Pre-hospital Termination of Life Support – New Decision Aids
February 2009
Pre-hospital Termination of Life Support – New Decision Aids
Search Strategy: An Ovid search combining the key words “emergency medical services”, “cardiopulmonary resuscitation”, and “termination” on Jan 8, 2009 yields 56 responses from which four significant articles are selected.
Another busy TCC day is interrupted by an EMT phone call from a BLS pumper with Northeast Fire Protection District. They have arrived on the scene of an 88 year old female “found down” by family with unknown downtime. Per EMT, she was apneic and pulseless upon their arrival with no signs of obvious death (rigor mortis, lividity, etc.). A family member has begun CPR. The EMT and fire fighters continue CPR and attach the AED which advises no shock. They have done approximately 10 minutes of CPR thus far. Unfortunately, both of Northeast’s ambulances are unavailable. One has just arrived on the scene of a nearby MVC with entrapment. The EMT surmises that the patient is likely deceased and would like to terminate resuscitation. Do you direct them to continue resuscitation or to terminate all efforts and proceed to the MVC?
Uncertain, you advise them to continue resuscitative efforts. Only minutes later, you receive another call from the same scene. An ALS ambulance from Gateway Ambulance has arrived and notes that the patient remains apneic and pulseless with asystole on the monitor. The paramedic would now like you to terminate the resuscitation so that all parties may go back into service. Should they continue resuscitation and transport to the ED, or may they return to service?
You are now so intrigued by all aspects of EMS and prehospital care that you forego the usual after-shift beers so you can go directly to the library for an exciting literature search.
PICO Question
Population: Pre-hospital, non-traumatic arrest victims
Intervention: Application of termination of resuscitation score by BLS or ALS pre-hospital personnel
Comparison: Routine pre-hospital care
Outcome: Prognostic accuracy for neurologically intact hospital
Years
Articles
Article 1: Derivation of a Termination-of-resuscitation Guideline for Emergency Medical Technicians Using Automated External Defibrillators, Acad Emerg Med 2002; 9: 671-678
ANSWER KEY
Article 2:Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest, NEJM 2006; 355: 478-487
ANSWER KEY
Article 3: Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers, Resuscitation 2007; 74:266-275
ANSWER KEY
Article 4: Prehospital Termination of Resuscitation in Cases of Refractory Out-of-Hospital Cardiac Arrest, JAMA 2008; 30:142-1438
ANSWER KEY
BLS TOR
Transport to the ED if any of the following pre-hospital Findings are noted in suspected cardiac arrest:
- AED shock delivered;
- Return of spontaneous circulation;
- EMS-provider witnessed arrest.
Otherwise consider termination of resuscitation efforts.
ALS TOR
Transport to the ED if any of the following pre-hospital findings are noted in suspected cardiac arrest:
- Arrest witnessed by EMS personnel
- Bystander witnessed the cardiac arrest
- Bystander CPR as performed
- A shock was delivered
- There was ROSC (prior to transport)
Otherwise, consider termination of resuscitation efforts.
Bottom Line
The Succinct Answer
In 1990 Lewis & Ruoff described the dismal outcomes for St. Louis patients arriving to the ED via EMS without a pulse. Twenty years later, pre-hospital resuscitation decisions are heterogeneous, expensive, and dangerous with variable survival rates. Use of a well-validated, well-accepted BLS or ALS TOR CDR may offer distributive justice. However, ethicists remain undecided about the definition of medical futility (Kellerman 1987, Schneiderman 1990, Lantos 1989, Marco 2000). Adult cardiac arrest patients lacking any pre-hospital BLS TOR findings are extremely unlikely to survive hospital discharge (0.5%, 95 CI 0.1 – 0.9%) with AED-trained, non-ALS pre-hospital providers. Theoretically, pre-hospital use of ALS TOR would permit field pronouncement in 30% of cases saving the unnecessary hospital transport of these patients. BLS TOR also had 100% sensitivity with better specificity than ALS TOR (50% vs. 32%) and would have permitted field pronouncement rates of 48%. The more conservative ALS TOR did not misclassify any patients, but also permitted the pre-hospital pronouncement rate of far fewer patients. If validated in other populations, these findings produce an ethical dilemma for pre-hospital and EM personnel since these scene-to-ED transports are expensive, risky, and may deprive more viable patients access to EMS in many settings where only one team may be available. Future prospective trials are needed to validate this prognostic accuracy while assessing reliability and EMS community acceptance of these decision aids to decrease low-yield transports to the ED.