Special Circumstances When Ceasing Resuscitation Efforts

Aka: Special Circumstances When Ceasing Resuscitation Efforts, Death Pronouncement in Emergency Resuscitation, Declaring a Patient Dead After Attempted Resuscitation, Ceasing Resuscitation Efforts

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II. Indications

  1. Failed Resuscitation by EMS/ED despite maximal medical efforts (or efforts consistent with patient wishes)

III. Approach: Specific Circumstances

  1. Ventricular Fibrillation or Ventricular Tachycardia (shockable rhythms)
    1. Most likely to identify a reversible cause and to respond to Resuscitation efforts
    2. Maintain high quality CPR
    3. Consider transport to ECMO or cath lab if refractory Ventricular Fibrillation or Ventricular Tachycardia
    4. Occult fine Ventricular Fibrillation has been identified by TEE in some cases thought to be Asystole
      1. Consider TEE during reuscitation, or consider single Defibrillation if suspected
  2. Asystole
    1. Indications to continue efforts
      1. Initial rhythm of Asystole in unwitnessed arrest without obvious signs of death
    2. Indications to cease efforts
      1. Persistent Asystole for >20 minutes of Resuscitation efforts (Neuro intact survival <1%)
  3. Pulseless Electrical Activity (PEA)
    1. Indications to continue efforts
      1. Heart Rate >40-60 per minute
      2. End-Tidal CO2 trending >20 mHg
    2. Indications to cease efforts
      1. Point-Of-Care Ultrasound without cardiac activity
      2. End-Tidal CO2 persistently 5-10 or less for 20-25 minutes despite Resuscitation
      3. Persistent PEA for >60 minutes of Resuscitation efforts (Neuro intact survival <2%)
      4. Age alone does not impact decision to continue Resuscitation
  4. Obesity and pseudo-PEA
    1. Obese patients are at high risk for Pseudo-EMD (pulses not palpable due to Obesity)
    2. Consider empiric IV fluid bolus (and Vasopressor) if Pseudo-EMD suspected
    3. EMS should transport for bedside Echocardiogram for cardiac standstill if in doubt
    4. Allow for adequate Resuscitation efforts before pronouncement
      1. Duration of code until ROSC is >20 minutes in 25% of Cardiac Arrest cases
      2. Goldberger (2012) Lancet 380(9852): 1473-81 [PubMed]
  5. Prolonged Resuscitation
    1. Consider Ceasing Resuscitation Efforts after >45 to 55 minutes of high quality CPR, ACLS
    2. Low likelihood of good neurologic outcomes with prolonged Resuscitation
      1. Witnessed arrest with maintained high quality CPR to ECMO may warrant continued efforts
  6. Low Baseline Quality of Life (e.g. Advanced Dementia, end-stage COPD, CHF, metastatic cancer)
    1. Those who survive Cardiac Arrest will have a lower quality of life than before the arrest
    2. Discuss with family or other POA when considering Stopping Resuscitation efforts
  7. Pediatric death pronouncements
    1. All cases are referred to medical examiner cases and are investigated by police

IV. Approach: Circumstances in which further Resuscitation efforts are futile

  1. Criteria (all three together predict nearly 0% chance of survival)
    1. No Return of Spontaneous Circulation (ROSC) prior to transport AND
    2. Cardiac Arrest was not witnessed AND
    3. Rhythm was not shockable
    4. Morrison (2009) Resuscitation 80(3): 324-8 [PubMed]

V. References

  1. Braude and Myers in Herbert (2016) EM:Rap 16(2): 18-9
  2. Shinar and Swadron in Herbert (2013) EM:Rap 13(3): 4-5
  3. Weingart and Swaminathan in Swadron (2022) EM:Rap 22(1): 3-5

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