End of the Road

 

 
 
 

Carol A. Cunningham, MD, FACEP, FAAEM | | Tuesday, November 30, 2010


The implementation of support for termination of resuscitation in the field for EMS was an overdue blessing, especially for those patients with irreversible or terminal conditions. Prior to its acceptance, EMS providers (as well as emergency department personnel) were driven by cardiac arrest protocols and medicolegal concerns to administer CPR until the cardiac monitor consistently displayed a line that was flatter than a pancake.

Today, a wide variety of advance directives can be legally implemented and customized to pair the patient’s wishes with the underlying medical condition. Through Internet access and the growth of hospice services, the general public has become knowledgeable about its options for these measures and its rights for end-of-life decisions. Many states have legislated advance directive programs that provide selective immunity provisions to care providers in prehospital and hospital settings.

However, the ability to terminate resuscitation in the field also raises new questions and issues that should be clarified for all members of the medical community. For example, what are the responsibilities and scope of practice of the EMS provider? What are the responsibilities and expertise of the physician in the emergency department that receives a patient who is dead on arrival (DOA)? How will our actions impact the patient’s survivors? Although most states have addressed these issues through legislation, it’s common for those actively participating in the management of these cases to be unaware of their own defined authority, as well as the authority of other medical professionals involved. This article might help shed some light on these issues.

Termination of Resuscitation
The American Heart Association supports considering termination of resuscitation when a patient hasn’t responded to CPR and advanced cardiac life support (ACLS). For EMS, the protocols to terminate resuscitation are usually determined by the EMS medical director and incorporate the consideration of multiple variables. These variables may include the patient’s age, underlying medical condition(s), core temperature, length of time in cardiopulmonary arrest, advance directives, family wishes, transport time, and estimated survivability from the illness or injury.

EMS providers may encounter patients with advance directives in place who don’t desire any treatment whatsoever; however, their family members might still call 9-1-1 after witnessing clinical deterioration or the onset of agonal breathing. Due to distraught emotions on scene, EMS personnel may need to move the patient to the squad and terminate resuscitation en route to the hospital simply to escape an emotionally charged scene and spare the family from additional emotional trauma.

In cases where resuscitation is terminated, the documentation of the patient run report must be completed in detail. In addition to the criteria designated by the EMS medical director, the time of termination of resuscitative efforts and the subsequent patient assessment, including vital signs and cardiac rhythm, must be documented in the report until the patient or the patient’s body is transferred to another party. As we all know, the termination of resuscitation doesn’t necessarily lead to immediate or imminent death.

Pronouncement of Death
Termination of resuscitation isn’t the same as pronouncement of death. They’re two distinctly separate and independent events and actions.

Although a broad range of medical professionals are granted the authority to determine whether a patient is deceased, the majority of states require that the actual pronouncement of death be conveyed by a licensed physician. For example, in Ohio, EMTs, paramedics, registered nurses, physician assistants, licensed practice nurses, chiropractors and coroner’s assistants are classified as “competent observers.” Competent observers possess the skills and training to be able to communicate a descriptive patient report to potentially allow a physician to legally convey the pronouncement of death without the physician personally examining the body of the deceased.

During air or ground transport, the route of travel for patients who are in cardiopulmonary arrest or whose resuscitation is terminated may occasionally cross jurisdictional boundaries. In most states, the pronouncement of death is done by the physician at the site where the patient’s prehospital transport has ended—even if the final destination differs from the one that was originally planned or if the death occurred while the prehospital care providers were airborne.

The pronouncement of death simply provides documentation that the individual is noted to be deceased on a specific date and time. The pronouncement of death also clears the way for a body to be stored in a morgue or transported to a funeral home. A patient can’t and shouldn’t be transported and stored in either of these locations until they’re officially pronounced dead. In most states, the coroner who serves the jurisdiction where the pronouncement of death has occurred is primarily responsible for the potential investigation of the patient’s death and potential autopsy, and they are a possible signatory of the death certificate.

Death Certificate Completion
Pronouncement of death is a separate and distinct action from serving as a signatory on a death certificate. The emergency physician who pronounces a patient dead isn’t necessarily legally obligated to complete or sign the death certificate.

Completion of a death certificate isn’t just an act of applying a signature to a document. The physician completing the death certificate must also, to the best of their ability, document the primary cause of death, as well as possibly documenting a secondary cause. The physician most qualified to complete this document frequently isn’t the emergency physician, because they’re typically the least familiar with the decedent or the decedent’s medical history. Instead, the preferred signatories are the deceased patient’s primary physician—who is most familiar with the patient's medical history, or the coroner—who has the ability to more accurately determine the cause of death by performing an autopsy and examining forensic evidence.

Death certificates are legal documents that carry substantial gravity for the decedent and the survivors, and the accuracy of the data entered upon it is crucial. The documented cause of death may affect the family's access to life insurance proceeds or other death benefits. The family members’ future medical insurance premiums, which are partially based upon "family history" risk factors, may also be affected by the diagnosis listed on the death certificate. Deaths that are recorded as a result of homicide, suicide or other violent etiologies add more factors to the equation.

The death certificate is the legal document required for the family to conduct business on the decedent's behalf and is filed in the courthouse forever.

Conclusion
Every member of the medical community should have an awareness of the legislated delineation of responsibilities in the termination of resuscitation through the completion of the death certificate. Once a death has occurred, the majority of the work that needs to be done is related to completing documentation, assessing the patient’s potential and expressed desire for organ donation and disposing of the body.

The majority of our efforts, however, should be directed at the provision of closure and support to the decedent’s loved ones. There will always be plenty of time to complete or amend the required documents for a DOA. However, there’s only chance to provide and maximize the support to the grieving family. This window of opportunity and immediate need should never be wasted.




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Related Topics: Administration and Leadership, Legal and Ethical, termination of resuscitation, cpr, Carol A. Cunningham, advance directives

 
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Carol A. Cunningham, MD, FACEP, FAAEMDr. Carol Cunningham is the State Medical Director for the Ohio Department of Public Safety, Division of EMS, an associate professor at the Northeast Ohio Medical University in the Department of Emergency Medicine, and a board certified emergency physician at Akron General Medical Center. She is the current chair of the National Association of State EMS Officials Medical Directors Council and is an item writer for the American Board of Emergency Medicine EMS Examination Task Force. Dr. Cunningham was honored as the 2012 recipient of the American Academy of Emergency Medicine’s James Keaney Leadership Award.

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