When to end CPR?

[afawver1003]

I am a college student majoring in Emergency Medical Services and in my college composition class, we have to write an argumentative regarding a contraversial issue in our field of study. My thesis for this paper is "EMS personelle should be allowed to cease CPR depending on situation circumstances." These circumstances being terminally ill patients, when a DNR is not present, if you know the pt isn't going to make it anyway ect. What are some other thoughts..opinions...views? Thanks!

 

[Medic Tim]

There are many areas where paramedics can call it without calling olmc for various situations. Are you looking for EMT , medic or both?

I take it in your area EMS cannot do this?

 

[NYMedic828]

Every patient is different.

You need to evaluate their age, cause of arrest and preexisting conditions to deem them viable or worthy of terminating efforts.

Trauma dont even bother if you don't have to...

 

[VFlutter]

As much as I would like to say that medics should be allowed to cease resuscitation on futile terminally ill patients I do not think it is a realistic option. Are you suggesting this based off family wishes or paramedic discretion? What criteria would you use? Who decides it is futile? Would it require contacting medical control?

In my opinion, anything besides obvious death and traumatic arrests will lead to more trouble that it is worth. Best option is continue BLS only to the nearest hospital and let them call it on arrival

 

[9D4]

I agree with chase. It'd be pretty difficult to tell if someone has a terminal condition. As it is, I've heard of "DNR" tattoos and EMS is required to ignore those unless proper papers are present. I can see the tat's being acceptable practice.

 

[TransportJockey]

As much as I would like to say that medics should be allowed to cease resuscitation on futile terminally ill patients I do not think it is a realistic option. Are you suggesting this based off family wishes or paramedic discretion? What criteria would you use? Who decides it is futile? Would it require contacting medical control?

In my opinion, anything besides obvious death and traumatic arrests will lead to more trouble that it is worth. Best option is continue BLS only to the nearest hospital and let them call it on arrival

Nope I'll take calling a doc than transport a dead body forty miles. I call on scene with mcep permission rather often, usually after twenty minutes of acls and they see still pulseless.

 

[Medic Tim]

As much as I would like to say that medics should be allowed to cease resuscitation on futile terminally ill patients I do not think it is a realistic option. Are you suggesting this based off family wishes or paramedic discretion? What criteria would you use? Who decides it is futile? Would it require contacting medical control?

In my opinion, anything besides obvious death and traumatic arrests will lead to more trouble that it is worth. Best option is continue BLS only to the nearest hospital and let them call it on arrival

Many services cannot afford a lucas or thumpers. You can't do good manual cpr in a moving ambulance. I won’t get into how dangerous a practice it is because we have beaten that horse to death on here already. Arrest pts for the most part are dead. The best shot they have is being worked on scene and then pronounced in the field...if they are even worked at all.....this obviously does not apply for every code as you need to take every pt, condition, logistics, etc into consideration.
The little chance arrest pts have of making it is reduced even more when you do ineffective cpr with some yahoo driving like an idiot to the hospital.

This may not help the op as I do not primarily practice in the US but... A family member can override it just like a family member can ask us not to start working on their family who doesn't have a DRN. We use the information on hand to determine what is to be done. We look at what the pt and the family wants....if it seems at all reasonable we follow their wishes.

 

[DrankTheKoolaid]

We are able cease resuscitation without OLMC here due to the area and lack of communication. Unless there is some strange circumstance i dont transport codes and they get 20 minutes of full ALS resus and i let the etco2 make my decision at the 20 minute mark.

Thats across the board for any codes.

 

[Christopher]

I am a college student majoring in Emergency Medical Services and in my college composition class, we have to write an argumentative regarding a contraversial issue in our field of study. My thesis for this paper is "EMS personelle should be allowed to cease CPR depending on situation circumstances." These circumstances being terminally ill patients, when a DNR is not present, if you know the pt isn't going to make it anyway ect. What are some other thoughts..opinions...views? Thanks!

