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Termination of CPR: Should we increase the duration of CPR before "calling it?"

Termination of CPR: Should we increase the duration of CPR before "calling it?"

Ahed Al Najjar Fellow of American Heart Association

EMS Research, Director Life Support

Prince Sultan College for EMSKing Saud University [email protected]

TOCPRTOCPR

On a second look through the 2010 AHA ECCGuidelines, I happened to read through the section onethics and found the section detailing termination ofresuscitation in the field. There are a few interestingtopics covered that I think warrant passing on.

Paramedics have a tendency to transportcardiac arrest patients even when they knowthat these efforts are futile.

The GoalsThe Goals

The goals of resuscitation are:

• To Preserve life

• To Restore health

• To Relieve suffering,

• To Limit disability, and

• To Respect the individual’s decisions, rights,

and privacy.

This is old news - if EMS doesn't get a pulse back by the

time the patient is moved onto the longboard, the

prognosis is grim.

Ethical Principles Ethical Principles That's why the authors of the ACLS guidelines support appropriate field termination-of-resuscitation, writing in the 2010 Ethics portion of the ACLS guidelines:

Field termination reduces unnecessary transport to the hospital ... , reducing associated road hazards that put the provider, patient, and public at risk. In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement.

More importantly the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.

Ethical Principles Ethical Principles

Healthcare professionals should consider ethical, legal, and

cultural factors when caring for those in need of CPR.

Although healthcare

providers must play a role

in resuscitation decision

making, they should be

guided by science, the

individual patient or

surrogate preferences, local

policy, and legal

requirements.

Scientific Evidence Scientific Evidence They provide a suggested algorithm for field

termination by paramedics, based on the most

recent evidence:

Study 1 Study 1

This study used data from a retrospective registry,

collecting data from 435 hospitals over a 9-year period

(2000-2008). They ended up with about 65,000 patients

who had a cardiac arrest while in the hospital

First, they looked at how long patients received resuscitative efforts, and

calculated the average duration of CPR at each hospital for patients who did

not have ROSC.

That last part is key - when the news reports talk about "how long patients

got CPR," what they really mean is "the average duration of CPR at each

hospital for nonsurvivors." Subtle, but important difference.

Last step - they looked at the "average" cardiac arrest patient at the

hospitals with the longest average duration of resuscitation, and

compared the survival rate with patients at the hospitals with the shortest

average durations

The finding The finding The hospitals that "coded" non-survivors for the shortest time did sofor about 16 minutes, while those hospitals in the more persistentgroup ran resuscitations for an average of 25 minutes.

So, does this apply to my patients in the field?So, does this apply to my patients in the field?

• This study only looked at in-hospital cardiac arrest

• They excluded arrests that occurred in the ED

• EMS codes were not included either

We already know that in-hospital cardiac arrest

patients are different from those in in the pre-hospital

realm, so the results are not immediately applicable

Study 2 Study 2

The aim was to establish scientifically supported

recommendations for termination of cardiopulmonary

resuscitation (CPR) in mountain rescue, which can be

applied by physicians and non-physicians

Literature search was performed; the results and recommendations were

discussed among the authors, and finally approved by the International

Commission for Mountain Emergency Medicine (ICAR MEDCOM) in

October 2011.

The finding The finding

CPR may be terminated when all of the following criteria

apply:

•Unwitnessed loss of vital signs

•No return of spontaneous circulation during 20 min of

CPR

•No shock advised at any time by AED or only asystole

on ECG

•No hypothermia or other special circumstances

warranting extended CPR

Why Terminate CPR?Why Terminate CPR?

Terminating resuscitation in the field

reduces transports which are considered

unnecessary by :

•60% in BLS systems

•40% in ALS systems

The AHA lays out two methods

for deciding when to terminate resuscitation:

one for BLS responders and

one for ALS responders

Termination Criteria - BLS responders Termination Criteria - BLS responders The BLS criteria must be present before thepatient is moved to the ambulance, so if you’vealready started transporting and suddenly realizethat the patient meets the criteria, keeptransporting.

The BLS criteria are also suggested only forareas in which the ETA for ALS resources islong. The criteria are :

The arrest was not witnessed by responders

No return of spontaneous circulation (ROSC)

No AED shocks delivered

The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards

Termination Criteria - ALS responders Termination Criteria - ALS responders The ALS criteria include the following requirements:

Unwitnessed arrest (by anyone, not just responders, in contrast to the

BLS criteria)

No bystander CPR

No ROSC after full ALS care

No defibrillation

The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards

Again, these criteria must be met on scene in order to terminate. If you’ve started transporting, you should continue with resuscitation

Ethics and Privacy Issues Related to Resuscitation ResearchEthics and Privacy Issues Related to Resuscitation Research

• Conducting clinical research in patients with

cardiopulmonary arrest is challenging

• Required Consent

• Legally authorized decision-maker

• Research interventions must frequently be implemented

at a time when it is impossible to obtain consent

• Patient privacy and the confidentiality

• Cultural communities

Last thoughts on futilityLast thoughts on futility

• Futility judgment should be based on upon professional

standards

• A goal not worth striving for is a personal preference, not

a decision based on futility

• Communicate openly

• Framing

- Not “nothing I can do” but “we’ll do everything possible

to ensure comfort and dignity”

• Futility shouldn’t be used to justify allocation issues.

Decisions should be explicit and justifiable

Last thoughts on CPR Termination Last thoughts on CPR Termination

• Additional research into the ethical

consequences, public opinion, and

feasibility and consequences of familial

consent in this setting.

• There are many unanswered questions in this setting,

including the impact of any policy on the CPR survival

rate.

• The impact of requesting consent from grieving families,

the significance of who requests consent, and public

opinion regarding disclosure.

Review

Questions/ Comments

Thanks!