Elsevier

Resuscitation

Volume 34, Issue 1, February 1997, Pages 51-55
Resuscitation

The decision to terminate resuscitative efforts: results of a questionnaire

https://doi.org/10.1016/S0300-9572(96)01048-9Get rights and content

Abstract

Despite all the progress made in emergency medicine, out-of-hospital resuscitative efforts still remain unsuccessful in the majority of cases and a decision concerning termination of cardiopulmonary resuscitation (CPR) has to be made. We used a multi-question survey to assess the attitude of emergency physicians towards the duration of an unsuccessful resuscitation attempt in non-traumatic cardiac arrest, and to identify the criteria affecting the decision to terminate CPR in the prehospital setting. More than 400 physicians participated in the inquiry on CPR in adults. If spontaneous circulation cannot be restored, the majority (65%) abandon the resuscitation attempt at the latest after performing advanced cardiac life support for 45 min. The participants indicated the following factors as criteria for the termination of unsuccessful CPR: pre-existing diseases (92%), presumed interval between onset of arrest and application of CPR (92%), duration of the resuscitation attempt (90%), age of the patient (89%), electrocardiographic (ECG) alterations such as persistent asystole/ventricular fibrillation or electromechanical dissociation (83%), persistent fixed and dilated pupils (78%), lack of brain stem reflexes (31%), body temperature (12%) and suspected drug intoxication (8%).

The answers reflect the physicians' opinions on termination of CPR even if they do not present real decisions under emergency conditions. The results indicate that in addition to the failure to restore spontaneous circulation, other factors are involved in decision making at the scene. A high rate of respondents include criteria of weak diagnostic value such as the pupillary status, or factors of doubtful prognostic significance such as the patient's age. Concerning the patient's history and underlying diseases, the emergency physician often has to resort to presumptions. We conclude that the decision to terminate CPR is made by most physicians considering the specific circumstances of the cardiac arrest.

Introduction

If spontaneous circulation cannot be restored within an adequate time by using all appropriate interventions in the prehospital setting such as intubation, defibrillation and drug administration, the responsible physicians or qualified members of the emergency personnel have to decide on the termination of the resuscitative attempt. Such a decision requires knowledge and experience in cardiopulmonary resuscitation (CPR). In the past, several national and international organizations developed standards and guidelines for CPR, including statements concerning the discontinuation of unsuccessful resuscitation 1, 2, 3. The European Resuscitation Council (ERC) recommends the consideration of a variety of factors: the environment and the access to emergency medical services, the application time course of basic life support and advanced life support measures, evidence of cardiac death, evidence of cerebral damage, potential prognosis and underlying disease process, age, temperature, drug intake and remediable precipitating factors (Table 1) [1]. No general time limit for unsuccessful CPR is given by the ERC [1]. The American Heart Association (AHA) states that resuscitation may be discontinued in the prehospital setting when the patient is non-resuscitable after an adequate trial of advanced cardiac life support; however, no specific duration of time would predict unsuccessful resuscitation [2]. In several studies, the influence of factors such as age, pre-existing diseases and time course of CPR on the primary success and the long-term prognosis have been studied 4, 5. However, predictive statements about the likelihood of successful resuscitation are merely probability statements based on large case series [6]. Available information on the patients' history and the course of the resuscitative attempts as well as the diagnostic measures are limited in the prehospital setting. It was our objective to determine, by questioning emergency physicians, the time interval within which resuscitative efforts are usually terminated and the importance attached to the different factors with respect to the decision to abandon CPR attempts.

Section snippets

Methods

A questionnaire on the prehospital performance of CPR in adults suffering from cardiac arrest primarily due to cardiac failure was developed, including questions on the termination of resuscitative measures. This questionnaire was distributed by mail to the members of the Association of Emergency Physicians in Northern Germany (Arbeitsgemeinschaft in Norddeutschland tätiger Notärzte (AGNN)), an interest group of emergency physicians. Some questions required multiple choice or free text answers.

Results

409 emergency physicians (39.6% of the AGNN members) filled in the questionnaire completely and sent it back for evaluation. Of the participants, 55% worked in the field of anaesthesiology, 18% in internal medicine, 11% in surgery, and 16% in other disciplines, of which most were general practitioners; 7% had 1–4 years professional experience in their discipline and 93% had more than 4 years, which closely resembles a qualification as a specialist in Germany. A total of 93% also indicated an

Discussion

Physician-staffed emergency medicine as it is carried out in many European countries basically enables the emergency physician to decide on the termination of resuscitative efforts and to pronounce someone dead in the field. The results of this questionnaire do not reflect the evaluation of real decisions under emergency conditions, but basic consideration of the participants. As members of an emergency physicians' association, they are supposed to be particularly interested in and informed

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