To resuscitate or not (bus stop spin off)

[Kiwiology]

So what does everybody think re when it is appropriate not to resuscitate somebody from cardiac arrest, or to terminate resuscitation?

If you regurgitate what your protocol or standing order says I am going to smack the crap out of you

My thoughts are

1) There is a general unwillingness to accept that the overwhelming majority of patients in cardiac arrest are not resuscitated to go on and have a meaningful quality of life

2) The small number of patients who are discharged neurologically intact is very small and has consistently been so for decades despite billions of dollars of funding thrown at it for all sorts of things designed to improve survival

3) Survival from cardiac arrest should not be a primary indicator of quality of clinical care provided by your service (in UK the #1 clinical quality indicator is ROSC ... *facepalm); adequate relief of pain or something is much more important

4) A "code save" does not somehow "make" you as a Paramedic (put down that laryngascope, that doesn't either!)

3) Acting in the best interest of the patient and/or family does not mean "doing everything possible"

4) In some cases it's a case of doing the best thing is doing nothing

5) A cardiac arrest resuscitation is incredibly undignified and quite brutal; is it really acting in the best interest of the patient to subject them to that for the small chance they are going to survive?

For example

Should a patient who is in asystole when the crew turn up be resuscitated?

Should a patient who is housebound and dying from severe end stage systemic disease be resuscitated?

Should somebody in a rest home (nursing home) who has a poor quality of life be resuscitated?

Should you cease working on somebody who has been down for a half hour?

Should you be forced to work somebody because the family wants it?

It seems by comparison (again) New Zealand is extremely liberal with guidelines around this sort of thing; they state

Deciding to commence resuscitation

• Resuscitation should begin unless there is a clear reason not to ... [including]:
  
  • Signs of rigour mortis or lividity
    
  • A clearly described advanced directive or living will [to include verbal directives]
    
  • Clinical scenarios where resuscitation is either futile or clearly not in the best interests of the patient ... examples include
    
    • unwitnessed cardiac arrest with asystole as the initial rhythm,
      
    • patients who are dying from cancer,
      
    • patients with severe end stage co-morbidities [that significantly limit a patient’s ability to lead a normal life ... [including] CORD, heart failure, kidney failure requiring dialysis and metastatic cancer with associated weight loss]
      

  [*]Competent patients have the right to decline ... resuscitation in the event of cardiac arrest

  [*]Family members do not have the right to either demand or decline resuscitation ...

  [*]Ambulance personnel should take into account all of the available information, including advance directives made by the patient, and act in what they believe is the patient’s best interest...

Deciding to stop resuscitation

• Stopping resuscitation requires clinical judgement on the likelihood of survival taking into account all of the following
  
  • The cause of the cardiac arrest
    
  • Whether or not the cardiac arrest was witnessed
    
  • Whether or not there was bystander CPR
    
  • Response time
    
  • The initial rhythm
    
  • The total estimated time in cardiac arrest
    
  • The patient’s co morbidities ...
    

  [*]In general it is appropriate to stop resuscitation approximately 20 minutes after the onset of resuscitation by ambulance personnel in poor prognosis scenarios and approximately 40 minutes after the onset of resuscitation by ambulance personnel in good prognosis scenarios.

  [*]It is appropriate to stop resuscitation earlier than that described above, if it becomes clear that it was inappropriate to have commenced resuscitation

Why should we subject the patient to unnecessary invasion of their person, temporarily destroy whatever setting they are in with people, consumable wrappers, equipment and a hive of activity (usually their home where the family is present) and put the family or whoever is present through the torment and largely false hope of hoping Nana is going to come back against overwhelming odds she is not?

Now if Nana drops infront of the telly and Sonny Jim is keen to start thumping on her chest that's a bit different, but what about if Nana is dying from kidney failure and can't walk two steps because of her COPD and is not really lucid because she is heavily medicated for ongoing chronic pain and has a poor quality of life?

Thoughts?

[Richard B the EMT]

You don't want me directly quoting agency, local, or state protocols, so I'll paraphrase a bit. No CPR if obvious death, like a decapitation. Judgment call if Dependant lividity seen.

Had one where the extended care facility called about a patient having difficulty breathing, described as "breathing noisily", but they were about to call 9-1-1 back as the patient seemed now to be quiet.

