Our BLS protocols do not spell out "death in the field", but ALS protocols do.
Here they are:
This protocol is designed to be used when EMS personnel encounter patients who are
dead at the time of arrival in which resuscitation is medically inappropriate or for use
immediately after the Cease-Effort Protocol 9102 has been performed.
A. Perform initial assessment as per any patient.
B. Determine history.
C. Criteria: The decision to not begin resuscitation may occur under the following
circumstances if ordered in consultation with MCP.
1. When there are changes to the body which indicate a prolonged postmortem
interval, i.e. decomposition, rigor in normothermic body.
2. Injuries incompatible with life such as decapitation or transection of torso.
3. Pulseless, apneic patients in multiple casualty situations where available
resources are required to maintain living patients.
4. Proper DNR documentation.
5. Resuscitation efforts pose a danger to the health and/or safety of the
rescuers.
D. Criteria: The decision to not begin resuscitation may occur under the following
circumstances by direct verbal contact and order of MCP.
1. Victims of trauma who are pulseless and apneic at the time of arrival of first
responders or EMS personnel.
2. Blunt trauma patients who become pulseless and apneic, cannot be
extricated quickly, and the entrapment precludes medically effective
resuscitation efforts.
3. Circumstances where beginning or continuing resuscitation is not medically
appropriate as determined by EMS personnel and direct contact with the
Medical Command Physician.
E. Procedure:
1. Contact Medical Command immediately and consult with MCP as required
in “C” and “D” above. Discuss situation and obtain confirmation that no
resuscitation is indicated.
2. After consultation with MCP, note exact time and date of declaration of
death.
3. Protect and preserve the scene until jurisdictional authority has been
determined as in #4 below.
4. Notify the Medical Examiner Authority (County or State) on all out-of-hospital
deaths except those registered with and receiving hospice care.
5. If the county authority is unavailable or does not call back within 10 minutes,
then contact the State Medical Examiner’s Office at 1-877-563-0426.
6. Unless hospice death, notify local law enforcement.
7. While awaiting return call from Medical Examiner Authority, collect the
following information:
a. Has patient been under the care of a regular attending physician. If
so, note the name and contact number. If death was expected,
attempt to contact physician and inquire if he or she will certify death
and sign the death certificate.
b. Past medical problems.
c. History and circumstances of death.
d. Inquire from family or those present about anatomical gift
documentation including drivers license or living will. Check for medic
alert tags concerning anatomical gift.
8. When Medical Examiner Authority calls, give above information. Medical
Examiner Authority will determine if case meets criteria for Medical Examiner
case. If yes, follow instructions from Medical Examiner.
9. If death does not meet criteria for Medical Examiner investigation, the
Medical Examiner Authority will release the body. Contact patient’s attending
physician and confirm the history and circumstances of the death. Assure
that the attending physician will certify the death and sign the death
certificate. Document the time and name of the physician. Assist family with
transport arrangements for the body to morgue or funeral home. If
anatomical gift information was discovered, then notify Medical Command
of the name and type of donation.
10. If the deceased has no attending physician or the physician refuses to certify
and sign the death certificate, then the case must be a Medical Examiner
case. Follow instructions of Medical Examiner.
11. EMS personnel are not required to transport the body, but may do so if
instructed and this is standard practice as a courtesy to the local community.
12. EMS personnel should document carefully the signs, symptoms, and vital
signs which confirmed and allowed the declaration of death. These facts
should be recorded in the patient care record.
13. For Medical Examiner cases, the hospital copy of the patient care record
should be completed and given to the Medical Examiner Authority if they are
on-scene or left with the body at the morgue if transport is made.
And here is the cease effort protocol (also ALS)
This protocol is designed to be used when in direct consultation with the Medical
Command Physician (MCP), the medical decision is made to discontinue resuscitation
efforts in the field and proceed to the Death in the Field Protocol 9101.
A. Criteria: EMS personnel may request orders to cease resuscitation efforts on a
patient in the field when any of the following are present:
1. Resuscitation initially started by first responders, family members, etc. is
determined to have been medically inappropriate (i.e. terminal cancer or
traumatic arrest).
2. Full cycle of ALS treatment has been unsuccessful and patient has been
confirmed pulseless and apneic by EMS for at least 20 minutes.
3. Proper “Do Not Resuscitate” documentation has been discovered or clarified
by family or power of attorney.
4. BLS resuscitation has proved unsuccessful and no ALS is available for an
extended period of time. Patient has been confirmed pulseless and apneic
by EMS for at least 20 minutes.
5. Physical exhaustion of available providers to provide care.
6. The scene environment is judged to be unsafe for rescuers to continue
resuscitation.
7. Extremely remote areas where evacuation may require hours or days.
B. Procedure:
1. EMS personnel will contact Medical Command and speak directly to the
MCP.
2. Specific history and details of care will be discussed and MCP will make final
decision, give final order to cease resuscitation, and note exact date and
time.
3. Proceed immediately to Death in the Field Protocol 9101.
C. Exceptions: The following situations may necessitate transport of patients and
continued resuscitation efforts per direct MCP order:
1. Volatile or potentially dangerous situations where movement of the patient
and exit from the scene is required for the safety of the rescuers.
2. Hypothermic patients. Treat per Cold Exposure Protocol 4503.
3. Pediatric patients less than 12 years of age.
Special Note: If patient is removed from scene and resuscitation continued, the
resuscitation efforts should be continued until arrival at the hospital.
