ROLE & Termination of Resuscitation
ROLE & Termination of Resuscitation
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Key Point's
Key Point's
Paramedics are increasingly being called upon to diagnose death and initiate the appropriate clinical response.
After cardiac arrest, resuscitation efforts including ALS must be made whenever there is a chance of survival, unless the person has made an ADRT refusing CPR in these circumstances.
Some conditions are incompatible with recovery and, in these cases, resuscitation should not be attempted.
In some situations, once the facts of the patient and situation are known, resuscitation efforts can be discontinued.
Patients can and do make anticipatory decisions NOT to be resuscitated. An ADRT must be respected and a DNACPR recommendation should be used to guide decision making on whether or not to attempt CPR.
These guidelines should be read in conjunction with local policies and procedures.
Introduction
Clinical management aims to differentiate between those for whom cardiac arrest is their natural end-of-life event and for whom resuscitation is not indicated, and those where there is a chance to restore life to a quality acceptable to the patient and by their wishes, through the provision of optimum pre-hospital care.
Where no explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.
However, in some circumstances where there is no recorded explicit decision regarding CPR, but death is imminent and unavoidable and CPR would not be successful (for example, a person in the advanced stages of an irreversible illness), a decision not to commence CPR should be considered to allow natural death to occur. For patients in whom there is no chance of survival, CPR is not supported; for example:
where resuscitation would be both futile and distressing for the patient, relatives, friends and healthcare personnel
where time and resources would be ineffective in undertaking such measures.
Every effort should be made to identify patients with a DNACPR decision, Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, treatment escalation plan or Advance Decision to Refuse Treatment (ADRT).
The views of the patient's general practitioner (GP) or relevant third party should be considered. Ask if the patient has a care plan or ADRT in place. Family members may be able to provide verbal information about the patient’s wishes, although this is not legally binding in this format.
CPR should not be attempted, or it should be abandoned if already started by the general public or volunteer responders, if the ambulance clinician is as certain as they can be that a person is dying as an inevitable result of underlying disease (it is, therefore, their natural end of life event) and CPR would not restart the heart and breathing for a sustained period.
Where there is uncertainty, it is acceptable to commence basic life support (BLS) while further information is rapidly gathered to enable the decision to be made about whether resuscitation can be stopped.
Conditions Unequivocally Associated with Death (ROLE)
Decapitation.
Massive cranial and cerebral destruction.
Hemicorporectomy or similar massive injury.
Decomposition/putrefaction
Where tissue damage indicates that the patient has been dead for some hours, days or longer.
Incineration
The presence of full-thickness burns with charring of greater than 95% of the body surface.
Hypostasis
The pooling of blood in congested vessels in the dependent part of the body in the position in which it lies after death. Initially, hypostatic staining may appear as small round patches looking rather like bruises but later these will combine to merge as the familiar pattern. Above the hypostatic engorgement, there is obvious pallor of the skin.
The presence of hypostasis is diagnostic of death – the appearance is not present in a live patient. In extremely cold conditions, hypostasis may be bright red in colour, and in carbon monoxide poisoning, it is characteristically ‘cherry red’ in appearance.
Rigor mortis ‒ the stiffness occurring after death from the post-mortem breakdown of enzymes in the muscle fibres.
Rigor mortis occurs first in the small muscles of the face, next in the arms, and then in the legs, with these changes taking between 30 minutes and 3 hours. The recognition of rigor mortis can be made difficult where, rarely, death has occurred from tetanus or strychnine poisoning.
In some, rigidity never develops (infants, cachectic individuals and the aged), while in others it may become apparent more rapidly, i.e. in conditions in which muscle glycogen is depleted, e.g. exertion (which includes struggling), strychnine poisoning and local heat (e.g. from a fire, hot room or direct sunlight).
Rigor should not be confused with cadaveric spasm (sometimes referred to as instant rigor mortis), which develops immediately after death without preceding flaccidity following intense physical and/or emotional activity. Examples include death by drowning or a fall from a height. In contrast with true rigor mortis, only one group of muscles is affected and not the whole body. Rigor mortis will develop subsequently.
Rigor is also distinct from trismus (spasm of the muscles around the jaw which may occur in those with a reduced level of consciousness). Rigor mortis is not isolated to jaw muscles alone.
Other Conditions Where Resuscitation May be Withheld or Discontinued
In addition to the conditions above, there are other criteria which can be used to confirm death, and which indicate that resuscitation should not be attempted, or may be discontinued:
The presence of a DNACPR (do not attempt cardiopulmonary resuscitation) decision or ReSPECT form that advises resuscitation is not to be attempted.
A valid Advance Decision to Refuse Treatment (ADRT), which refuses cardiopulmonary resuscitation, or a Lasting Power of Attorney (LPA) for Health and Welfare that includes decisions related to life-sustaining treatments and where CPR is refused by the attorney.
If a person is known to be in the final stages of an advanced, irreversible condition, in which attempted CPR would be both inappropriate and unsuccessful, CPR should not be started or can be stopped if already commenced. Even in the absence of a recorded DNACPR decision, ambulance clinicians may be able to recognise this situation and make an appropriate decision, based on clear evidence that they should document. Examples of clear evidence include the presence of anticipatory medications, hospice or palliative care notes and advance care plans, but always refer to local guidance. While seeking evidence or where there is doubt, it is appropriate to start BLS and seek senior clinical advice. The relatives/carers should be included in the decision making process.
NB: An advanced and irreversible condition is an illness or injury that can no longer be cured and care is refocused to promote quality of life, comfort and symptom control. Examples of conditions are not confined to cancer, but also include organ failure (e.g. heart, respiratory, renal and liver), neurological illness (e.g. motor neurone disease, Parkinson’s, Dementia) and advanced frailty in older people.
When identifying patients near end of life, it is useful to utilise available screening tools, such as the Gold Standards Framework (GSF) or the Supportive and Palliative Care Indicators Tool (SPICT). They offer insight into a patient’s pattern of deterioration and an overall impression of their stage of illness. Further information to support this can also be gleaned from the patient’s history, medical notes and any completed advance personalised care plan.
Submersion for longer than 90 minutes
There is no realistic chance that CPR would be successful if ALL the following exist together:
>15 minutes have elapsed since the onset of cardiac arrest.
No evidence of bystander CPR in the 15 minutes before the arrival of the ambulance.
Exclusion factors are absent (drowning, hypothermia, poisoning/overdose, pregnancy, child/neonate).
Asystole for >30 seconds on the ECG monitor screen. CPR should only be paused for a 30-second asystole check if all other criteria are met.
Whenever possible, a confirmatory ECG demonstrating asystole should be documented as evidence of death. In this situation, a 3- or 4-electrode system using limbs alone will cause minimum disturbance to the deceased. If a paper ECG trace cannot be taken, it is permissible to make a diagnosis of asystole from the screen alone (NB due caution must be applied in respect of electrode contact, gain and, where possible, using more than one ECG lead).
It is important that to confirm death, the rhythm is unequivocally persistent and continuous asystole. If CPR is stopped when any other rhythm is present (i.e. agonal rhythm or PEA), it is important to wait until all cardiac electrical activity has ceased and the ECG shows asystole. Only at this stage should the patient be declared life extinct and the family/relatives informed that this is the case. This is because there have been well-documented cases where spontaneous ROSC has occurred following termination of resuscitation.
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