Decisions to terminate resuscitation
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.
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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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