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R02: Resuscitation Decision Making
Updated:
Reviewed:
Introduction
This guide was developed to assist paramedics and EMR’s with resuscitation decision making. Multiple sources of clinical guidelines and recommendations were sourced including the International Liaison Committee on Resuscitation (ILCOR), BC Resurrect data base, Canadian Heart and Stroke, and the Canadian Cardiovascular Society. This tool will help paramedics and EMR’s decide:
- When to initiate and when to withhold resuscitation efforts
- When to contact CliniCall
- When to consider early transport
Essentials
All Paramedics and EMRs: all license levels are required to contact CliniCall Support Services any time they discontinue a resuscitation in the field that does not meet obvious death criteria or have a valid legal direction.
PCP and EMR with no ACP (or CCP) in attendance: 25% of cardiac arrests in BC do not have an ACP in attendance. For resuscitations led by EMRs or PCPs, an early call to CliniCall is mandatory. This call should occur after CPR, rhythm analysis and defibrillation attempts have occurred. This may take several CPR and analyze cycles. Once the call has been made to CliniCall, EMRs and PCPs will be guided through treatable causes and/or the discontinuation of resuscitation pathway.
ACP and CCP: 75% of cardiac arrests in BC are attended to by ACP paramedics. ACP and CCP practitioners can independently apply both rapid and general discontinuation criteria but must consult with CliniCall for confirmation before discontinuing resuscitation efforts and implementing ROLE criteria. Evidence suggests that cardiac arrests in BC have improved survival and neurological outcomes if an ACP unit arrives within 10 minutes of 911 call (Grunau., 2019).
4 possible discontinuation points:
- Rapid discontinuation criteria are for patients who have a very low likelihood of meaningful survival, where resuscitation of a futile patient may be distressing for patient, family, and health care personnel.
- 20-minute minimum resuscitation criteria are reserved for patients who have a low likelihood of meaningful survival but don’t meet all rapid discontinuation criteria.
- 30-minute minimum resuscitation criteria are for patients with witnessed arrests, who may have had transient ROSC, but whose initial rhythm was non-shockable.
- 40-minute minimum resuscitation criteria is an extended effort for patients whose initial rhythm was shockable.
This does NOT mean Clinicall needs to be called multiple times. PCP and EMR (without ACP support) call early in the resuscitation to discuss treatable causes and an appropriate discontinuation point, they might only make one phone call. CliniCall may give a standing order to discontinue at any one of the 4 mentioned points based on history of chief complaint, bystander CPR, and initial rhythm (shockable vs non-shockable). ACP and higher can work through the criteria in this CPG independently and address treatable causes but must contact CliniCall before discontinuing resuscitation. All paramedics and EMRs are free to contact CliniCall earlier than specified in this CPG to discuss changes in patient condition, treatable causes, or early discontinuation.
Interventions
First Responder (FR) Interventions
Not applicable for first responders.
Emergency Medical Responder (EMR) & All License Levels Interventions
Rapid Discontinuation Criteria
In instances where history is unclear, start CPR and resuscitation efforts until you can gather more information. Rapid discontinuation criteria allows for the early cessation of resuscitation in circumstances where resuscitation has been started, but additional information obtained on scene indicates that continued efforts would be futile. The following four are individual considerations for rapid discontinuation.
- Prolonged no-flow duration. All of the following elements must be satisfied prior to discontinuation for prolonged no-flow duration :
- The patient was observed to be unresponsive and presumed pulseless for at least 20 minutes prior to the arrival of emergency services, and
- No CPR was provided during this 20-minute collapse period, and
- The patient is not exhibiting any signs of life ('signs of life extinct' - see below), and
- The patient’s cardiac rhythm is asystole, or pulseless electrical activity of less than 30 beats per minute, or an AED does not detect a shockable rhythm.
- Terminal illness. A patient in the final stages of a terminal illness where death is imminent and unavoidable, and where CPR would not be successful, but for whom no formal 'No CPR' decision has been made.
- Lawful direction. When resuscitation is ongoing and a lawful direction to withhold CPR becomes available (including an advanced directive, a medical order for scope of treatment, a 'No CPR' form, or the discovery of a 'No CPR' Medic Alert bracelet or necklace).
- Valid direction from a representative. Paramedics and EMRs who receive valid direction from a representative who is explicitly named in a representation agreement or an advanced care plan. (Where it is possible, attach a clear photo of the documentation to the ePCR.)
- A representation agreement is a document used for substitute decision-making and is different from the power of attorney.
If any of the above criteria are met, Paramedics and EMRs (all license levels) must consult CliniCall prior to terminating resuscitation efforts and confirmation of ROLE, except for when a lawful or valid direction from a health care representative is present and confirmed.
General discontinuation consultation
General discontinuation criteria apply to most cardiac arrests where the patient is initially considered viable and does not meet the criteria for rapid discontinuation. General discontinuation criteria involve 3 potential discontinuation points.
20-minute minimum resuscitation only when ALL 3 criteria are met.
- Unwitnessed by Paramedics, EMR or FR’s and
- non-shockable rhythm throughout and
- no ROSC at any time for any duration
30-minute minimum resuscitation when the following criteria are met.
- Initial rhythm was non-shockable
40-minute minimum resuscitation when the following criteria are met.
- Initial rhythm was Shockable
Before resuscitation can be discontinued and applying ROLE criteria, you must consult CliniCall to discuss possible treatments, discontinuation criteria and ROLE procedure. The CliniCall consultation for discontinuation may have occurred earlier in the resuscitation with standing orders.
