What are your state’s laws or practices about stopping CPR efforts by ERS personnel in the field?

Brain Death

Situation

The emergency nurse receives a call from emergency response system

(ERS) personnel, who are in route with R.G., a young man involved

in a motorcycle crash. He was not wearing a helmet and has a large

open skull fracture. Transport from the accident scene was delayed

by 45 min because of a severe thunderstorm and traffic congestion.

R.G. has fixed, dilated pupils and is in cardiac arrest. Estimated

arrival at the hospital is still another 45 min because of the severe

weather. EMS personnel request permission to stop resuscitation

efforts.

Ethical/Legal Points for Consideration

• Criteria for brain death include coma or unresponsiveness,

absence of brainstem reflexes, and apnea (see Chapter 9).

• The definition of death has changed with the advent of new

technology, monitoring devices, and interventions.

• In a situation in which the professional responsible for

determining a state of death is in remote contact with the patient,

but the monitoring devices available provide virtual contact with

the patient, a remote diagnosis of death may be legally

acceptable.

• Brain death criteria do not address patients in a permanent

vegetative state since the brainstem activity in these patients is

adequate to maintain heart and lung function.

• CPR is not appropriate when survival is not expected or the

patient is expected to survive without the ability to communicate.

Quantitative futility implies that survival is not expected after

CPR under given circumstances. In the absence of mitigating

factors, prolonged resuscitative efforts are unlikely to be

successful and can be stopped if there is no return of spontaneous

circulation at any time during 30 minutes of cumulative

advanced life support.

• It is ethical for ED personnel to stop treatment started by ERS

personnel in the prehospital setting if there is valid, after-the-fact

evidence that these interventions are now inappropriate.

Discussion Questions

• What are your feelings about cessation of brain function vs.

cessation of heart and lung function as the criteria for death of a

patient?

• What are your state’s laws or practices about stopping CPR

efforts by ERS personnel in the field?