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.

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.

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).

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)

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).

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.

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.

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.