R01: Commencing and Withholding Resuscitation

Clinical Medical Programs
Updated: 
Reviewed: 

Introduction

This guideline has been designed to provide information to paramedics on the holistic aspects of cardiac arrest management – specifically, when to commence and withhold resuscitation.

Beginning CPR

In cases of cardio-pulmonary arrest, start CPR in accordance with the following clinical practice guidelines:

• → N02: Adult cardiac arrest
• → M06: Pediatric cardiac arrest
• → M09: Neonatal resuscitation 
• → N04: Traumatic cardiac arrest

Withholding CPR

In some circumstances, it is appropriate to withhold CPR.  These circumstances include:

• When the patient exhibits obvious signs of death, such as
  • Putrefaction and decomposition
  • Hypostasis (lividity) or rigor mortis (whole body)
• When the patient has sustained injuries that are incompatible with life, such as
  • Decapitation
  • Cranial and cerebral destruction
  • Hemicorporectomy (transection)
  • Incineration
  • Fetal maceration
• Where performing CPR may endanger the life, health, or safety of paramedics
• Where a lawful direction to withhold CPR has been provided to paramedics.  This may include documentation such as an advanced directive, medical order for scope of treatment (MOST), a No CPR form, or the presence of a No CPR  MedicAlert bracelet or necklace.

If at any stage paramedics are unclear about the criteria for withholding CPR in a specific case, CPR should be started and consultation with CliniCall should be sought to discuss option.

References

1. Grunau B, et al. Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation. 2016. [Link]
2. Grunau B, et al. External validation of the universal termination of resuscitation rule for out-of-hospital cardiac arrest in British Columbia. 2017. [Link]
3. Grunau B, et al. Gains of continuing resuscitation in refractory out-of-hospital cardiac arrest: a model-based analysis to identify deaths due to intra-arrest prognostication. 2017. [Link]
4. Morrison LJ, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. 2006. [Link]
5. Reynolds JC, et al. Association between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest: implications for prolonging or terminating resuscitation. 2016. [Link]