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;

• Are aged 80 years or over and
• Obviously frail (Frailty Score 7, 8 or 9).

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.

PEA associated with a rhythm that is compatible with cardiac output may indicate a “low-flow” or "pseudo-PEA" state where cardiac output is present but insufficient to produce a palpable central pulse. In this setting, have a very low threshold for consulting with the Clinical Support desk and/or ASMA for further management advice.

Any Termination of Resuscitation in patients with a PEA presenting with a narrow complex and/or a rate of 40 beats per minute or higher must have a consultation with a Clinical Support Paramedic and/or ASMA prior to termination of efforts.

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.

Prognostic Indicators