Determination of DeathDetermination of DeathCT State EMS CT State EMS

GuidelinesGuidelines

Training TopicsTraining Topics

BackgroundBackground Exceptions to Initiating or Continuing Exceptions to Initiating or Continuing

ResuscitationResuscitation DNR OrdersDNR Orders Termination of Resuscitative EffortsTermination of Resuscitative Efforts Documentation RequirementsDocumentation Requirements Special CircumstancesSpecial Circumstances

BackgroundBackground

All “Clinically Dead” patients shall receive All “Clinically Dead” patients shall receive resuscitative measures unless meeting resuscitative measures unless meeting contraindications identified later in this program.contraindications identified later in this program.

““Clinically Dead” means an unresponsive patient Clinically Dead” means an unresponsive patient without respirations or a carotid pulse.without respirations or a carotid pulse.

BackgroundBackground

The person who has the highest level The person who has the highest level of currently valid EMS certification, of currently valid EMS certification, and who has direct voice and who has direct voice communication for medical orders, communication for medical orders, and who is affiliated with an EMS and who is affiliated with an EMS organization present at the scene will organization present at the scene will be responsible for, and have the be responsible for, and have the authority to direct, resuscitative authority to direct, resuscitative activities. activities.

ONLY Exceptions for BLS initiating and ONLY Exceptions for BLS initiating and maintaining resuscitative measuresmaintaining resuscitative measures

DecapitationDecapitation Decomposition or putrefactionDecomposition or putrefaction Transection of the torsoTransection of the torso IncinerationIncineration Dependent lividity with rigor. Dependent lividity with rigor.

EXCEPT: EXCEPT: victims of lightning strikes, victims of lightning strikes, drowning or hypothermiadrowning or hypothermia

Exceptions to Initiating or Exceptions to Initiating or Continuing Resuscitation for ALSContinuing Resuscitation for ALS

Patient has a valid DNR order.Patient has a valid DNR order.• Note that Advanced Directives and living wills Note that Advanced Directives and living wills

are not the same as a DNR order and are not are not the same as a DNR order and are not recognized by EMS in Connecticutrecognized by EMS in Connecticut

• A W-10 is not an acceptable DNR orderA W-10 is not an acceptable DNR order

Traumatic injury or body condition clearly Traumatic injury or body condition clearly indicating biological death.indicating biological death.

Exceptions to Initiating or Exceptions to Initiating or Continuing Resuscitation for ALSContinuing Resuscitation for ALS

The following cases requireThe following cases require

additional assessment:additional assessment:•Dependent Lividity and/or rigorDependent Lividity and/or rigor

mortis mortis •Injuries incompatible with lifeInjuries incompatible with life

(e.g., crush injuries,(e.g., crush injuries,

exsanguination, severe exsanguination, severe

displacement of brain matter)displacement of brain matter)

Additional Assessment in Cases of Additional Assessment in Cases of Dependent Lividity and/or Rigor MortisDependent Lividity and/or Rigor Mortis

Attempt to reposition the airway and look, Attempt to reposition the airway and look, listen and feel for at least 30 seconds; listen and feel for at least 30 seconds; respirations absentrespirations absent

Palpate the carotid pulse for at least 30 Palpate the carotid pulse for at least 30 seconds; pulse is absentseconds; pulse is absent

Check Pupils; Pupils non-reactiveCheck Pupils; Pupils non-reactive

Additional Assessment in Cases of Additional Assessment in Cases of Dependent Lividity and/or Rigor MortisDependent Lividity and/or Rigor Mortis

Cardiac Monitor asystole in 2 leads Cardiac Monitor asystole in 2 leads (Paramedics)(Paramedics)

If all of the above are confirmed, no CPR is If all of the above are confirmed, no CPR is required or if CPR has been initiated, it required or if CPR has been initiated, it may be discontinued.may be discontinued.

Dependent Lividity

Rigor Mortis

Injuries Incompatible with Life

Valid “Do Not Resuscitate” OrdersValid “Do Not Resuscitate” Orders

DNR DNR Transfer Transfer FormsForms• Needs to be Needs to be

signed by a signed by a licensed licensed physician or physician or registered registered nursenurse

Valid “Do Not Resuscitate” OrdersValid “Do Not Resuscitate” Orders

Valid “Do Not Resuscitate” OrdersValid “Do Not Resuscitate” Orders

www.medicalertbracelet.comwww.medicalertbracelet.com

Revocation of a DNR OrderRevocation of a DNR Order

The Patient or an “Authorized The Patient or an “Authorized Representative” may verbally tell a Representative” may verbally tell a certified EMT or higher they wish to certified EMT or higher they wish to alter their DNR Status.alter their DNR Status.

The statement needs to be entered The statement needs to be entered on the Patient Care Report.on the Patient Care Report.

