Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest

Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2008; 300(12):1432-8. DOI: 10.1001/jama.300.12.1432
Source: PubMed


Identifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce health care resources.
To validate 2 out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group, one for use by responders providing basic life support (BLS) and the other for those providing advanced life support (ALS).
Retrospective cohort study using surveillance data prospectively submitted by emergency medical systems and hospitals in 8 US cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between October 1, 2005, and April 30, 2008. Case patients were 7235 adults with out-of-hospital cardiac arrest; of these, 5505 met inclusion criteria.
Specificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.
The overall rate of survival to hospital discharge was 7.1% (n = 392). Of 2592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2%) patients survived to hospital discharge. Of 1192 patients (21.7%) who met ALS criteria, none survived to hospital discharge. The BLS rule had a specificity of 0.987 (95% confidence interval [CI], 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.
In this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

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    • "10 Fourth, the literature on prognostication is inconsistent and difficult to interpret, despite the presumed success of the APACHE system. For example , one study retrospectively examined over 5,500 cases of out-of-hospital cardiac arrest and found that two simple rules had excellent specificity and positive predictive value for identifying patients who will not survive to hospital discharge, with the rule for basic life support providers at 99.8% specificity and the rule for advanced life support providers at 100% specificity (Sasson et al., 2008). Yet, a more recent prospective study involving over 1,100 patients with out-of-hospital cardiac arrest attempted to derive a prediction rule based on logistic regression analysis involving a number of relevant factors, such as initial cardiac electrical rhythm, time until basic life support, etc. (Pircher et al., 2009), and was not nearly as successful. "
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    ABSTRACT: In this essay I examine the formal structure of the concept of futility, enabling identification of the appropriate roles played by patient, professional, and society. I argue that the concept of futility does not justify unilateral decisions to forego life-sustaining medical treatment over patient or legitimate surrogate objection, even when futility is determined by a process or subject to ethics committee review. Furthermore, I argue for a limited positive ethical obligation on the part of health care professionals to assist patients in achieving certain restricted goals, including the preservation of life, even in circumstances in which most would agree that that life is of no benefit to the patient. Finally, I address the objection that professional integrity overrides this limited obligation and find the objection unconvincing. In short, my aim in this essay is to see the concept of futility finally buried, once and for all. © The Author 2015. Published by Oxford University Press on behalf of the Journal of Medicine and Philosophy Inc.
    Journal of Medicine and Philosophy 08/2015; 40(5). DOI:10.1093/jmp/jhv019 · 0.79 Impact Factor
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    • "This study reported the positive predictive value of patient mortality of those who agreed to the criteria to be 99.5%. Sasson et al. [3] reported that in instances of no shock prior to transport, no witnessing of the arrest by bystanders or emergency medical personnel, and no CPR administered by a bystander, the survival rate of advanced life support recipients subjected to termination of resuscitation criteria performed in the absence of ROSC was 5 out of 2592. Additionally, 1,192 patients subjected to advanced life support termination criteria were all expired. "
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    ABSTRACT: The usefulness of using the bispectral index (BIS) for monitoring during cardiopulmonary resuscitation (CPR) is not clearly understood. However, BIS has been a popular anesthetic monitoring device used during operations. The case presented is of a pregnant woman going into cardiac arrest due to an amniotic fluid embolism during a Cesarean section. CPR was performed, but neither the return of spontaneous circulation (ROSC) nor the return of consciousness was achieved, despite 50 min of effective CPR. However, CPR was continued based on BIS. ROSC was achieved, and an alert consciousness state was reached 1 day postoperation. This finding suggests that BIS be used as a basic monitoring device during CPR and that it may help in deciding to continue CPR.
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    • "One can never be certain, even in large-scale studies, that a treatment is beneficial (better than no treatment or an alternative treatment); therefore, one submits observations to the test of reasonableness. A good example of the application of our quantitative proposal is the publication of a Basic Life Support guideline based on empirical outcomes of out-of-hospital attempted CPR whose recommendation for terminating efforts followed the quantitative threshold we proposed (Sasson et al. 2008). The notion of reasonableness is accepted in another major sector of society where a person’s life may be at stake: American courts of law. "
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    ABSTRACT: It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word "to suffer") is a person who seeks the healing (meaning "to make whole") powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions-comfort care-the physician's obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life.
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