Most patients who suffer cardiac arrest will not survice even if resuscitation attempts are valiant. This protocol addresses this issue as well as the issue of safety risks involved in transporting the 'coded' patient code 3 in traffic. It will allow you the option to cease resuscitation efforts which have already begun on an unsalvageable patient, who does not otherwise meet the criteria listed in the DO NOT ATTEMPT RESUSCITATION (DNAR) protocol. Personnel must approach this situation with extreme tact and caring. Recognize that the family of the patient you will cease efforts on will become your next patient. You must be able to communicate the rationale for your decisions accurately, tactfully and courteously.

1. Verify that the patient is question meets the following:
   1. Initial ECG was asystole in two or more leads.
   2. Patient has been treated per the CARDIAC ARREST protocol and CARDIAC LIFE SUPPORT: ASYSTOLE protocol.
   3. Patient has received CPR throughout resuscitation attempt.
   4. Patient has been successfully intubated using an endotracheal tube.
   5. Patient has had successful IV access initiated and maintained patent.
   6. Patient has received at least:
      1. 2 'rounds' of Epinephrine IVP
      2. 2 'rounds' of Atropine IVP
      3. 250 ml of Normal Saline
   7. Patient has remained in asystole without evidence of significant PEA, any Ventricular Fibrillation or Ventricular Tachycardia.

2. Verify that the patient in question DOES NOT MEET ANY of the following:
   1. Patient age is less than 50 years old.
   2. Patient is hypothermic secondary to immersion or environmental exposure.
   3. Patient has arrested secondary to an overdose of medication.
   4. Patient has arrested secondary to penetrating trauma, but does not meet criteria listed in DO NOT RESUSCITATE (DNR) protocol, for determination of dead on scene secondary to injuries incompatible with life. (e.g.- no partial decapitation secondary to self-inflicted gunshot wound.)
   5. Patient has arrested secondary to trauma received from or while in the custody of Law Enforcement agency. (e.g., Patient found arrested in jail cell or suspect suspect cardiac arrest during arrest procedure.)
   6. Patient has arrested secondary to gross hazardous materials exposure, has been properly decontaminated and is not involved in an MCI.

3. Any patient that is described by #'s 2A through 2F must have resuscitative efforts continued until arrival at the E.D.

4. If all criteria for number 1 and 2 above have been met, and the patient's family appears to be emotionally 'under control', you should (while CPR is continued);
   1. Quickly isolate all family members into an area where you can speak to them.
   2. Explain that secondary to downtime, patient age, previous history, lack of cardiac electrical activity on arrival, and the continued lack thereof throughout resuscitive efforts lead you to believe that "everything that can be done, has been done." Explain you would like to stop the resuscitation and allow the family to say "good-bye" to their loved one.
   3. Ask if there is anyone in the family that objects to this; explaining that if anyone does, you will transport the patient to the hospital now.
   4. If no family members have objected to ceasing efforts, contact Medical Control at GRMC to request permission to cease resuscitive efforts. Be sure to document the Physicians name on the patient care report (PCR).

5. Once the resusciation has been stopped, carefully clean the area of debris. Detach BVM/Ventilator and cardiac monitor. Do not extubate or remove any other invasive equipment. Close all IV's.
6. If you believe the family will wish to view the patient, you should explain the ETT and any other invasive devices that will be in view. Preparing the family in this way may prevent some of the 'shock value' this viewing will cause.
7. Request Law Enforcement in not already on scene and OMI. Dispatch should also be able to contact a chaplain if family requests (you should offer).
8. Do not leave the scene until Law Enforcement or OMI arrive and take custody of the victim.
9. Upon leaving, contact the family one last time to offer assistance and/or condolences.

NOTE:

The decision to cease efforts relies heavily on the Paramedic's ability to explain the situation to the family and control the scene. If at any time the Paramedic believes he/she will encounter a family thay may become overly distraught or even aggressive, the attempt to cease resuscitative efforts should not be made. Transport the patient to the hospital. Code 1 transport is indicated per the EMERGENCY EQUIPMENT UTILIZATION protocol. However, if family is nearby or on-board, code 3 transport is discretionary.