Paramedics are called upon to decide whether to initiate resuscitation and when to stop resuscitation, once begun.  This is the ability to recognize that a patient is “life extinct”.

 

WITHOLDING RESUSCITATION

 

Several signs are indicators that resuscitation should not be initiated.  Intrinsic factors such as mass and surface area of the body, and extrinsic factors such as environmental conditions, temperature and any insulation of the body (e.g. blankets, or clothing) will all affect the rate of post mortem changes.

 

1. Do Not Resuscitate (DNR) Order

   1. A duly completed DNR is sufficient grounds to not initiate resuscitation. The DNR must be examined carefully.  The following are common elements in a robust and valid DNR. 1

      1. Patient’s name and identifying information

      2. Patient’s diagnosis

      3. Reason(s) for issuing the DNR

      4. Date of issue

      5. Date of next review

      6. Name and signature of patient or patient proxy

      7. Name and signature of medical practitioner issuing order

      8. Documentation of discussion with patient

      9. Documentation of discussion with family

      10. Documentation of level of intended intervention in partial DNR orders  

2. Vital Signs Absent 2 3. 

   1. The following examination should be performed initially, and then repeated in ten minutes.4 5

      1. No palpable carotid pulse

      2. No heart sounds for 60 seconds (assessed in the 4th intercostal space in the left mid-clavicular line) 4 5

      3. No breath sounds for 60 seconds

      4. Fixed, dilated pupils

      5. No response to central painful stimuli

      6. Asystole in more than one ECG lead

      7. Patient is presumed to have been dead (e.g. unwitnessed arrest) for greater than 10 minutes.6

3. Rigor Mortis 7

   1. The stiffening of the body after death. Depending on intrinsic and extrinsic conditions it will usually begin 1-6 hours after death, is complete by approximately 12 hours after death, and will resolve approximately 24 hours after death. Rigor mortis often appears initially in smaller muscles such as the jaw or eyelids.  Note that patients who have been rigorously exerting themselves immediately prior to death (e.g. those who were struggling, drowning patients, athletes, etc.) may immediately rigor (known as cadaveric spasm).  This is not a sign that these patients cannot be resuscitated. 8

4. Livor Mortis 7

   1. Also called hypostasis, is the purplish/red colouration that appears on dependant regions of the body that have not been exposed to post mortem pressure. Depending on intrinsic and extrinsic conditions it will usually begin approximately an hour after death, is pronounced by 3-4 hours after death, and is fixed approximately 6-8 hours after death, although the timing of Livor Mortis is highly variable. Livor Mortis may not be appreciable in the severely anaemic, those who died of massive haemorrhage, or in the dark-skinned patient.

5. Algor Mortis 7   

   1. The cooling of the body after death.  The rate of cooling is highly variable in accord with intrinsic and extrinsic factors.

6. Decomposition

   1. Gross decomposition of the body is a contraindication to resuscitation

7. Injuries Incompatible with Life

   1. Massive traumatic injuries such as decomposition and hemicorporectomy are generally incompatible with life, especially in remote areas. 

 

It is appropriate to not initiate resuscitation if there is a risk to Paramedic safety.6

 

A recent study showed that patients >80 years old who had an unwitnessed cardiac arrest and present in a non-shockable rhythm were not resuscitatable.  This is a non-validated study, but it has face validity as a decision rule to predict futile resuscitation efforts.9 

 

 

TERMINATING RESUSCITATION

 

In patients who meet the following criteria it is appropriate to cease resuscitation efforts, regardless of their current ECG rhythm:

1. have received advanced life support care for greater than 45 minutes,

2. who have not had ROSC

3. are not hypothermic

4. have no compelling reason to continue to the resuscitation (e.g. pupillary reactions, respiratory effort of any sort, otherwise young and healthy) 6

 

ILCOR recommends “considering terminating resuscitation when ALL of the following criteria apply before moving to the ambulance for transport (see Figure 2): (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered.” 10

 

 

REPORTABLE DEATHS

 

Rules vary by jurisdiction but in the following circumstances the death should be reported to Police.  In such cases the body of the patient and the scene surrounding the body should be disturbed as little as possible.2

 

1. The patient is unknown

2. The death was violent or unnatural

3. The death happened in suspicious circumstances

4. The death was a healthcare related death

5. The death occurred while under the care of a health care professional (e.g. in clinic, or hospital)

6. The death occurred as a result of Police operations

7. The patient is a child

8. The patient was disabled and living in a high-care residential service

9. The patient was arrested under a mental health act

 

 

 

References:

 

1.        Sidhu, N. S., Dunkley, M. E., Egan, M. J. & Medical, T. “Not-for-resuscitation” orders in Australian public hospitals: policies, standardised order forms and patient information leaflets. Med. J. Aust. 186, 72–75 (2007).

2.        Queensland Ambulance Service Clinical Quality and Patient Safety Unit. Clinical Practice Guidelines: Other/Recording of life extinct (ROLE)/management of a deceased person. https://www.ambulance.qld.gov.au 0–3 (2018).

3.        South Australia Ambulance Service Clinical Performance and Safety Unit. CPG-036-ICP Declaration of Life Extinct V 2.1. (2015).

4.        St John Ambulance, N. Z. Clinical Procedures and Guidelines, 2019-2021. (2019).

5.        Wellington Free Ambulance. Clinical Procedures and Guidelines. 146–180 doi:10.1016/B978-141604485-7.50013-5

6.        Ambulance Victoria. Clinical Practice Guidelines for Ambulance and MICA Paramedics. https://www.ambulance.vic.gov.au (2018).

7.        Almulhim, A. M. & Menezes, R. G. Postmortem Changes. StatPearls [Internet] March 22, 0–5 (2019).

8.        Okada, Y. et al. Survival After Cardiac Arrest With Instantaneous Rigorlike Stiffness: A Case Report. Ann. Emerg. Med. 73, 393–396 (2019).

9.        Glober, N. K. et al. A simple decision rule predicts futile resuscitation of out-of-hospital cardiac arrest. Resuscitation 142, 8–13 (2019).

10.      Mancini, M. E. et al. Part 3: Ethical Issues. Circulation 132, S383–S396 (2015).