UTSW/BioTel Policy: Determination of Death in the Field, Termination of Resuscitative Efforts in the Field, and Do Not Resuscitate (DNR)

Purpose: To provide guidance for determining when prehospital resuscitation attempts are not indicated, when paramedics may terminate resuscitative efforts in the field, and when and how to apply Do Not Resuscitate (DNR) Orders. Paramedics should use good judgment and common sense in the application of these guidelines. Multi-Casualty Incidents (MCI) patients are EXEMPT from this policy.

General Information:

  1. In all situations where any possibility of life exists, make every effort to resuscitate the patient.
    1. Very often, the reported "down time" inaccurately predicts resuscitation potential.  The patient may have been in bradycardia or simply unconscious for a period of time, yet still perfusing blood to the brain. Additionally, time information received from bystanders is often inaccurate.
    2. Pupil size and response to light can be inaccurate indicators of death, as the eyes can be affected by oral or locally applied medications.  Pupils can fixate after only one or two minutes of global anoxia.  Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia, and yet can be resuscitated without long-term neurological deficit.
  2. EMS personnel do not PRONOUNCE death, but rather DETERMINE death based on predetermined criteria. Only a BioTel Medical Command Physician can PRONOUNCE death.

 

A) CRITERIA TO DETERMINE DEATH IN THE FIELD:

  1. EMS personnel are not required to initiate resuscitative measures if ANY of the following criteria exists:
    1. Decapitation;
    2. Decomposition;
    3. Rigor Mortis;
    4. Dependent Lividity;
    5. Incineration;
    6. Visual MASSIVE trauma to the brain or heart that is CLEARLY incompatible with life;
    7. Presence of a VALID Do Not Resuscitate order, documentation or bracelet/medallion;
    8. ALS units may discontinue resuscitation attempts for victims of blunt or penetrating traumatic cardiac arrest, if no EMS-witnessed signs of life are present AND ECG monitoring confirms asystole.
  2. With the exception of blunt traumatic arrest, an ECG strip is not required for any patient who meets any of the above criteria.
  3. For patients in blunt traumatic arrest, a cardiac rhythm strip demonstrating asystole MUST BE OBTAINED AND DOCUMENTED.
  4. EMS personnel are not obligated to continue resuscitation efforts initiated by other persons on the scene when the patient meets any of the above criteria. This includes telephone CPR initiated by the direction of Emergency Medical Dispatchers.


Once Death has been Determined:

  1. Immediately notify the appropriate law enforcement agency and remain on-scene until they arrive.
  2. Cover the body with a sheet or other suitable item.
  3. Do not remove any property from the body or from the scene for any purpose.
  4. Leave the body at the scene, in the care of the appropriate law enforcement agency.

B) TERMINATION OF RESUSCITATIVE EFFORTS IN THE FIELD:

General Information:

  1. Make every effort to resuscitate all patients who do not meet the criteria outlined in above in Section A.  However, studies show that rapid transport for in-hospital resuscitation after unsuccessful prehospital Advanced Cardiac Life Support (ACLS) efforts rarely, if ever, results in survival to hospital discharge.  Additionally, the risks associated with high-speed transport outweigh the extremely small likelihood of benefit.
  2. Field deaths not covered by this policy require assessment by a transporting paramedic and consultation with the BioTel Medical Command Physician for pronouncement of death.
  3. During the initial resuscitation effort, EMS personnel or appropriate fire/rescue personnel will inform the family of the progress of the resuscitative efforts and possible implementation of this policy. If any family member or responsible party objects to the termination of resuscitation efforts in the field, OR if paramedics determine that pronouncement in the field is either not appropriate or might be unsafe, continue the resuscitation and transport the patient to the closest appropriate receiving hospital emergency department. Notify BioTel immediately of the circumstances.

