When to stop CPR

When to cease resuscitative efforts is a constant topic in the medical education and medical ethics communities. While certain scenarios are usually cut and dry, such as mortal wounds with significant destruction to vital organs, other scenarios such as end-stage disease generate uncertainty to the providers medical judgement. So here we go, the question and background presented to me:

85 year old female patient in cardiac arrest with comorbidity (simultaneous presence of two or more chronic diseases/conditions in a patient) of HCC (Hepatocellular Carcinoma, aka liver cancer), HCV (Hepatitis C Virus, author note: assumed to be the cause of HCC), and “large amounts” [exact volume unknown] of hematemesis (vomiting blood).

It was reported that CPR [Cardiopulmonary Resuscitation] and ALS [Advanced Life Support] measures were immediately started. Progress the “code” for an unknown amount of time and the patient converts into ROSC [Return of Spontaneous Circulation, the goal of CPR] and re-arrested a reported four times. Secondary [assumed] to the hematemesis, two units of packed RBC [red blood cell] were transfused to the patient without additional units being available per the blood center. Also note that the relative (relation degree unknown) of the patient asked for efforts to stop and “let her die in peace”.

 On the fifth presentation of cardiac arrest the senor physician called for a vote to either continue or cease resuscitative efforts. The vote resulted in the cessation of resuscitative efforts and the patient terminated. 

 Several questions are asked, as followed;
What are the guidelines for stopping CPR in cardiac arrest? 
At this time (2018), the American Heart Association, DOES offer guidelines to cease [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”] resuscitative efforts for in-hospital providers but no current algorithm exists, that I know of currently. Specifically to this event, the presentation of hematemesis requiring two units of RBC without additional units available from the network [as questioned, it was assumed the patient needed additional units], the repeated arrests, the almost certainty of severe secondary hypoxic brain injury, and wishes of the family should be a strong indicator to lead a provider to cease resuscitative efforts. It should be noted that the author is assuming that cardiac arrest means PEA/Asystole over the wording of arrhythmia, a poor prognosis on its own standing. It is also assumed that PETO2 is less than 10mmHg related to poor pulmonary perfusion secondary to hypovolemia, also a cited reason is cease resuscitative efforts [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”].

 Is it right to exhaust all efforts to resuscitate without consideration of quality of life post-event? 
 If this is the only aspect of the question without any consideration to other patients in the network, without prior wishes from the patient, and assumed resources at unlimited supply then we have to say “yes”. However we do not provide in a vacuum and we do have to consider other patients as well as the resources dedicated as part of you care plan. We also direct our efforts with the finite resources available. I might suggest reading the AHA journal article “Part 2: Ethical Aspects of CPR and ECC”; 2000 which I will link at the bottom. I will say that for this scenario everything appears to be checked off on the list for ceasing supportive efforts. Also consult your bioethics office at your establishment for additional guidance.

What is the medicological response of the efforts for this patient? 
 I cannot speak to a full physician provider level but I can speak to the paramedic level and as an ACLS instructor. Immediate CPR is given followed in tandem to aggressive airway suctioning with efforts to ultimately provide an advanced airway. I am applying a heightened focus on prevention of foreign substance aspiration given the ejection of total body blood volume, route of exit, and assumed subsequent drop in pulmonary perfusion. To simplify the statement, what is the point of making blood go round-and-round if I cannot get air to go in-and-out. At the physician level I would suggest chest tubes if not already in place.

  I need to note that I would require my team to place an IV/IO to provide large volume fluid bolus or ideally blood units if available. I would continue to follow the established ACLS algorithm with two minutes of CPR cycles with 1mg of Epi 1:10,000, each other two minute cycle I would withhold Epi. Consider your H&T’s (try not to eye roll), which in this case should be going off like a billboard light in the dark. Hypoxia, Hypovolemia, Hemothorax (I added that one), and Toxins (suspect because of your lab statement comment) secondary to the liver cancer.

   If these supportive measure are not maintainable (Hypovolemia) then working the arrest to the 20 minute mark with noted levels of your PETCO2 leads to the reasonable decision to cease CPR. I hope this answers the questions you presented and I am happy to answer more.

 If I cannot answer your question(s) I know which resources to contact to deliver appropriate answers.

American Heart Association - 2015 Guidelines (2018). “Terminating Resuscitative Efforts”, 117,

American Heart Association (2000) “Part 2: Ethical Aspects of CPR and ECC”, Retrieved 2018, http://circ.ahajournals.org/content/102/suppl_1/I-12

American Thoracic Society Journal (2015). “CEASE: A Guide for Clinicians on How to Stop Resuscitation Efforts”, Retrieved 2018, https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201412-552PS

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