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.
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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.

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