UNCONTROLLED WHEN PRINTED

If there is any doubt about the following criteria or it is not obvious – commence resuscitation;

  • Decomposition, larval infestation or putrefaction

OR

  • Signs of Rigor Mortis OR Gravitational Dependent Post-Mortem Hypostatis in association with Determination of Death criteria

OR

  • Major traumatic injuries incompatible with life; for example:
    • Decapitation, Significant Cranial destruction, Significant Truncal destruction
    • Hemicorporectomy / trans-lumbar amputation
    • Obvious Injuries with Exsanguination or Profound blood loss inconsistent with life
    • Document ALL relevant findings carefully

OR

  • Major Incidents / Multi Casualty situations where clinical resources are overwhelmed, and applied Triage Pack guidelines indicate death/futility of a victim with no signs of life

When recognising life extinct, a Determination of Death must be made with the following criteria:

  • No Central Pulses at all and
  • Asystole for >30 seconds[1] and
  • Fixed and Dilated pupils with NO corneal reflexes at all and
  • No signs of Breathing at all and
  • No Auscultated Heart Sounds (if in scope of practice)

Some pacemaker spiking activity may be observed for some time after death. If an AED is used, it must have ‘No Shock Advised’, especially if there is no screen on the device. Have a low threshold for seeking advice from Clinical Support Desk where necessary.

Refer to Supplementary Notes for Deceased Persons if necessary


There may be circumstances where the commencement of resuscitation may be unwanted or very unlikely to reverse the situation favourably, unless there are compelling reasons or special circumstances. Determination of Death should be followed thereafter.

If there is any doubt about the following criteria or it is not obvious– commence resuscitation;

  • Prolonged Cardiac Arrest (i.e. estimated downtime greater than 15 minutes) and
  • Generally unwitnessed and
  • First assessed rhythm is Asystole and
  • Not received a defibrillation shock and
  • No compelling reasons or special circumstances to continue

Expected Deaths / Advanced Directives;

  • There is credible evidence that death was expected as a result of terminal illness
  • The individual has taken the Voluntary Assisted Dying substance
  • It is the patient’s wishes not to be resuscitated and have previously been clearly communicated and this seems reasonable to attending St John staff. It is not necessary to sight an advanced directive[2]

Residential Care Facility[3] patients who;

Patients in the Community with ALL the following

  • Aged 80 or over with
  • Asystole as the presenting rhythm, and
  • Clearly frail (Frailty Score 7,8 or 9) - most will have life-limiting co-morbidities e.g. Chronic Renal Failure, Advanced Dementia or Cerebrovascular disease, Hemiplegia, Advanced COPD, Chronic Cardiovascular disease.

If the criteria for ROLE or Withholding resuscitation are subsequently met, then efforts for those patients may be terminated and Determination of Death can be made.

When Special Circumstances or Compelling Reasons to continue are identified, efforts should be extended (e.g. younger age, refractory VF/ recurrent arrest or timely access to ECMO.). Any decision to terminate should be made very cautiously and discussed with Clinical Support Desk and / or ASMA.

In other cases, maximally directed resuscitation must be continued. However, it is recognised there will be occasions when resuscitation efforts may be considered futile.

Sound clinical judgement and reasoning should always apply and take into consideration many factors and prognostic indicators.

Termination of Resuscitation may apply if;

  • The presenting rhythm is Asystole, not SJA witnessed, and remains in Asystole after 20 min of maximally directed resuscitation

OR

  • The presenting rhythm is shockable, not SJA witnessed, and progresses quickly and remains in, Asystole OR wide, slow PEA (<40/min) after 20 – 30 mins with NO other favourable signs of response to efforts (e.g. high EtCO2)

OR

  • The destination ED is > 15 minutes away from the arrest location, 20 minutes or more of maximal BLS/ALS has been applied, ROSC has not been achieved at any stage and there are no special circumstances or other compelling reasons to continue.

OR

  • A specifically authorised SJA clinician makes a reasonable decision based upon prognostic futility either on scene or via the Clinical Support Desk or ASMA.

OR

  • Prolonged CPR in Blunt Traumatic Cardiac Arrest after reversible causes have been addressed is almost never associated with a good outcome. If delivery to an ED cannot be achieved within 25 minutes from arrival on scene, it is reasonable to terminate resuscitation if NO ROSC is achieved after 10 minutes, and Determination of Death criteria are met.

If in doubt, contact the Clinical Support Desk. Volunteer Crews should have a low threshold to do so.

Refer to Supplementary Notes for Deceased Persons if necessary


The decision to terminate resuscitation efforts requires sound judgement. Determining the likely cause of the cardiac arrest and good background history is important. There is no specific or absolute time for a decision to be made as each case will be different.