Traumatic Injury or Body ConditionTraumatic Injury or Body Condition--Paramedic Only----Paramedic Only--

Crush InjuriesCrush Injuries

ExsanguinationsExsanguinations

Entrapped PatientsEntrapped Patients

Termination of Resuscitative EffortsTermination of Resuscitative Efforts

Patient does not meet Exceptions to Initiating or Patient does not meet Exceptions to Initiating or Continuing ResuscitationContinuing Resuscitation

Direct Medical Oversight should be established Direct Medical Oversight should be established prior to terminating efforts.prior to terminating efforts.

Consider the needs of survivors when considering Consider the needs of survivors when considering the discontinuation of a resuscitation, especially if the discontinuation of a resuscitation, especially if crisis management services may be needed.crisis management services may be needed.

Termination of Resuscitative EffortsTermination of Resuscitative EffortsNon-Traumatic ArrestNon-Traumatic Arrest

-- Paramedic Only ---- Paramedic Only --

ACLS is administered for an amount of time to be ACLS is administered for an amount of time to be determined in conjunction with online medical controldetermined in conjunction with online medical control

No return of spontaneous pulse or evidence of No return of spontaneous pulse or evidence of neurological functionneurological function

Asystole in 2 leadsAsystole in 2 leads

No evidence of overdose, hypothermia, or internal No evidence of overdose, hypothermia, or internal bleeding or preceding traumableeding or preceding trauma

All paramedics involved in care agree that discontinuation All paramedics involved in care agree that discontinuation is appropriate.is appropriate.

Traumatic Cardiac ArrestTraumatic Cardiac Arrest

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

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

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

Traumatic Cardiac ArrestTraumatic Cardiac Arrest

Patient must be at least 18 years old.Patient must be at least 18 years old.

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

Do not delay the initiation of BLS measures to Do not delay the initiation of BLS measures to contact Medical Directioncontact Medical Direction

Blunt TraumaBlunt Trauma-- Paramedic Only ---- Paramedic Only --

Resuscitation may be terminated Resuscitation may be terminated with approval of Medical Direction, with approval of Medical Direction, patients who are found pulseless, patients who are found pulseless, apneic, and without organized ECG apneic, and without organized ECG activity upon the arrival of EMS at activity upon the arrival of EMS at the scenethe scene

Penetrating TraumaPenetrating Trauma-- Paramedic Only ---- Paramedic Only --

Patients found pulseless and apneic Patients found pulseless and apneic should have further assessment for should have further assessment for neurologic function, spontaneous neurologic function, spontaneous movement, or organized ECG movement, or organized ECG findings.findings.

If all signs of life are absent On-Line If all signs of life are absent On-Line Medical Direction may order Medical Direction may order termination of efforts.termination of efforts.

Special Procedures - PhysiciansSpecial Procedures - Physicians

A private physician who has an ongoing A private physician who has an ongoing relationship with the patient, who relationship with the patient, who produces a identification showing their produces a identification showing their name and physician license number, may name and physician license number, may pronounce death even if EMS personnel pronounce death even if EMS personnel are present. are present.

If the physician assumes care and death If the physician assumes care and death is not pronounced, the physician must is not pronounced, the physician must accompany the patient to the hospital, and accompany the patient to the hospital, and medical control needs to be notified.medical control needs to be notified.

Special Procedures – RN or Special Procedures – RN or Hospice ProviderHospice Provider

An RN from a home health care or hospice An RN from a home health care or hospice agency at the scene that has had an agency at the scene that has had an ongoing relationship with the patient ongoing relationship with the patient andand is operating under the orders of the is operating under the orders of the patients physician is authorized to patients physician is authorized to pronounce death even if EMS personnel pronounce death even if EMS personnel are present.are present.

Medical control will be notified and EMS Medical control will be notified and EMS personnel will document the information.personnel will document the information.

DocumentationDocumentation

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

Disposition of RemainsDisposition of Remains

EMS can assist family and police.EMS can assist family and police.

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

If in a non-secure environment, transport If in a non-secure environment, transport the body to the hospital, if safety is a the body to the hospital, if safety is a concern.concern.

Case StudiesCase 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 StudiesCase Studies

A field arrest in the care of a BLS ambulance ismet by a Paramedic Intercept.

The paramedic believes that resuscitation should not be continued.

?

Case StudiesCase Studies

A 35 y/o patient has died at home, without the benefit of a DNR order, family members

present state the patient did notwant any resuscitation done.

?

Credits:Credits:

Eric Bennett NREMT-PEric Bennett NREMT-P Nancy Brunet RNNancy Brunet RN Raffaella Coler RN, M.Ed.Raffaella Coler RN, M.Ed. Terry Devito RN, M.Ed.Terry Devito RN, M.Ed. Doug Ferkol NREMT-PDoug Ferkol NREMT-P State of CT EMS Advisory Committees:State of CT EMS Advisory Committees:

• Education and Training Sub-CommitteeEducation and Training Sub-Committee• CEMSMACCEMSMAC• Clinical CoordinatorsClinical Coordinators