Terminating Resuscitation Efforts in the Field

  1. UTSW/BioTel paramedics may terminate all resuscitation efforts of a presumed primary (medical) cardiac arrest WITHOUT BIOTEL CONSULTATION ONLY if ALL of the following criteria are met:
    1. Patient is an adult over 70 years of age;
    2. Patient is in a nursing home or other long-term care facility;
    3. Effective ventilation with a BVM (chest rise and fall, auscultation of breath sounds in four places, absence of gastric sounds) or with a supraglottic airway or endotracheal tube is being provided.
    4. IV or IO access has been established;
    5. The patient was found in asystole, remains in asystole, and has failed to respond to Advanced Cardiac Life Support (ACLS) guidelines:
      1. For a minimum of 20 minutes, regardless of the previous CPR time and the arrest interval. Time begins with paramedic initiation of ALS care (IV, advanced airway).
      2. For a minimum of 30 minutes, if the arrest occurred in the presence of EMS personnel.
    6. The ETCO2 reading is less than 20 mmHg while performing high-quality chest compressions.

UNLESS ALL OF THESE CRITERIA HAVE BEEN MET, PARAMEDICS MUST CONSULT BIOTEL PRIOR TO FIELD PRONOUNCEMENT.

UTSW/BioTel paramedics SHALL NOT terminate resuscitation efforts if:

  1. The patient is less than 18 years of age.
  2. The patient is visibly pregnant.
  3. The cardiac arrest may be due to trauma and EMS providers note any signs of life OR the cardiac rhythm is anything but asystole.
  4. The cardiac arrest MAY BE associated with hypothermia, drug overdose, toxicological exposures, airway obstruction, or electrocution.
  5. If the cardiac arrest has occurred in a crowded public setting, excluding patients in nursing homes or extended care facilities.
  6. If the scene situation might place EMS providers in jeopardy.
  7. When the family will not accept the termination of resuscitative efforts in the field.
  8. If there is an inability to communicate with family present at scene or due to language or cultural barrier. (This does not imply that medics must contact absent family members before making the decision. It only applies if contact with the family is already established.)
  9. If the patient has persistent Ventricular Fibrillation, pulseless Ventricular Tachycardia, any narrow QRS complex, or any organized QRS complex at a rate of at least 40.
  10. If the patient demonstrates any neurological signs.
  11. If the patient has a return of spontaneous circulation (pulse) for even a brief period. Return of spontaneous circulation during resuscitation for even a brief period is a positive prognostic sign and warrants consideration of transport to a receiving hospital emergency department.


Once Death has been Determined

  1. Immediately notify the appropriate law enforcement agency and remain on scene until they arrive.
  2. Cover the body with a sheet or other suitable item.
  3. Do not remove any property from the body or the scene for any purpose.
  4. Leave all medical devices (i.e., endotracheal tube, IV, ECG pads, etc.) applied to the body in place.
  5. The body is to be left at the scene with the appropriate law enforcement agency.

 

C) DO NOT RESUSCITATE (DNR) ORDERS

The desire of the patient supersedes any Out-of-Hospital DNR Order!

Various individuals can revoke a DNR order at any time. These include the patient (including a competent minor) or a person who identifies himself or herself as the patient’s legal guardian, a qualified relative, or a person having a medical power of attorney. Revocation can be in the form of verbal communication to responding paramedics, destruction of the form, or removal of a DNR device such as a bracelet or medallion.

Qualified relatives are defined in the following priority; the patient’s

  1. Spouse;
  2. Reasonably available adult children;
  3. Parents; or
  4. Nearest living relative.

Identifying DNR Order Devices and Determining their Validity
EMS personnel shall accept any one of the following devices as proof of a valid DNR order. EMS personnel are not required to accept or interpret an out-of-hospital DNR order that does not meet the requirements of this policy. If doubt exists as to whether the DNR Order Form presented is valid, EMS personnel will initiate resuscitation until discovery of a valid DNR order or transfer of patient care to a higher level. DNR requests that do not meet the approved form outlined in this policy (including requests by a Medical Power of Attorney) require BioTel
authorization.

DNR Order Form
The official Texas Department of State Health Services Out-of-Hospital Do-Not-Resuscitate Form is an original, single page form with a Texas DNR logo in the upper, left-hand corner of the page. Duplicate copies are valid. Consider the form valid if the following conditions exist:

DNR Bracelet
There are two acceptable DNR bracelets. The first is a white, plastic, hospital-type bracelets with the word “TEXAS” (or a representation of the geographical shape of Texas and the word “STOP” imposed over the shape and the words “DO NOT RESUSCITATE”. The bracelet contains no other identifying information. The other type of DNR bracelet is made of stainless steel, looks similar to the “medic alert” bracelets, and is inscribed with the words “TEXAS DO NOT RESUSCITATE – OOH.