C Cause / Special circumstances / compelling reasons– e,g, Sudden collapse of presumed cardiac origin, overdose, asphyxia, drowning, pregnancy etc. – would all favour prolonged resuscitation / transport to ED
R Resuscitative Effectiveness – e.g. Good CPR quality measured via feedback device, CPR induced femoral pulses, EtCO2 fluctuations, Refractory or Recurrent VF – would all favour prolonged resuscitation
A Ask and include the team
F Futile features – e.g. Time in arrest, unresponsive to resuscitation, poor EtCO2, slow PEA or agonal activity, co-morbidities, neurological functional status, frailty / physiological reserve to recover and ICU admission likelihood – would favour termination
T Transport, Time and Handling risks – e.g. Is it feasible and safe to move and transport the patient? Consider bariatric features, location and time to ED, public place, etc.
E Explain and engage with family or other necessary parties – Families should not necessarily be asked whether efforts should cease as they are often unprepared. Be empathetic, tactful and honest. Provide support to them in their time of loss
D Document rationale for decisions clearly and fully

Prognostic Indicators

Prognostic Continuum

Less FavourableMore Favourable
Prolonged down timeShorter down time
UnwitnessedWitnessed
Non-Shockable presentation Shockable presentation
No bystander CPR Bystander CPR
No AED Shock AED Shock
EtCO2 values falling Normal / High EtCO2
Wide Complex PEANarrow Complex PEA
Advanced FrailtyLow Frailty
Older (> 80 y/o) less likely to admit ICUYounger more likely to admit ICU
Significant Co-Morbidities Less significant Co-Morbidities

A Medical Practitioner may certify Life Extinct. They may also issue a Cause of Death Certificate where they believe the death had a known cause and the deceased is known to them.

Ambulance Officers may certify Life Extinct under the provisions of the Coroner. A Life Extinct Form, electronic or paper, is required for any deceased patient that SJA attends.

In Voluntary Assisted Dying cases:

  • Any handwritten / hard copy life extinct form must not be notated to reflect VAD; this is a legal requirement. Reference to expected death or advanced directive will be sufficient if at all.
  • ePCR life extinct forms should ordinarily have the option relating to advanced directive selected.

Reportable Deaths: Deaths in these categories require notification to the coroner.

  • Appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury.
  • Person who immediately before death was a person held in care. (*)
  • Appears to have been caused or contributed to by any action of a member of the Police Force.
  • A person whose identity is unknown.

(*) The term “person held in care” means a person held:

  • Under the Child Welfare Act.
  • In custody under the Prisons Act.
  • In any centre under the Alcohol and Drug Authority Act 1974.
  • As an involuntary patient or apprehended or detained within the meaning of the Mental Health Act 2014.
  • As a detainee under the Young Offenders Act 1994.

An important point to understand is that once the decision has been made to report the death to the Coroner, all evidence of medical intervention in the deceased must remained untouched. This means that all tubes, intravenous lines and other aspects of medical intervention must be left in situ as these could be examined in detail. In the case of children, the endotracheal tube may be cut off at the lips if there is to be a viewing of the body.

Obvious Deaths:

This is the only category in which Police Officers may/will issue a Life Extinct form.

Suspicious Deaths:

Suspicious deaths may include criminal acts, suicides, stabbings, shootings, overdoses or where the information gathered does not make sense. Where Officers suspect a suspicious death Police need to be called immediately and the scene secured. Documentation is important and any details you gather should be included. This is evidence and may be required by a court. Patient care to others should not be delayed. If CPR is stopped please leave the scene as is. Should this happen Officers need to be aware that they will contribute to evidence at the scene and may inadvertently contaminate the scene. In cases of a hanging; the knot used to form a noose should be left tied and the rope cut away from the knot where possible. Do not cut down the deceased if there is an obvious death and CPR is not considered.

Non Suspicious Deaths:

Non suspicious circumstances may include deaths at home of natural causes. If there are no suspicious circumstances, the Medical Practitioner may be phoned and once given the circumstances surrounding the death asked if a Cause of Death Certificate will be forthcoming. If so there is no need to contact Police. The relatives may then be advised to contact a funeral service of their choice and make all further arrangements. The name of the Medical Practitioner and time contacted must be documented. Should the deceased’s Medical Practitioner be unavailable or a Death Certificate is not forthcoming, then the Police must be called and advised of the situation. Officers may be required to take the deceased to the mortuary on request of police.

Wellbeing and Support Services:

Officers who attend these deaths might find themselves reacting to these potentially traumatic events and may need to contact Wellbeing and Support. This service is available to all frontline staff, 24 hours per day.

Many people, especially relatives, may also require some support. They should be signposted, based on the situation, to the St John WA bystander card (available at depots) and/or to their GP for additional support.

Complete list of Support & Resources available here.

  • Community Services are available on the bystander card
  • If it’s an MVA; Road Trauma Support WA is available
  • if it’s a suicide; Lifeline, Suicide Call-back Line and Beyondblue (depression) are good resources
  • Mental Health Emergency Response Line (1300 555 788) is useful in several situations

Wellbeing and Support:

All hours contact: 08 9373 3827
wellbeingandsupport@stjohnwa.com.au



References
References

Key Terms & Links

Dalhousie Clinical Frailty ScaleClinical Frailty Scale

[1] There will be occasions where some activity of a dying heart can be observed. These are most commonly defined as very wide, disorganised and extremely slow complexes. Wait for this to deteriorate to Asystole. This may take several minutes and Determination of Death can be made thereafter.

[2] These do not have to be in writing, and can be communicated to St John staff verbally as long as it is from a trusted / credible source. Refer to the Guardianship and Administration Act 1990.

[3] This is an end of life event. These patients may be in a shockable rhythm but all have extremely poor outcomes regardless of presenting rhythm.

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Clinical Services

Responsible Manager
Head of Clinical Services

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