43 Termination of Resuscitation in the Out - of - Hospital Setting

The irreversible cessation of life may be diffi cult to determine with complete confi dence, particularly in the austere environment of out-of-hospital emergency care. As a result, resuscitation efforts are often initiated and continued by EMS providers, even in circumstances that are likely to be medically futile. In cases of nontraumatic cardiac arrest, few unassailable criteria exist for determining medical futility at the time of initial patient encounter other than certain physical signs of irreversibility such as dependent lividity or rigor mortis. Thus historically, the general medical recommendation has been to attempt to resuscitate all patients, adult or child, in the absence of rigor or lividity. Conversely, well-founded medical guidelines are available for decisions regarding termination of resuscitation in such medical patients once they have received a trial of BLS and advanced cardiac life support (ACLS) for a fi nite period of time. In practice, however, the fi nal decision to proceed with on-scene termination of resuscitation ultimately may be determined more by family and EMS provider comfort levels within the specifi c on-scene environment and circumstances. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), presence of vital signs, and the ECG fi ndings are most commonly used to determine futility, both in terms of initiating or continuing resuscitation efforts. In general, trauma patients who are asystolic (confi rmed ECG fl at line) on-scene are candidates for on-scene determination of futility and cessation of efforts, regardless of the mechanism of injury. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are also candidates for immediate cessation of efforts once they lose their pulses and respirations. Again, some logistical issues may affect these decisions beyond the medical criteria for termination of efforts. Regardless of the medical futility criteria, appropriate training of EMS providers, involving both operational and psychosocial issues, must be implemented before those personnel are authorized to implement on-scene termination of resuscitation policies. In addition, the policies themselves need to be modifi ed and adapted for various jurisdictional issues and resources. Furthermore, although current determinations of medical futility, as delineated in this discussion, are important to establish for societal needs, the individual patient’s ultimate right to receive resuscitative efforts must be kept in mind, particularly as new medical advances are developed. Although the same criteria for termination of resuscitation might be applied in the in-hospital setting for similar medical futility reasons, for all of these stated reasons, the termination of resuscitation efforts in the out-of-hospital setting, using EMS personnel to do so, is a unique situation that 43 Termination of Resuscitation in the Out-of-Hospital Setting CHAPTER