Priority 4 – Termination of Resuscitation

Where JRCALC Clinical Guidelines allow for termination of resuscitation (TOR). This applies only to Paramedics. All others should continue BLS and request senior support.

Decisions on termination of resuscitation, where the patient is presenting with PEA (Pulseless Electrical Activity), must be made by an Advanced Paramedic, Consultant Paramedic or Doctor (whether on scene, or remotely). Where this is not possible, the patient must be transported, with ongoing resuscitation, to hospital.

Endotracheal tubes or Supraglottic airways must be left in situ. Fluid should be disconnected, and IV cannula or IO device must be capped and left in situ. The only exception to this is where a GP has confirmed that they are able to issue a Medical Certificate of Cause of Death (MCCD) and in line with local policy.

If there is a realistic chance that CPR could be successful, then resuscitation should continue to establish the patient’s response to ALS interventions (ALS is defined in Advanced Life Support).

The guideline has extended the period of ALS from 20 minutes (in the previous guidelines) to 30 minutes because there is evidence of additional survivors with good neurological outcomes in this group. We are aware that there are numerous possibilities in terms of changes in the rhythms seen during a cardiac arrest and that clinical professional judgement remains the main factor in decision-making related to all aspects of cardiac arrest management, including the appropriate period of attempted resuscitation. The key message is that if resuscitation is attempted, a minimum period of 30 minutes is likely to optimise chances of neurologically intact survival, irrespective of the initial rhythms.

This means that there should be a minimum of 30 minutes of advanced life support (in non-special circumstances) before clinicians should consider terminating the resuscitation effort. During the 30 minutes, the patient does not have to be in single rhythm and clinical judgement should be applied when multiple rhythms are seen during the resuscitation.

If clinicians require advice on the termination of resuscitation, they should request it from the clinical hub and state it is time critical.

Special Circumstances:

• Pregnancy
• Hypothermic patients (where hypothermia is the primary cause of the cardiac arrest)
• Suspected drugs overdose/poisoning
• Infants, children and adolescents (i.e. all those

These patients should be transported to the nearest facility with ongoing resuscitation, unless the circumstances would make transport futile (seek senior clinical support).