DRAFT 3 5/21/2007

Determination of Death CT State EMS Guidelines

Training Topics

      Background Exceptions to Initiating or Continuing Resuscitation DNR Orders Termination of Resuscitative Efforts Documentation Requirements Special Circumstances

Background

 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.

Exceptions to Initiating or Continuing Resuscitation  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  Traumatic injury or body condition clearly indicating biological death.

Exceptions to Initiating or Continuing Resuscitation  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  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  Cardiac Monitor asystole in 2 leads (Paramedics) or AED “No Shock Advised” (EMT-Bs) 

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  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

 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  Decapitation  Decomposition or putrefaction  Transection of the torso  Incineration

Traumatic Injury or Body Condition  Crush Injuries  Exsanguinations  Entrapped Patients

Termination of Resuscitative Efforts  Patient does not meet Exceptions to Initiating or Continuing Resuscitation  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 No return of spontaneous pulse or evidence of neurological function Asystole in 2 leads No evidence of overdose, hypothermia, or internal bleeding or preceding trauma All paramedics involved in care agree that discontinuation is appropriate.

Traumatic Cardiac Arrest

 Victims of drowning, lightning strike or significant hypothermia shall have ALS resuscitative measures initiated.

 Cardiac arrest that does not correlate with traumatic condition shall have ALS resuscitative measures initiated.

 Logistical factors should be considered (public place, crew safety, family wishes etc.)

Traumatic Cardiac Arrest

 Patient must be at least 18 years old.

 Resuscitation may be terminated if clinical death found when EMS arrived on scene  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

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Penetrating Trauma -- Paramedic Only --

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

 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  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

 A Patient Care Report needs to be completed for each clinically dead patient who has had resuscitation performed, discontinued or withheld.

Disposition of Remains

 EMS can assist family and police.

 If the body is in a secure place, the body may be turned over to police.

 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 16 or 17.

They do not fit the identified guidelines for Determination of Death.

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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:

    Eric Bennett NREMT-P Raffaella Coler RN, M.Ed.

Doug Ferkol NREMT-P State of CT EMS Advisory Committees: • Education and Training Sub-Committee • CEMSMAC • Clinical Coordinators