The Case
A frantic call comes in on the box: “CPR in progress—three minutes out!” Emergency medical services (EMS) abruptly rolls in with a 41-year-old female schoolteacher who became unresponsive at work. The school personnel provided immediate bystander CPR, and EMS arrived on scene five minutes after the patient lost pulses. EMS continued CPR but had neither established IV access nor given any medications. You immediately dichotomize her prognostic profile. You note that she is young and had a witnessed arrest, immediate CPR, and a potentially reversible cause of cardiac arrest. In the back of your mind, however, you are also assessing the negative prognostic variables: resuscitative efforts have been under way for at least 15 minutes with no IV access, no code medications were given, and she was not intubated in the field.
In the emergency department, you establish access, intubate, and attempt defibrillation for what appears to be ventricular fibrillation. Attempted resuscitation continues with multiple rounds of advance cardiovascular life support (ACLS) medications. By the fourth shock, 30 minutes after the arrest, her pupils are fixed and dilated. The patient’s family arrives and is obviously distraught, urging you to save her life. The pressure of knowing her prognosis, the urgency of her family’s pleas to continue resuscitative efforts, and a sense of professional failure now weigh on your mind as you approach the decision to terminate resuscitation. Your team turns to you expectantly, waiting for direction.
Discussion
A particularly challenging situation occurs when the family of a patient in cardiac arrest desires protracted attempts to save a loved one. Although clinicians may be tempted to honor family member requests in order to avoid confrontation or save time, interventions should only be considered when there exists at least a possibility of medical benefit for the patient.1 Respect for patient autonomy and family wishes is sometimes used to justify providing nonbeneficial resuscitative treatment. Such action, however, ignores family member bias and the limitations of surrogate decision making, and it also violates clinicians’ dual professional responsibility to protect both patients’ health interests and scarce health care resources.2,3
Despite the development of CPR more than half a century ago, the prognosis for patients with cardiopulmonary arrest (CPA) remains grim. The prehospital survival rate to neurologically intact hospital discharge for victims of out-of-hospital cardiac arrests is approximately 3 percent, and rates of survival in ED patients who arrest are in the range of 20 percent.4 For patients who arrest in the field, studies from prehospital systems in many countries have validated a basic life support (BLS) rule for termination. This rule highlights three criteria that characterize physiologic futility with a 99.8 percent predictive value: 1) EMS did not witness the arrest, 2) no shock was delivered prior to transport, and 3) there was a failure to obtain return of spontaneous circulation (ROSC) prior to transport. Similar studies evaluating ED arrest patients reveal that recurrent arrests are less likely to result in ROSC and, ultimately, survival to hospital discharge.5
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