We have defined protocols for termination of resuscitation and for "obvious death". For a truly terminal patient without a DNR, if I have an agonal or asystolic rhythm on the monitor that classifies as "obvious death" enough to call it on our own and get up with their personal MD to see if they'll sign the death certificate.

Otherwise the simple answer is to call the ED and speak with a doc, but in this case BLS/CPR should be done while waiting because more than once (especially with pacemakers present) I've been asked to work the code 3-rounds and terminate only if there is no change.

And by the way: termination of resuscitation by paramedics in the field is not controversial, or at least it hasn't been in the 5 years I've been in EMS.

 

[NYMedic828]

As much as I would like to say that medics should be allowed to cease resuscitation on futile terminally ill patients I do not think it is a realistic option. Are you suggesting this based off family wishes or paramedic discretion? What criteria would you use? Who decides it is futile? Would it require contacting medical control?

In my opinion, anything besides obvious death and traumatic arrests will lead to more trouble that it is worth. Best option is continue BLS only to the nearest hospital and let them call it on arrival

Why? This only costs the healthcare system countless dollars for a second ALS workup by hospital staff for no purpose whatsoever. Odds are the first work-up from an ALS crew was worthless anyway.

An 80 year old woman who arrests for unknown reasons doesn't have to be terminally ill but what purpose is there on me transporting her?

If a paramedic is not capable of determining a patient to be clinically deceased then they certainly have no business administering treatments on living patients.

 

[usalsfyre]

As much as I would like to say that medics should be allowed to cease resuscitation on futile terminally ill patients I do not think it is a realistic option. Are you suggesting this based off family wishes or paramedic discretion? What criteria would you use? Who decides it is futile? Would it require contacting medical control?

In my opinion, anything besides obvious death and traumatic arrests will lead to more trouble that it is worth. Best option is continue BLS only to the nearest hospital and let them call it on arrival

Wrong....most progressive services and even the AHA recommendations state 20 minutes of ACLS and then call it if no response.

 

[VFlutter]

An 80 year old woman who arrests for unknown reasons doesn't have to be terminally ill but what purpose is there on me transporting her?

I totally agree but how are we going to practically implement it. What about that 80 year olds family who would have wanted everything done. Are you going to have to defend your decisions in court? Is your defense going to be "she was 80, she probably didn't have a great quality of life to begin with". I am just saying there needs to be some type of protocol and guidelines other than just paramedic discretion.

I agree with the 20 min then calling it but it sounded like the OP was talking about calling it off the present illness and history.

 

[NYMedic828]

I totally agree but how are we going to practically implement it. What about that 80 year olds family who would have wanted everything done. Are you going to have to defend your decisions in court? Is your defense going to be "she was 80, she probably didn't have a great quality of life to begin with". I am just saying there needs to be some type of protocol and guidelines other than just paramedic discretion.

I agree with the 20 min then calling it but it sounded like the OP was talking about calling it off the present illness and history.

What is there to implement? We already terminate onscene...
I have terminated countless elderly and non elderly arrests.


As long as you make the effort to resuscitate the patient for 20 minutes as per AHA guidelines and explain in a professional manor that you have done everything a hospital would do, you can't be sued so who cares if they want you in court. They don't have a leg to stand on.

 

[Christopher]

I totally agree but how are we going to practically implement it. What about that 80 year olds family who would have wanted everything done. Are you going to have to defend your decisions in court? Is your defense going to be "she was 80, she probably didn't have a great quality of life to begin with". I am just saying there needs to be some type of protocol and guidelines other than just paramedic discretion.

I agree with the 20 min then calling it but it sounded like the OP was talking about calling it off the present illness and history.

HPI + agonal rhythm + unwitnessed = obvious death.

