CRITERIA FOR DEAD-ON-ARRIVALS, PREHOSPITAL TERMINATION OF CPR, AND DO-NOT-RESUSCITATE ORDERS

Uniform, nationwide criteria are needed to guide decisions to terminate or withhold prehospital ACLS. Wide variability exists and undoubtedly contributes to the haphazard nature of cardiac arrest survival statistics. Although interagency comparisons can be standardized to some degree by restricting comparisons to identifiable subsets of patients, guidelines for the initiation and termination of ACLS in the field are needed to allocate EMS resources in an optimal manner. Based on my review of the literature, three recommendations are offered for careful consideration. First, in the absence of criteria of proven sensitivity and specificity for the determination of recent death, the threshold for attempting resuscitation in the field should be extremely low. The abilities of bystanders to accurately estimate ''downtimes' and of paramedics to determine death in the field are unclear and potentially poor. Second, in general, failure of a patient to respond to determined provision of prehospital ACLS in the field is highly predictive of death and warrants termination of efforts. However, any decision to cease efforts in the field should require the approval of on-line medical control. Rapid transport of patients for further attempts at resuscitation in a hospital ED should be strongly discouraged unless the patient has been managed by a ''basic life support only'' EMS, is profoundly hypothermic, or sustains a second cardiac arrest after an initial return of spontaneous circulation. Given the evidence accumulated to date, the burden of proof should shift to those who believe that rapid transport to the hospital is justified in cases of refractory out-of-hospital cardiac arrest. Until that proof is generated, transport for techniques of an investigational nature (eg, cardiopulmonary bypass in the ED) should be permitted only if approved by an institutional review board. Third, model legislation is needed to authorize EMS providers to withhold prehospital resuscitative efforts from terminally ill patients who wish to forego this life-sustaining treatment. This initiative should involve the input of several professional organizations, including the American Heart Association, National Association of EMS Physicians, Society for Academic Emergency Medicine, and the American College of Emergency Physicians. With the involvement and support of these organizations, more states may be encouraged to adopt consistent and workable laws. However, implementation of any nationwide prehospital DNR policy will be extremely difficult.