Almost since the beginning of cardiopulmonary resuscitation (CPR), there has been an ongoing controversy in EMS circles over when it is appropriate to begin CPR or when it should be stopped.
The increase of treatment options in cardiac arrest such as the use of automatic external defibrillators (AEDs) has further complicated matters. Finally, legal considerations about who can pronounce someone dead and many malpractice considerations have led to studies attempting to describe when it is futile to begin CPR.
A group of researchers in Scotland looked into what criteria should determine when patients with an unexpected cardiac arrest are not salvageable.
"The scene is familiar (to paramedics everywhere)," noted Dr. Andrew Marsden, an emergency medicine doctor in Edinburgh. "Ambulance staff respond to an emergency telephone call and find a pulseless, apneic corpse, in their view clearly beyond help. Since there are no definitive signs of death, ambulance personnel cannot pronounce 'life extinct' and must begin the charade of full resuscitation measures."
In Scotland, and most of the U.S., the only time paramedics can withhold resuscitation is when there are obvious signs of death such as decapitation, putrefaction or rigor mortis. With the introduction of automated external defibrillators and the electrocardiogram (ECG) monitor, however, investigators have been able to prove that paramedics can now identify those patients not likely to survive.
Studies in the U.S. have estimated that halting obviously futile attempts at resuscitation could save roughly $1 billion a year. There is also a cost to the individuals involved. A report from New Mexico found most emergency medical technicians had at least once in their careers decided to stop CPR without an order from medical control or against the requirements of a protocol or standing order. Nearly half admitted to be troubled by that decision.
The Scottish researchers looked at records of all CPR attempts undertaken from 1988 to 1994 by that country's ambulance services. They examined hospital and ambulance service run records as well as reviewing the archived automatic defibrillator rhythm strips (see British Medical Journal, July 1, 1995).
The resuscitation database was examined for patients where arrival of the ambulance was more than 15 minutes after the collapse; no bystander CPR was performed during that time; there was no pulse or breathing when the first paramedics got to the scene; and asystole or other rhythm where defibrillation is useless was the first tracing on the ECG. Four hundred fifteen people met the criteria.
Out of all these people, only one patient was discharged alive from the hospital. Five other patients with shockable rhythms were admitted to the hospital but died soon after. Among the 240 patients in the study who were not defibrillated, none were discharged from the hospital alive.
The AEDs in use during the study had been found to correctly identify a shockable rhythm between 90 and 99 percent of the time and a non-shockable one even more often. One concern of the researchers, however, was whether the AEDs had failed to identify a potentially treatable rhythm in the non-shock group. Only eight patients (4 percent of the study group) were identified as possibly having ventricular fibrillation but a definitive diagnosis was impossible due to interference from the CPR.
"There were no survivors among patients who met these conditions, so the mission of treatment in these patients would not have influenced survival," Marsden said. "Of the eight patients with possible ventricular fibrillation in the non-shocked group, none had truly flat line asystole and would have been routinely resuscitated under our guidelines."
The researchers have developed an algorithm for deciding whether to begin CPR and other measures. If a patient is found in cardiopulmonary arrest, pulseless and apneic, and CPR has not been started within 15 minutes of collapse, the AED is attached. If there is a shockable rhythm upon presentation, then resuscitation protocols are started.
Other indications requiring a full response include all types of cases in which survival following prolonged cardiac arrest has been reported. Among these would be drowning, hypothermia and poisoning or overdose. For ethical and other reasons, ambulance personnel should always attempt resuscitation on any child or during pregnancy to support both the mother and the fetus.
"Even when all of these things occur, to offer the patient even the very slimmest chance of survival, paramedics should give CPR for at least one minute," Marsden said. "Only after this, when further checks confirm pulselessness, apnea and a non-shockable or flat rhythm for 10 seconds, should resuscitation attempts be abandoned." Since only a doctor can confirm death in most jurisdictions, arrangements should be made to have a doctor come to the scene or transport the patient to a hospital. Local laws would mandate how this is to be done.
The researchers stressed that this algorithm is to be used only in cases of unexpected death. If a terminally ill patient is being transported, then local "do not resuscitate" laws would take effect. "We recognize that this issue is controversial and sensitive," Marsden said. "Vigorous resuscitation should be undertaken whenever there is a chance for survival, no matter how slim. Nevertheless, futile efforts at resuscitation are distressing both for staff and for relatives, and realistic guidelines are needed."
Kurt Ullman, a Firehouse® contributing editor, is a registered nurse and regional chairman of the volunteer Indiana Arson and Crime Association.
