Effective: 02-18-22
Supersedes: 06-22-20
Purpose: 1) To clarify for EMS services and their EMTs when resuscitative measures may be withheld for patients in cardiac arrest and 2) to define when EMTs can cease resuscitative measures already initiated.
Policy:
EMS services and EMS personnel should be aware that the nursing staff of a health care facility, such as a skilled nursing facility, may need a physician order (including a medical control physician’s order, if allowed by nursing home policy) to halt resuscitation attempts, even in the case of patients meeting EMS “obvious death” criteria, as set out below. Nursing staff and EMS personnel should come to a cooperative decision on continuation or termination of resuscitation; this process may include obtaining physician input and orders. If the medical professionals at the bedside are unable to reach agreement on attempting or terminating efforts, the presumption should be to continue resuscitative efforts and transport the patient to an emergency department.
Exceptions to Initiation of Resuscitation
Other than in overriding circumstances such as a large mass-casualty incident or a hazardous scene, the following are the only exceptions to initiating and maintaining resuscitative measures in the field:
1. Current, valid DNR, verified per the Medical Orders for Life Sustaining Treatment (MOLST) / Comfort Care Protocol.
2. Trauma inconsistent with survival
2.1. Decapitation: severing of the vital structures of the head from the remainder of the patient’s body
2.2. Transection of the torso: body is completely cut across below the shoulders and above the hips.
2.3. Evident complete destruction of brain or heart
2.4. Incineration of the body
2.5. Cardiac arrest (i.e. pulselessness) documented at first EMS evaluation when such condition is the result of significant blunt or penetrating trauma and the arrest is obviously and unequivocally due to such trauma, EXCEPT in the specific case of arrest due to penetrating chest trauma and short transport time to definitive care (in which circumstance, resuscitate and transport)
3. Body condition clearly indicating biological death.
3.1. Complete decomposition or putrefaction: the skin surface (not only in isolated areas) is bloated or ruptured, with sloughing of soft tissue, and the odor of decaying flesh.
3.2. Dependent lividity and/or rigor: when the patient’s body is appropriately examined, there is a clear demarcation of pooled blood within the body, and/or major joints (jaw, shoulders, elbows, hips, or knees) are immovable.
3.3. Procedure for lividity and/or rigor: All of the criteria below must be established and documented in addition to lividity and/or rigor in order to withhold resuscitation:
· Respirations are absent for at least 30 seconds; and
· Carotid pulse is absent for at least 30 seconds; and
· Lung sounds auscultated by stethoscope bilaterally are absent for at least 30 seconds; and
· Both pupils, if assessable, are non-reactive to light.
Cessation of Resuscitation by EMTs
Emergency Medical Technicians must continue resuscitative measures for all patients in cardiac arrest unless contraindicated by one of the exceptions below.
1. EMTs at all levels of certification may cease resuscitative efforts at any time when any “Exception to Initiation of Resuscitation” as defined above is determined to be present.
2. Massachusetts Statewide Treatment Protocol 6.11 (Witholding and Cessation of Resuscitation by EMT-Paramedic) which allows Paramedics to cease resuscitative efforts in certain cases without findings of obvious death criteria is not approved by the AHMD.
Special Considerations and Procedures
1. If, during transport, EMTs cease resuscitation of a patient in accordance with the requirements above, they shall continue to the closest appropriate hospital for pronouncement of death. This is always a special circumstance that is in the interest of public health and safety, and in Massachusetts meets the requirements of 105 CMR 170.365.
2. During transports when resuscitative efforts have appropriately been ceased in accordance with the requirements above, EMTs must cover the person with a sheet, transport without the use of emergency vehicle audible and visual warning devices, and notify the receiving hospital in advance.
3. In all cases where EMTs have withheld or ceased resuscitative efforts in accordance with the requirements above, and left the person in the field, procedures must include notification of appropriate medical or medico-legal authorities, such as police.
4. EMS trip record documentation must reflect the criteria used to determine obvious death or allow cessation of resuscitative efforts.
Transport of Deceased Body
An ambulance shall not be used to transport a dead body except in special circumstances where it is in the best interest of public health and / or safety to do so. If requested to transport a dead body by the police or coroner’s office, a Field Supervisor should respond to the scene to complete a written report. The agency requesting transport must make contact with the receiving facility prior to initiation of transport. The supervisor shall confirm the acceptance of the body by the receiving facility. A detailed record as to the reason why the body must be transported shall be completed by the Field Supervisor and submitted to the Clinical Director. The report shall contain the name(s) of the individual(s) or officer in charge of authorizing transport and the reason(s) why other means of transportation could not be utilized. In the event that the reason was due to a public health issue caused by an infectious disease, the Field Supervisor shall make sure that the transporting crew receives any necessary medical attention that may be required as a result of their contact with the body. No movement of a body will be made until proper PPE is utilized by the EMTs and/or Paramedics attending the body. In addition, the vehicle must be field stripped and thoroughly decontaminated.
Reference: MA OEMS STP