By Betty T. Tran, MD, MSc, Editor
: Torke AM, et al. CEASE: A guide for clinicians on how to stop resuscitation efforts. Ann Am Thorac Soc 2015;Feb 9 [Epub ahead of print].
Although health care providers undergo hours of training and recertification to provide resuscitative efforts for patients in cardiopulmonary arrest, few are given guidance in terms of when and how to stop it. On the basis of available clinical evidence and ethical principles, Torke and colleagues aimed to provide a framework by which clinicians can organize their thinking about when to discontinue resuscitative efforts, which includes communicating effectively with families. Their proposed guide is summarized by the mnemonic CEASE (clinical features that predict survival):
-
Clinical features that predict survival: Knowledge of a patient’s clinical history is critical, as pre-arrest factors such as age, metastatic cancer, poor functional status, renal insufficiency, hypotension, and non-cardiac diagnosis are associated with poor neurologic and/or survival outcomes.
-
Effectiveness of resuscitation efforts: There is no standard decision aid to stop in-hospital resuscitation efforts, but the length of resuscitative efforts and the patient’s physiological response in real time should be assessed as part of the decision to continue or stop resuscitative efforts. For example, initial ventricular fibrillation or pulseless ventricular tachycardia is associated with better outcomes than asystole or pulseless electrical activity, and survival has been reported to be inversely proportional to resuscitation times.
-
Ask the other clinicians present for input: Good communication among team members involved in the resuscitative effort is necessary to exchange relevant knowledge in real time; a collaborative, non-hierarchical environment should be the goal.
-
Stop resuscitation efforts: It is the responsibility of the code leader to decide when to stop resuscitation efforts if the efforts are unsuccessful or the interventions needed to support circulation are unsustainable. Although this is a clinical judgment based on objective as well as subjective information, it is important to note that it is a decision made by the team leader and not within the purview of the patient’s family members.
-
Explain to the family what has happened: At the end of the resuscitative efforts, the care team is obligated to inform family members what occurred, answer questions, and provide emotional support. This should be done compassionately and involve core skills that can be taught.
COMMENTARY
The article by Torke and colleagues provides an organized approach to discontinuing resuscitative efforts in cardiopulmonary arrest situations. For clinicians who work in the critical care environment, the framework presented is intuitive, and done enough times, almost reflexive. In some situations, stopping CPR is not a difficult decision, especially if we know beforehand that it is unlikely to be beneficial (e.g., the patient with terminal illness who is unlikely to survive CPR, the patient admitted with septic shock who is already on maximum vasopressors). Ideally, resuscitative efforts would be avoided in these situations altogether, but this is dependent on various factors during goals of care discussions with patients and families. During the other times, resuscitative efforts may last longer, especially if we believe that the underlying cause can be reversed. Overall, I suspect many of us think through the clinical situation in our heads, view the resuscitative results and discuss with our colleagues in real time, and debrief with family afterwards, all of which occur without having to consciously deliberate the individual steps.
On the other hand, this schema is probably most useful for physicians-in-training and other clinicians who have fewer encounters with critically ill patients and/or cardiopulmonary arrest situations. I have often witnessed residents excitedly lead code resuscitative efforts (with or without referencing their Advanced Cardiovascular Life Support pocket cards, which do not provide an endpoint), only to continue efforts to no end much to the discomfort of nursing and other ancillary staff. This is likely motivated by lack of experience, fear of stopping too soon, and as the authors note, “tremendous momentum to continue [advanced treatment interventions].” Although the CEASE mnemonic is not a decision rule to substitute for clinical judgment, it provides an organized approach to handling resuscitative efforts until more experience is gained.