He was quiet, and also displaying lividity. I followed protocols, determined for "Presumption of Death" per department, local, and state protocols, then asked my partner to confirm by doing the same. When he did, I said to him, "confirmed for DOA at...Hours", only to hear the gasp from the facility charge nurse behind me.

She had observed the noisy breathing, and wanted us to check the patient out, when he apparently was having his "death rattles". The call to 9-1-1 was made almost an hour after the observation, and my ambulance was at the intersection just across the street from the facility, so it was directly from "Dispatch" to "On Scene", no "On the way" signal transmitted.

[croaker260]

You know what they say, there is no such thing as an original thought.... This was discussed in detail at my agency before. It may be time to discuss it again...

I am qouting the KCM1 systems policy to with-holding rescusitation...

You may withhold or stop resuscitation if any of the following are present:

•Injuries incompatible with life

•Advance directive stating resuscitation be withheld

•Dependent lividity, rigor mortis

•Compelling reasons to withhold resuscitation

It is this LAST LINE that is the most interesting...

Compelling reasons to withhold resuscitation

A single sentance that may (eventually ) improve how we with-hold care and provide dignity....

The Compelling reasons part of this process :

"Compelling reasons" can be invoked when written information is not available, yet the situation suggests that the resuscitation effort will be futile, inappropriate, and inhumane. A resuscitation effort may be withheld when the following two conditions are BOTH met:

1) Extensive medical history such as terminal illness or long-standing, intractable disease

2) Request from the family that no resuscitation effort be attempted

The EMT should specifically ask the family about their resuscitation wishes or the presence of advanced directives.

If a resuscitation effort has been initiated and the EMT is provided with an advanced directive or compelling reasons that such an effort should be withheld, the resuscitation should be stopped.

Documentation is important. On the MIR, describe the patient’s medical history, presence of advanced directive if any, or verbal request to withhold resuscitation efforts.

I think you may get some interesting reading off of the "compelling Reasons" protocol that the KCM1 system has had in place since about 1998. It takes the concept of DNR/DNI past the protocol level into the common sense and humane thinking level.

http://www.annals.or.../9/634.full.pdf

If you can find the associated article in a 2006 issue of JEMS, it is a very good overview of the program itself too.

Edited May 13, 2012 by croaker260

[Bieber]

In general, I think that resuscitation attempts should be made on scene, where the patient is found or nearby if they have to be moved for access, and discontinued if the patient fails to respond to therapy on scene. There's no scene transporting the dead, we're only killing them a little more slowly.

Should a patient who is in asystole when the crew turn up be resuscitated? Without evidence of clinical death? Sure. Will we get them back? Very unlikely. Run them, call them.

Should a patient who is housebound and dying from severe end stage systemic disease be resuscitated? Do they want to be resuscitated? If so, then sure, let's try. Ethically it gets tricky when we start to think about what are we really accomplishing here, but at the end of the day I think that if the patient wants us to at least attempt to get them back, we should honor that wish as long as they're viable.

Should somebody in a rest home (nursing home) who has a poor quality of life be resuscitated? Again, same as before. If it's what they want and there's no reason to think that they are non-viable, let's give them the chance they want.

Should you cease working on somebody who has been down for a half hour? Absolutely. There's virtually zero chance for a meaningful recovery of any kind. We need to stop thinking in terms of "getting a pulse back is our job" and realize that the ONLY thing that matters is getting a patient discharged neurologically intact; anything less is a failure.

Should you be forced to work somebody because the family wants it? No. We can't bring the dead back to life, and if the family wants us to pound on a corpse's chest the only thing that does is to degraded both the patient and us.

"I'm sorry, they're dead. If there was something I could do something to change that I would, but there isn't and I can't. I'm sorry."

[island emt]

Well put young Jedi!

[craig]

In general, I think that resuscitation attempts should be made on scene, where the patient is found or nearby if they have to be moved for access, and discontinued if the patient fails to respond to therapy on scene. There's no scene transporting the dead, we're only killing them a little more slowly.

Should a patient who is in asystole when the crew turn up be resuscitated? Without evidence of clinical death? Sure. Will we get them back? Very unlikely. Run them, call them. Not always, why run with an arrest protocol if the patient is asystolic and they have been that way without any resuscitation attempt for greater than 20 minutes before paramedic arrival…..

