Determination of Death CT State EMS Guidelines

1. Determination of DeathCT State EMS Guidelines

2. Training Topics • Background • Exceptions to Initiating or Continuing Resuscitation • DNR Orders • Termination of Resuscitative Efforts • Documentation Requirements • Special Circumstances

3. Background • All “Clinically Dead” patients shall receive resuscitative measures unless meeting contraindications identified later in this program. • “Clinically Dead” means an unresponsive patient without respirations or a carotid pulse.

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

5. ONLY Exceptions for BLS initiating and maintaining resuscitative measures • Decapitation • Decomposition or putrefaction • Transection of the torso • Incineration • Dependent lividity with rigor. EXCEPT: victims of lightning strikes, drowning or hypothermia

6. Exceptions to Initiating or Continuing Resuscitation for ALS • Patient has a valid DNR order. • Note that Advanced Directives and living wills are not the same as a DNR order and are not recognized by EMS in Connecticut • A W-10 is not an acceptable DNR order • Traumatic injury or body condition clearly indicating biological death.

7. Exceptions to Initiating or Continuing Resuscitation for ALS The following cases require additional assessment: Dependent Lividity and/or rigor mortis Injuries incompatible with life (e.g., crush injuries, exsanguination, severe displacement of brain matter)

8. Additional Assessment in Cases of Dependent Lividity and/or Rigor Mortis • Attempt to reposition the airway and look, listen and feel for at least 30 seconds; respirations absent • Palpate the carotid pulse for at least 30 seconds; pulse is absent • Check Pupils; Pupils non-reactive

9. Additional Assessment in Cases of Dependent Lividity and/or Rigor Mortis • Cardiac Monitor asystole in 2 leads (Paramedics) • If all of the above are confirmed, no CPR is required or if CPR has been initiated, it may be discontinued.

10. Dependent Lividity

11. Rigor Mortis

12. Injuries Incompatible with Life

13. Valid “Do Not Resuscitate” Orders DNR Transfer Forms Needs to be signed by a licensed physician or registered nurse

14. Valid “Do Not Resuscitate” Orders

15. Valid “Do Not Resuscitate” Orders www.medicalertbracelet.com

16. Revocation of a DNR Order • The Patient or an “Authorized Representative” may verbally tell a certified EMT or higher they wish to alter their DNR Status. • The statement needs to be entered on the Patient Care Report.

17. Traumatic Injury or Body Condition--Paramedic Only-- • Crush Injuries • Exsanguinations • Entrapped Patients

18. Termination of Resuscitative Efforts • Patient does not meet Exceptions to Initiating or Continuing Resuscitation • Direct Medical Oversight should be established prior to terminating efforts. • Consider the needs of survivors when considering the discontinuation of a resuscitation, especially if crisis management services may be needed.

19. Termination of Resuscitative EffortsNon-Traumatic Arrest-- Paramedic Only -- • ACLS is administered for an amount of time to be determined in conjunction with online medical control • No return of spontaneous pulse or evidence of neurological function • Asystole in 2 leads • No evidence of overdose, hypothermia, or internal bleeding or preceding trauma • All paramedics involved in care agree that discontinuation is appropriate.

20. Traumatic Cardiac Arrest • Victims of drowning, lightning strike or significant hypothermia shall have ALS resuscitative measures initiated. • Cardiac arrest that does not correlate with traumatic condition shall have ALS resuscitative measures initiated. • Logistical factors should be considered (public place, crew safety, family wishes etc.)

21. Traumatic Cardiac Arrest • Patient must be at least 18 years old. • Resuscitation may be terminated if clinical death found when EMS arrived on scene • Do not delay the initiation of BLS measures to contact Medical Direction

22. Blunt Trauma-- Paramedic Only -- • Resuscitation may be terminated with approval of Medical Direction, patients who are found pulseless, apneic, and without organized ECG activity upon the arrival of EMS at the scene

23. Penetrating Trauma-- Paramedic Only -- • Patients found pulseless and apneic should have further assessment for neurologic function, spontaneous movement, or organized ECG findings. • If all signs of life are absent On-Line Medical Direction may order termination of efforts.

24. Special Procedures - Physicians • A private physician who has an ongoing relationship with the patient, who produces a identification showing their name and physician license number, may pronounce death even if EMS personnel are present. • If the physician assumes care and death is not pronounced, the physician must accompany the patient to the hospital, and medical control needs to be notified.

25. Special Procedures – RN or Hospice Provider • An RN from a home health care or hospice agency at the scene that has had an ongoing relationship with the patient and is operating under the orders of the patients physician is authorized to pronounce death even if EMS personnel are present. • Medical control will be notified and EMS personnel will document the information.

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

27. Disposition of Remains • EMS can assist family and police. • If the body is in a secure place, the body may be turned over to police. • If in a non-secure environment, transport the body to the hospital, if safety is a concern.

28. Case 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. ?

29. Case Studies A field arrest in the care of a BLS ambulance is met by a Paramedic Intercept. The paramedic believes that resuscitation should not be continued. ?

30. Case Studies A 35 y/o patient has died at home, without the benefit of a DNR order, family members present state the patient did not want any resuscitation done. ?

31. Credits: • Eric Bennett NREMT-P • Nancy Brunet RN • Raffaella Coler RN, M.Ed. • Terry Devito RN, M.Ed. • Doug Ferkol NREMT-P • State of CT EMS Advisory Committees: • Education and Training Sub-Committee • CEMSMAC • Clinical Coordinators