Elsevier

Resuscitation

Volume 39, Issues 1–2, November 1998, Pages 7-13
Resuscitation

Decisions to terminate resuscitation

https://doi.org/10.1016/S0300-9572(98)00098-7Get rights and content

Abstract

To gain more insight into decision making around the termination of resuscitation (CPR), we studied factors which influenced the time before discontinuing resuscitation, and the criteria on which those decisions were based. These criteria were compared with those of the European Resuscitation Council (ERC) and the American Heart Association (AHA). For this study, we reviewed the audiotapes of resuscitation attempts in a hospital. A total of 36 attempts were studied, involving 27 men and nine women, mean (S.D.) age 64 (18) years. A total of 19 patients received resuscitation on general wards, and 17 in the emergency room after an out-of-hospital circulatory arrest. The median interval time (range) from start to termination was 33 min (8–81 min). Results from multiple linear regression showed that a delay greater than 5 min in first advanced life support measures, drawing a sample for biochemical analysis, and the patient's response shown by return of spontaneous circulation were independently associated with the time of terminating resuscitation. The team used a number of criteria which can be found in the guidelines of the ERC and the AHA, but also used additional criteria. The ERC and the AHA criteria were not sufficient to cover all termination decisions. We conclude that the point in time to terminate resuscitation is not always rationally chosen. Updating of the current guidelines for terminating resuscitation and training resuscitation teams to use these guidelines is recommended.

Introduction

In hospitals ≈40–60% of all resuscitation attempts have to be discontinued 1, 2. There are no strict rules about the timing to terminate a resuscitation attempt, but the American Heart Association (AMA) and the European Resuscitation Council (ERC) give general guidelines 3, 4. Both organizations formulate circumstances which justify the termination, such as the provision of an appropriate attempt with basic and advanced life support without restoration of the circulation [3], or evidence of cardiac death [4]. Besides indicating when resuscitation may be discontinued, the ERC underlines conditions which justify the prolongation of resuscitation efforts. These include conditions such as drug intoxication, hypothermia and treatment of potentially correctable conditions causing the arrest (e.g. tension pneumothorax). The ERC guidelines are more specific than those of the AHA, but both organizations give no general criteria about the exact moment in time when resuscitation should be terminated. Thus, the guidelines of the AHA and the ERC give a foothold for decisions to terminate cardiopulmonary resuscitation, but specific aspects are left to the physician's judgement.

Decisions about termination can be complex, and involve use of medical information, assessment of treatment options, and handling of rationales for termination. There is little formal knowledge about the practice of termination of in-hospital resuscitation attempts. To gain more insight, we studied the factors which influence the time to terminate resuscitation, and the criteria for those decisions. These criteria were compared with the guidelines of the ERC and the AHA. For this study, we reviewed the audiotapes of discontinued resuscitation attempts by a hospital resuscitation team.

Section snippets

Setting

The study was carried out in the Academic Medical Center in Amsterdam (tertiary care, university teaching hospital, 1030 beds). The hospital has a 24-h resuscitation team or teams, the members of which are a resident anesthesiologist, a resident cardiologist and an anaesthesiology-nurse. The team receives training in advanced life support according our hospital protocol, which is in agreement with the advanced life support protocols of the AHA and the ERC 5, 6. The response time of the team

Results

During the study period, 56 terminated resuscitation attempts were audio-taped. Of these tapes, 20 could not be analyzed because of poor audio quality (n=10), or because the maximum tape length (45 min) was exceeded and the team did not change the tape (n=10). There were no significant differences between the included and excluded patient data with regard to age and gender, reason for admission, time of day and location of the attempt.

A total of 36 patients were studied, and the median time

Discussion

Decisions to stop resuscitation are frequently taken and are associated with emotional and ethical problems [8]. To evaluate the process of decision making, we looked into the decisions of our team and showed that the time of termination varied considerably. As can be expected, the response of the patient proved to be an important determinant of this point in time, but there were also less obvious factors, such as the adequacy of first order advanced life support measures and taking

Acknowledgements

This study was supported by a grant from the Netherlands Heart Foundation

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