Should a patient who is housebound and dying from severe end stage systemic disease be resuscitated? Do they want to be resuscitated? If so, then sure, let's try. Ethically it gets tricky when we start to think about what are we really accomplishing here, but at the end of the day I think that if the patient wants us to at least attempt to get them back, we should honor that wish as long as they're viable.Unless they have a DRN that is available, morally and legally we are charged with attempting resuscitation of that patient (.....studying ethics and legal requirement of paramedics at uni atm)

Should somebody in a rest home (nursing home) who has a poor quality of life be resuscitated? Again, same as before. If it's what they want and there's no reason to think that they are non-viable, let's give them the chance they want. See above

Should you cease working on somebody who has been down for a half hour? Absolutely. There's virtually zero chance for a meaningful recovery of any kind. We need to stop thinking in terms of "getting a pulse back is our job" and realize that the ONLY thing that matters is getting a patient discharged neurologically intact; anything less is a failure. No argument on this one

Should you be forced to work somebody because the family wants it? No. We can't bring the dead back to life, and if the family wants us to pound on a corpse's chest the only thing that does is to degraded both the patient and us.

"I'm sorry, they're dead. If there was something I could do something to change that I would, but there isn't and I can't. I'm sorry." Can not agree more, why put the family through it and give them any sliver of false hope that the magical paramedic powers will awaken their family member from the eternal sleep

[Arctickat]

So what does everybody think re when it is appropriate not to resuscitate somebody from cardiac arrest, or to terminate resuscitation?

If you regurgitate what your protocol or standing order says I am going to smack the crap out of you

It seems by comparison (again) New Zealand is extremely liberal with guidelines around this sort of thing; they state

Did you just quote what your protocol or standing order says?

Consider the crap smacked outta you.

Should a patient who is in asystole when the crew turn up be resuscitated?

Yes, provided that CPR has been in progress and the collapse was witnessed or near witnessed..ie, grandpa's been on the crapper for quite a while, I'd better check on him, not, she went to lay down a couple of hours ago. I have one Asystole patient alive today with a good quality of life, and several others who survived several days. I only count that one though. The only reason I mention the others is because it gives family members closure when they can travel back home and be with their loved one when the plug is pulled.

Should a patient who is housebound and dying from severe end stage systemic disease be resuscitated?

No, fortunately most of these people are realistic enough to sign a DNR.

Should somebody in a rest home (nursing home) who has a poor quality of life be resuscitated?

Nope, and policy for the level 4 long term care facility is that everyone is encouraged to sign a DNR.

Should you cease working on somebody who has been down for a half hour?

Yes, it's in my protocols..Whoops. I'll go beyond the 30 minute mark if I'm feeling optimistic, and usually I do just to make my doctor earn his paycheque.

Should you be forced to work somebody because the family wants it?

Nope, family has no input regarding my decision to work a code or not, but they are considered.

[DwayneEMTP]

...Should a patient who is in asystole when the crew turn up be resuscitated? Without evidence of clinical death? Sure. Will we get them back? Very unlikely. Run them, call them.

...Should you cease working on somebody who has been down for a half hour? Absolutely. There's virtually zero chance for a meaningful recovery of any kind. We need to stop thinking in terms of "getting a pulse back is our job" and realize that the ONLY thing that matters is getting a patient discharged neurologically intact; anything less is a failure...

Aren't those two statements contradictory?

And this is funny as hell right here...

"...Competent patients have the right to decline ... resuscitation in the event of cardiac arrest..."

[mobey]

I am curious about al the ... 's in the OP "Quote"

They seem curiously placed to add emphasis on the lines that support Kiwi's standpoint.

[croaker260]

Uhm, not that I am taking credit for this, but did anyone bother to really look at my links? If I understand the original post, it wasnt as much about predicting poor outcomes as it was about honoring wishes.

Anyway, I was very impressed with the KCM1 Compelling Reasons Approach... comments?

You know what they say, there is no such thing as an original thought.... This was discussed in detail at my agency before. It may be time to discuss it again...

I am qouting the KCM1 systems policy to with-holding rescusitation...

It is this LAST LINE that is the most interesting...

A single sentance that may (eventually ) improve how we with-hold care and provide dignity....

The Compelling reasons part of this process :

I think you may get some interesting reading off of the "compelling Reasons" protocol that the KCM1 system has had in place since about 1998. It takes the concept of DNR/DNI past the protocol level into the common sense and humane thinking level.

http://www.annals.or.../9/634.full.pdf

If you can find the associated article in a 2006 issue of JEMS, it is a very good overview of the program itself too.