August 2, 2006

Rules urged on when to halt care in cardiac arrest

By Gene Emery

BOSTON (Reuters) - About two-thirds of cardiac arrest
patients taken to hospitals by emergency medical technicians
die anyway, and probably most could be declared dead at the
scene, according to research published on Wednesday.

The report in the New England Journal of Medicine suggests
that certain emergency medical services -- not those staffed by
paramedics -- could ease the distress of loved ones and
dramatically reduce the number of hopeless but expensive
hospital trips.

The assessment of 1,240 cardiac arrest rescue runs over two
years in Ontario, Canada, found that only 1 in 500 people
survived to be discharged from the hospital if EMTs could not
restart the circulation, automatic defibrillators did not shock
the heart, and rescue workers were not present when the heart
stopped beating effectively.

The University of Toronto team led by Laurie Morrison said
new guidelines letting EMTs know when to give up "would result
in a decrease in the rate of transportation from 100 percent of
patients to 37.4 percent," a reduction she characterized as
"pretty phenomenal."

"These findings suggest that it is possible to identify a
subgroup of patients ... in whom resuscitative efforts can be
discontinued and the patient pronounced dead in the field,"
Gordon Ewy of the University of Arizona Health Sciences Center
added in an editorial.

But even if the new results are widely adopted, Ewy
cautioned, "medical judgment will still be required to
determine when enough is enough."

Requiring medical personnel to keep treating cardiac arrest
patients in futile situations "limits the availability of EMS
personnel to care for other patients, increases patients'
waiting times in emergency departments, decreases the available
beds and equipment in emergency departments and hospitals, and
diverts care from patients who are potentially more likely to
survive," the researchers wrote.

In addition, Morrison told Reuters, new guidelines across
North America would likely make it easier for loved ones to
cope. Having a sudden death pronounced at the scene seems to be
more therapeutic than having it done at a hospital.

"When family members observe a resuscitation (attempt that
is unsuccessful), they come away with the feeling that
everything was done," she said.

"But when you go to an emergency department, the family is
put into a room where you don't hear or see anything for 20 or
30 minutes. That horrible 30 minutes is pretty tough on
families," Morrison added.

The findings do not apply to victims of cardiac arrest
treated by EMTs who are trained in advanced life support
techniques, the researchers said.

Nor do they apply to paramedics, who can use various
medicines and intubation to try to restart the heart and keep
patients alive. Paramedics already have similar standards.