Baby Medic just posted about doing three codes in two days. He includes this snippet:
Thirty-nine years old, the family said, and they thought she was alive this morning but they couldn’t be sure. Someone thought they heard her get up and make coffee. “The lady deserves a chance at that age,” the doctor said over the radio after refusing your request to discontinue resuscitation. “Bring her on in.”
In our region, we have certain criteria in which a paramedic can discontinue resuscitation on their own — found in asystole and no response after 20 minutes of ACLS resuscitation, including tube, IV and three rounds of meds. Anything else you have to call for permission to cease. In the future, it is my understanding, we will be complying with a forthcoming statewide guideline that will require us to call a physician to discontinue any resuscitation. Note: This does not include people with rigor mortis and dependent lividity, etc. Under the current guideline the only age restriction is 18 years of age. If your patient is under 18, you must call to cease even an asystole resuscitation.
See Discontinuation of Prehospital Resuscitation Protocol page 160 of protocols or 162 of Adobe reader.
Without having talked to Baby Medic or knowing anything about his call, if the patient was found asystole and not responding after 20 minutes of ACLS, it sounds like he was going above and beyond the guideline by calling in.
My question is this: How much should age factor into your decision to cease a resuscitation?
From personal experience, I have worked babies who were rigored — I worked them more for the parents and the other first responders and maybe even for myself than through any hope of bringing them back. I have also worked 90 years olds and been secretly upset when I have gotten pulses back in the 20th minute of resuscitation (seeing a blip on the monitor when I was looking for a final asystole to allow me to finally cease) because now I have to transport a living corpse, broken ribs and all to the hospital where once the epi wears off, the patient will surely be pronounced dead.
So where does the line lie?
Here’s a generic scenario:
Unknown down time. Asystole, but still warm with no rigor. No sign of drug intoxication, trauma, drowning or electrocution. You work them for 20 minutes and they are still asystole. The scene is a private apartment. There is no family. There is no significant medical history beyond the norms for their age(meaning a 2-year-old has no medical problems, a 80-year-old has expected chronic problems).
At what age limits (within this scenario) do you feel comfortable ceasing a resuscitation on your own?
Ethically should 2-year-olds, 20-year-olds, 36-year-olds, 55-year-olds, 78-year-olds and 99-year-olds be treated differently?
At what age do people, to paraphrase the physician in Baby Medic’s story, deserve a chance to live?
Should we have more rigid guidelines to make these determinations for us or should we just continue to use our judgement based on everything we see and feel?
And is it wrong that different medics or different physicians will produce different responses to the same cases?
To resolve the ambiguity should we go backwards to the old days of transporting everyone in cardiac arrest even though the science shows people in asystole after 20 minutes have virtually no chance of meaningful survival?
On a corollary, I have found that with the new CPR, I am having more and more initially asystolic patients develop electrical activity and or pulses deeper into the 20 minutes — once even after I have told the patient’s physician and family that I am terminating the resuscitation.
No easy job — this one of ours.