The decision to terminate resuscitative efforts: results of a questionnaire

Despite all the progress made in emergency medicine, out-of-hospital resuscitative efforts still remain unsuccessful in the majority of cases and a decision concerning termination of cardiopulmonary resuscitation (CPR) has to be made. We used a multi-question survey to assess the attitude of emergency physicians towards the duration of an unsuccessful resuscitation attempt in non-traumatic cardiac arrest, and to identify the criteria affecting the decision to terminate CPR in the prehospital setting. More than 400 physicians participated in the inquiry on CPR in adults. If spontaneous circulation cannot be restored, the majority (65%) abandon the resuscitation attempt at the latest after performing advanced cardiac life support for 45 min. The participants indicated the following factors as criteria for the termination of unsuccessful CPR: pre-existing diseases (92%), presumed interval between onset of arrest and application of CPR (92%), duration of the resuscitation attempt (90%), age of the patient (89%), electrocardiographic (ECG) alterations such as persistent asystole/ventricular fibrillation or electromechanical dissociation (83%), persistent fixed and dilated pupils (78%), lack of brain stem reflexes (31%), body temperature (12%) and suspected drug intoxication (8%). The answers reflect the physicians opinions on termination of CPR even if they do not present real decisions under emergency conditions. The results indicate that in addition to the failure to restore spontaneous circulation, other factors are involved in decision making at the scene. A high rate of respondents include criteria of weak diagnostic value such as the pupillary status, or factors of doubtful prognostic significance such as the patient's age. Concerning the patient's history and underlying diseases, the emergency physician often has to resort to presumptions. We conclude that the decision to terminate CPR is made by most physicians considering the specific circumstances of the cardiac arrest.