 

[Brandon O]

My concern is that with the current progress that post-ROSC hypothermia (and some other tricks, but mostly the big chill) is demonstrating, we are seeing patients survive with good outcome who as recently as a few years ago we'd have all "known" would never make it. In other words, prognostication has gotten trickier, and I'm not sure it's clear anymore whether that 80 minute code is truly just going through the motions. It probably is, but I don't know how we can differentiate it at this point, and I don't think anybody does.

 

[Christopher]

My concern is that with the current progress that post-ROSC hypothermia (and some other tricks, but mostly the big chill) is demonstrating, we are seeing patients survive with good outcome who as recently as a few years ago we'd have all "known" would never make it. In other words, prognostication has gotten trickier, and I'm not sure it's clear anymore whether that 80 minute code is truly just going through the motions. It probably is, but I don't know how we can differentiate it at this point, and I don't think anybody does.

With a decent presenting rhythm and bystander CPR, I think it is reasonable to be more inclusive.

 

[NYMedic828]

My concern is that with the current progress that post-ROSC hypothermia (and some other tricks, but mostly the big chill) is demonstrating, we are seeing patients survive with good outcome who as recently as a few years ago we'd have all "known" would never make it. In other words, prognostication has gotten trickier, and I'm not sure it's clear anymore whether that 80 minute code is truly just going through the motions. It probably is, but I don't know how we can differentiate it at this point, and I don't think anybody does.

If you did a full 20 minute workup, if the patient does not improve in any way then it isn't viable to continue efforts. (assuming asystole)

 

[Brandon O]

With a decent presenting rhythm and bystander CPR, I think it is reasonable to be more inclusive.

I agree, but that's what I mean... when you throw all of the different factors together, how many pluses do you need to have in order to be optimistic? How do you determine the gray areas? It used to be that in all but the most perfect cases, we'd pretty much assume they weren't coming back, but with the current techniques, and particularly through the retrospective lens of hypothermia, we know that's no longer true... we just don't know how true it's not. And obviously termination of resuscitation is something you only want to do when everyone's very sure about futility.

46 yo with 6 minute downtime, okay bystander CPR for 10 minutes after that, 30 minute code by EMS, refractory VF for first 15 and asystole thereafter. Call it? No? How about after 40 minutes? 50? At what point are we sure there's no chance?

Capnography might help cut through some of this but the evidence isn't too wieldy there yet either.

 

[Christopher]

I agree, but that's what I mean... when you throw all of the different factors together, how many pluses do you need to have in order to be optimistic? How do you determine the gray areas? It used to be that in all but the most perfect cases, we'd pretty much assume they weren't coming back, but with the current techniques, and particularly through the retrospective lens of hypothermia, we know that's no longer true... we just don't know how true it's not. And obviously termination of resuscitation is something you only want to do when everyone's very sure about futility.

If we choose to work it, we're working the code to ROSC or futility. Stopping with a terminal rhythm and low ETCO2 (<10 and trending down) after 25 minutes of EMS high quality CPR, secured airway, and lots of normal saline flushes (i.e. ACLS drugs). I highly doubt our current methodology will have meaningful numbers return after that amount of time.

46 yo with 6 minute downtime, okay bystander CPR for 10 minutes after that, 30 minute code by EMS, refractory VF for first 15 and asystole thereafter. Call it? No? How about after 40 minutes? 50? At what point are we sure there's no chance?

Certainly been there and it sucks, especially sucks when you've had ROSC intermittently too. Usually somebody says, "we're not making any progress," and we get another 3 rounds in, let a doc know, and call it after that.

I really wish we had ECMO for those calls.

Capnography might help cut through some of this but the evidence isn't too wieldy there yet either.

It's better than our gut in most cases.

 

[DrParasite]

Why? This only costs the healthcare system countless dollars for a second ALS workup by hospital staff for no purpose whatsoever. Odds are the first work-up from an ALS crew was worthless anyway.

so many doctors, with all their education, and all the nurses, with their education, and all the paramedics, with all their education, are all wrong? and they keep performing these worthless workups, costing healthare how much money, knowing they have no impact on survivability?