Transcript Determination of Death CT State Guidelines

Determination of Death
CT State EMS
Guidelines
Training Topics
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Background
Exceptions to Initiating or Continuing
Resuscitation
DNR Orders
Termination of Resuscitative Efforts
Documentation Requirements
Special Circumstances
Background
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All “Clinically Dead” patients shall receive
resuscitative measures unless meeting
contraindications identified later in this program.
“Clinically Dead” means an unresponsive patient
without respirations or a carotid pulse.
Background
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The person who has the highest level
of currently valid EMS certification,
and who has direct voice
communication for medical orders,
and who is affiliated with an EMS
organization present at the scene will
be responsible for, and have the
authority to direct, resuscitative
activities.
ONLY Exceptions for BLS initiating and
maintaining resuscitative measures
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Decapitation
Decomposition or putrefaction
Transection of the torso
Incineration
Dependent lividity with rigor.
EXCEPT: victims of lightning strikes,
drowning or hypothermia
Exceptions to Initiating or
Continuing Resuscitation for ALS
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Patient has a valid DNR order.
• Note that Advanced Directives and living wills
are not the same as a DNR order and are not
recognized by EMS in Connecticut
• A W-10 is not an acceptable DNR order
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Traumatic injury or body condition clearly
indicating biological death.
Exceptions to Initiating or
Continuing Resuscitation for ALS
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The following cases require
additional assessment:
•Dependent Lividity and/or rigor
mortis
•Injuries incompatible with life
(e.g., crush injuries,
exsanguination, severe
displacement of brain matter)
Additional Assessment in Cases of
Dependent Lividity and/or Rigor Mortis
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Attempt to reposition the airway and look,
listen and feel for at least 30 seconds;
respirations absent
Palpate the carotid pulse for at least 30
seconds; pulse is absent
Check Pupils; Pupils non-reactive
Additional Assessment in Cases of
Dependent Lividity and/or Rigor Mortis
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Cardiac Monitor asystole in 2 leads
(Paramedics)
If all of the above are confirmed, no CPR
is required or if CPR has been initiated, it
may be discontinued.
Dependent Lividity
Rigor Mortis
Injuries Incompatible with Life
Valid “Do Not Resuscitate” Orders
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DNR Transfer
Forms
• Needs to be
signed by a
licensed
physician or
registered
nurse
Valid “Do Not Resuscitate” Orders
Valid “Do Not Resuscitate” Orders
www.medicalertbracelet.com
Revocation of a DNR Order
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The Patient or an “Authorized
Representative” may verbally tell a
certified EMT or higher they wish to
alter their DNR Status.
The statement needs to be entered
on the Patient Care Report.
Traumatic Injury or Body Condition
--Paramedic Only-
Crush Injuries
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Exsanguinations
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Entrapped Patients
Termination of Resuscitative Efforts
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Patient does not meet Exceptions to Initiating or
Continuing Resuscitation
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Direct Medical Oversight should be established
prior to terminating efforts.
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Consider the needs of survivors when considering
the discontinuation of a resuscitation, especially if
crisis management services may be needed.
Termination of Resuscitative Efforts
Non-Traumatic Arrest
-- Paramedic Only -
ACLS is administered for an amount of time to be
determined in conjunction with online medical control
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No return of spontaneous pulse or evidence of
neurological function
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Asystole in 2 leads
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No evidence of overdose, hypothermia, or internal
bleeding or preceding trauma
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All paramedics involved in care agree that discontinuation
is appropriate.
Traumatic Cardiac Arrest
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Victims of drowning, lightning strike or significant
hypothermia shall have ALS resuscitative measures
initiated.
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Cardiac arrest that does not correlate with traumatic
condition shall have ALS resuscitative measures initiated.
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Logistical factors should be considered (public place, crew
safety, family wishes etc.)
Traumatic Cardiac Arrest
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Patient must be at least 18 years old.
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Resuscitation may be terminated if clinical death
found when EMS arrived on scene
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Do not delay the initiation of BLS measures to
contact Medical Direction
Blunt Trauma
-- Paramedic Only -
Resuscitation may be terminated
with approval of Medical Direction,
patients who are found pulseless,
apneic, and without organized ECG
activity upon the arrival of EMS at
the scene
Penetrating Trauma
-- Paramedic Only -
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Patients found pulseless and apneic
should have further assessment for
neurologic function, spontaneous
movement, or organized ECG
findings.
If all signs of life are absent On-Line
Medical Direction may order
termination of efforts.
Special Procedures - Physicians
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A private physician who has an ongoing
relationship with the patient, who
produces a identification showing their
name and physician license number, may
pronounce death even if EMS personnel
are present.
If the physician assumes care and death
is not pronounced, the physician must
accompany the patient to the hospital,
and medical control needs to be notified.
Special Procedures – RN or
Hospice Provider
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An RN from a home health care or hospice
agency at the scene that has had an
ongoing relationship with the patient and
is operating under the orders of the
patients physician is authorized to
pronounce death even if EMS personnel
are present.
Medical control will be notified and EMS
personnel will document the information.
Documentation
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A Patient Care Report needs to be
completed for each clinically dead
patient who has had resuscitation
performed, discontinued or withheld.
Disposition of Remains
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EMS can assist family and police.
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If the body is in a secure place, the body
may be turned over to police.
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If in a non-secure environment, transport
the body to the hospital, if safety is a
concern.
Case Studies
You arrive on scene of a traumatic cardiac arrest
of a victim who
appears to be 14 or 15.
They do not fit the identified
guidelines for Determination of Death.
?
Case Studies
A field arrest in the care of a BLS ambulance is
met by a Paramedic Intercept.
The paramedic believes that resuscitation should not
be continued.
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Case Studies
A 35 y/o patient has died at home, without the
benefit of a DNR order, family members
present state the patient did not
want any resuscitation done.
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Credits:
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Eric Bennett NREMT-P
Nancy Brunet RN
Raffaella Coler RN, M.Ed.
Terry Devito RN, M.Ed.
Doug Ferkol NREMT-P
State of CT EMS Advisory Committees:
• Education and Training Sub-Committee
• CEMSMAC
• Clinical Coordinators