EMS personnel will honor either bracelet around the patient’s wrist as if it were a valid DNR Order Form. Do not honor a DNR bracelet unless the patient is wearing it around the wrist. Do not remove the bracelet from the patient, even if the patient is deceased.

DNR Necklace:
The DNR necklace is made of a stainless steel chain, 16 to 18 inches in length with a one-inch diameter disk attached. Inscribed on the disk is the same information as is found on the metal bracelet. EMS personnel will honor this necklace worn around the patient’s neck as if presented with a valid paper DNR Order form.

Do not honor a DNR necklace unless the patient is wearing it around the neck. Do not remove the necklace from the patient, even if the patient is deceased.

Out-of-State DNR Orders
EMS personnel may accept a paper Out-of-Hospital DNR form that the patient executed in another state, as long as the order appears valid and there is no reason to question the authenticity of the order. EMS personnel may not accept any bracelets, necklaces, or other similar devices as proof of Out-of-State DNR Orders.

Do Not Honor a DNR Order form if:

  1. There is alteration in the meaning of the form, e.g., some of the listed treatments are marked through as if to reject them.
  2. The patient communicates a desire to revoke the order.
  3. The order is revoked by the attending physician, legal guardian, a close relative (spouse, child, parent, or nearest living relative), or the person who has proxy or Durable Power of Attorney for Health Care.
  4. The patient is pregnant.
  5. You cannot conclusively match the name on the form to the identity of the patient.
  6. Unnatural or suspicious circumstances are present.


Compliance with Out-of-Hospital DNR Order

  1. EMS personnel must match the name on the DNR order form to the identity of the patient.
  2. EMS personnel must agree that the out-of-hospital TDH DNR order form appears to be valid.
  3. If the patient is found in or develops cardiac and/or respiratory arrest,
    1. EMS personnel will honor the DNR order by withholding placement of the AED, manual defibrillator, CPR, transcutaneous pacing, advanced airway, and artificial ventilation.
    2. If assessment or treatment begins and someone presents a valid DNR order form for the patient, EMS personnel shall stop the assessment and/or treatment immediately - even if a positive response has occurred.
  4. If the patient has a DNR order that appears valid, and the patient is not in cardiac or respiratory arrest,
    1. EMS personnel will provide care, such as opening the patient’s airway, providing oxygen, IV fluids or medications (other than resuscitation medications), or any other treatment directed toward making the patient comfortable including controlling bleeding, splinting and administering medications.
    2. The DNR Order form must accompany the patient during transport to a receiving hospital emergency department.

Documentation
Following the field declaration of death, EMS personnel should contact BioTel to document statistical information required by Texas Department of State Health Services. When the response team encounters a DNR order form, a bracelet, or a necklace, the medic should document the following items within the patient care record.

  1. An assessment of the patient’s condition.
  2. The type of DNR device (DNR paper form, bracelet, or necklace) used to confirm the DNR status.
  3. Any problems encountered during implementation of the DNR order.
  4. The name of the patient’s attending physician.
  5. The full name, address, telephone number, and relationship to the patient of any witness used to identify the patient.

Interacting with the Family/Loved Ones
The following guidelines will assist prehospital personnel in their interaction with family members or loved ones present on the scene:

  1. The moment resuscitative efforts stop for one person, EMS personnel acquire a new set of patients - the family and loved ones.
  2. Briefly describe the circumstances leading to the death. Review with them the sequence of events that transpired. Avoid euphemisms such as, “he’s passed on”, “she is no longer with us”, or “he’s left us”. Instead, use the words death, dying, or dead.
  3. Allow time for the family to process the events and the information provided. Make eye contact. Consider appropriate physical contact with family members to indicate empathy and compassion. Convey your feelings with a phrase such as, “you have my (our) sincere sympathy”, rather than “I am (we are) sorry”.
  4. Allow as much time as necessary for questions and discussion. Review the events several times to make sure there is complete understanding and to facilitate further questions.
  5. Allow the family the opportunity to see their relative. If equipment is still connected, inform the family in advance.
  6. Know in advance what happens next and who will sign the death certificate. One of the survivors will surely ask, “What do we do next?” Be prepared with a proper answer, such as “You will need to contact a funeral home”, etc.