinions in Critical Care. 2009 Jun; 15 (3):203-8.

Vukmir, Rade B. (2004), Survival And Outcome From Prehospital Cardiac Arrest . The Internet Journal of Rescue and Disaster Medicine. 2004 Volume 4 Number 1.