EMS, Termination Of Resuscitation And Pronouncement of Death

EMS personnel are often the first medical providers to initiate care of critical patients outside of the hospital. As the first contact with patients, they often encounter difficult medical and ethical situations, none more so than when critical patients are in the peri-arrest and cardiac arrest state. These situations include issues of whether to initiate cardiopulmonary resuscitation versus determination of death already being present or when to terminate an active yet futile resuscitation. Traditional approaches to patients who are not breathing or do not have a pulse have been to transport patients to the nearest hospital as quickly as possible with medical care performed in a moving ambulance. However, recent advances in paramedicine and outcomes related data have called these traditional approaches into question. Studies have shown that a prehospital emphasis with on-scene CPR until the return of spontaneous circulation (ROSC) results may optimize care for the patient. Staying on the scene to perform high-quality CPR (with ideal compression quality, minimum “hands-off” time, and best conditions to perform interventions) may provide better care with transport commencing if/when ROSC has occurred.Despite recent advancements in CPR care, data has shown that both prehospital and hospital-related CPR outcomes are exceedingly poor. Estimates are that less than 11% of patients suffering from out of hospital cardiac arrest (OHCA) survive to discharge from the hospital. The subset of those patients who survive with favorable neurological status is even lower, with studies showing those rates anywhere between 2 to 9% of all patients with OHCA.There are approximately 400000 outside of hospital cardiac arrests (OHCA) annually in the United States and Canada. The impact of the decision to initiate resuscitation and for how long those efforts are to continue has revealed potential benefits to not transporting patients receiving CPR or who are deemed to have an exceedingly low chance of ROSC. These benefits extend to the following groups:Patients: Research has shown the importance of high-quality CPR in achieving the return of spontaneous circulation (ROSC) and the difficulty in attaining it during transport. Staying at the scene rather than immediately transporting may provide higher quality care.EMS Personnel: The process of responding to patients who have medical emergencies and subsequently transporting those patients is not benign. The National Highway Traffic Safety Administration (NHTSA) has published data showing that approximately 59.6% of ambulance crashes occur while responding to a medical emergency. Other data has also shown that ambulances are almost twice as likely to be involved in a crash when performing lights and sirens emergency type responses versus non-emergent lights and sirens use.Community: The National Association of EMS Physicians (NAEMSP) recently highlighted the effects of resource utilization on the community and the extent to which when an ambulance is transporting a patient, it is not available to transport other patients in need; this leads to delays for those who may also be suffering an emergency.As the quality of CPR care continues to be studied and further guided by outcomes related data, the decision of whether to treat patients with complete on-scene CPR (with subsequent transport only if they achieve ROSC) versus immediate transport immediately upon first patient contact should have improved clarity. Protocols should incorporate the latest data and a working knowledge of local community resources to help identify those patients that will most benefit.

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