Survey the scene

Responders evaluate the situation to ensure that CPR is the correct next step:

• The patient is not irreversibly deceased (e.g., decapitation, rigor mortis, livor mortis)
• The scene is safe
• No evidence of a DNR order

Respecting Patients’ End-of-Life Wishes

Responders must make sure that they are respecting patients’ wishes at the end of life. If there is evidence of a DNR order or an advanced directive communicating that resuscitation is not wished, this must be honored.

DNR Order

Patients have a legal right to make choices regarding end-of-life care. It is unethical for healthcare providers to go against patients’ wishes. All healthcare providers that treat cardiac arrest patients should be aware of the law as well as the policies and practices of their local communities. Before providing cardiac arrest care, responders should ask:

• Can DNR be an acceptable choice for the patient?
• Is there evidence of a DNR, such as alert tags, bracelets, or anklets?
• Is there an advanced directive indicating expressed wishes about end-of-life care?

Responders should be aware that just because a patient or family member calls emergency medical services does not mean that resuscitation efforts are always appropriate. The family may call to obtain assistance with a dying loved one. It may be appropriate to consult hospice in such situations to respect the wishes of the dying patient. This can be the case in a patient with a terminal condition who does not want possibly painful interventions or reduced quality of life in exchange for more time. 

While some responders may be cautious of legal repercussions for withholding care, the increased awareness and knowledge regarding advanced directives and DNR is helping to assuage this concern.

Terminating Resuscitation Efforts

The decision to terminate resuscitation is never set in stone, but rather depends on individual code circumstances, such as the length of the code, quality of resuscitation, atypical history of events, and local policies. 

Responders should always give the best resuscitation effort (assuming there is no contraindication). The decision to terminate is based on the collective impression of the responders as well as judgment regarding the likelihood of benefit versus harm of continued intervention. Some of the considerations responders should include are:

• Quality of resuscitation
  • Quality and length of CPR
  • Advanced airway placement and effective ventilation
  • Defibrillation availability and use
  • IV or IO access and the use of epinephrine
  • Underlying and reversible etiologies
  • Persistent asystole
• Atypical history of illness (that may require a more prolonged resuscitation effort)
  • Young patient
  • Significant hypothermia
  • Underlying toxin exposure, drug overdose, or electrolyte imbalances 
  • Cold water immersion
  • Family opposition to terminating resuscitation

Managing Arrest Inside versus Outside of the Hospital

Some differences must be kept in mind in regard to arrests occurring in the hospital versus outside the hospital. 

When an arrest occurs in the hospital, responders must consider:

• The interval from arrest to CPR
• The interval from arrest to defibrillation
• Comorbid conditions
• Pre-arrest level of functioning
• Initial cardiac rhythm at the time of the arrest
• Patient’s response to resuscitation

These factors can help guide the management of arrest, although no one can be used in isolation. While prolonged resuscitation is not necessarily associated with improved outcomes, there is evidence that a longer resuscitation effort in the hospital is associated with improved short-term outcomes, including ROSC and survival at discharge, compared to shorter resuscitative efforts. This is especially true in patients with asystole or PEA arrest.  

When an arrest occurs outside of the hospital, responders must continue resuscitation until one of these final stages is reached:

• ROSC
• Transfer to an emergency medicine expert
• Diagnosis of irreversible death
• Exhaustion of responders
• Obvious hazard to responders or others if the resuscitation is continued
• Protocol or medical expert indicating time to terminate resuscitation efforts

Length of Resuscitation 

There is some consensus regarding signals indicating the need to terminate resuscitation efforts in both IHCAs and OHCAs. Emergency responders should be aware of the policies and practices of their local hospital or system.

Inability to achieve an ETCO₂ > 10 mm Hg using waveform capnography following at least 20 minutes of resuscitation does portend a negative outcome and should be used to help decide when to terminate resuscitation. However, this should never be seen as a call to terminate resuscitation without considering other factors. If a patient is not intubated, a specific ETCO₂ reading should never be used as a guide to terminate resuscitation. 

Of course, evidence that resuscitative efforts should be prolonged, such as drug overdose or severe hypothermia, should not be overlooked. Additionally, if the patient has a brief ROSC, consideration should be given to prolonging the resuscitation. 

There are some other considerations to keep in mind:

• There are protocols to terminate resuscitation outside of the hospital. These should be adhered to by state and local legislation
• Emergency responders should be aware of protocols for managing the patient’s remains, obtaining a death certificate, and providing resources to the family regarding funeral home pickup of the deceased.
• EMS should provide access to social workers and clergy to provide counseling and assistance to the family. Large EMS services may also provide personnel available to give support and resources to family members in OHCA at the scene.
• Patients with DNR or advanced directives declining resuscitative efforts should have access to emergency care for acute illnesses or injuries while still maintaining the decision not to receive CPR or ACLS care. 
•  Primary care providers should assist patients with terminal conditions to prepare for death. They should be aware of the laws related to death pronouncement, obtaining a death certificate, and other issues such as removing the body with the aid of the coroner, and the police department’s role. 
• Primary care providers should have a discussion with patients and their family members regarding comfort care, pain management, and end-of-life care, along with the use of EMS, hospice, and other resources near the time of death. Additionally, resources regarding funerals, removal of the body, bereavement counseling, and spiritual and religious services should be offered.  
• DNR orders issued in the hospital are temporary and must be reinstated outside of the hospital. Consequently, if a patient is being transferred, new DNR documentation should be obtained to ensure the patient and family’s wishes are upheld outside of the hospital setting. 
• Patients have the right to die at home if they choose. Hospice and palliative care physicians are experienced and can assist with this. 

Managing Transport of Arrest Patients 

Not all patients must be transferred to a medical facility while in arrest. If adequate interventions and resources are available outside of a medical facility, care should be provided at the patient’s location. However, if a higher level of care that is only available at a medical facility is required, such as cardiopulmonary bypass or embolectomy, the patient should be transferred as needed. 

Arrest patients who achieve ROSC outside of the hospital should be transferred to an appropriate medical facility with comprehensive post-arrest management, including cardiac, neurologic, and critical care. The same is true of an in-hospital arrest patient who is at a facility that does not have access to robust post-arrest care.