NORTH COAST EMERGENCY MEDICAL SERVICES Policy #2305

POLICIES AND PROCEDURES Page # 1 of 3

Subject: Medical Control

Determination of Death --Limited Advanced and

Advanced Life Support Personnel

Associated Policies: 2304, 2307

I. Authority and Reference (incorporated herein by reference)

A. Division 2.5 of the Health and Safety Code.

B. California Code of Regulations, Title 22.

C. North Coast Emergency Medical Services Policies and Procedures.

II. Purpose:

To establish regional policy and procedure for limited advanced and advanced life support (LALS/ALS) personnel to determine and document death in the prehospital setting. For the purpose of this policy, "LALS/ALS personnel" is defined as a rescuer that is a currently certified or licensed EMT-II or EMT-P within the North Coast EMS Region. Additionally, this policy shall outline procedures to be followed whenever CPR is withheld or discontinued in the prehospital setting (Also, refer to Policy #2307).

III. Policy:

A. Do Not Resuscitate (DNR) requests: CPR should not be initiated on a pulseless, non-breathing patient when a valid "Do Not Resuscitate" (DNR) request,"No Code," or "No CPR" order meeting policy #2307 requirements is presented.

B. Obvious Death: CPR does not need to be initiated if a pulseless, non-breathing patient has one or more of the following conditions:

1. Decapitation.

2. Decomposition.

3. Incineration of the torso and/or head.

4. Visible exposure, destruction, and/or separation of vital internal organs (brain, spinal cord, liver, heart, or lungs).

5. Rigor or livor mortis (without contributing environmental factors - see special information).
    1. Major trauma resulting in full arrest with a known down time of greater than 20 minutes with no CPR initiated.
    2. Severe injuries obviously incompatible with life.
    3. Submersion greater than or equal to 24 hours.

C. Possible Death: CPR does not need to be initiated if on pulseless, non-breathing patients who do not meet the above conditions but do meet the following criteria (when CPR has not been initiated).
    1. Confirmed asystole upon placement of a cardiac monitor for at least two minutes.
    2. Absence of apical heart tones or breath sounds upon chest auscultation.
    3. Absence of breath sounds upon tracheal auscultation.

 

 

D. Discontinuation of CPR: Resuscitation attempts may be discontinued under the following circumstances:
    1. Upon presentation of a valid "Do Not Resuscitate" (DNR) request,"No Code," or "No CPR" order meeting policy #2307 requirements

2. When the EMT is exhausted and cannot continue resuscitative efforts.

3. When the Base Hospital Physician directs the discontinuation of resuscitative efforts based on the information available to him/her. Some suggested guidelines are:

a. Documented apnea and pulselessness > 10 minutes without CPR.

b. No response to ACLS > 30 minutes.

c. No ventricular activity after 10 minutes of ACLS.

IV. Procedure

A. LALS/ALS Personnel need not initiate CPR when death has been determined using the criteria outlined above.
  1. A cardiac monitor may be used by LALS/ALS personnel to assist in their determination of death without being committed to initiation of other ALS procedures.

C. Discontinuation of CPR:

1. Identify all mortal injuries or confirm that a valid "Do Not Resuscitate" (DNR) request,"No Code," or "No CPR" order meeting policy #2307 requirements is provided.

2. Record EKG rhythm strip and confirm asystole.

3. Contact base hospital, relay all facts/findings and request permission to "discontinue CPR".

D. When CPR is not initiated, or has been discontinued, by BLS, LALS, or ALS personnel:

1. Notify base hospital physician or MICN of findings via radio or telephone.

2. Notify County Coroner or appropriate investigative authorities if this has not already been done.

3. Complete NCEMS Prehospital Care Report (PCR) with all surrounding facts, findings, and time death was determined.

V. Special Information:

A. Division 2.5 of the California Health and Safety Code, Section 1798.6(a), states that the authority for patient care management in an emergency shall be vested in that licensed or certified health care professional, which may include any paramedic or other pre-hospital emergency personnel, at the scene of the emergency who is most medically qualified specific to the provision of rendering medical care.
  1. If directed by a law enforcement officer to transport a victim who is obviously dead, comply with the order and document the incident upon arrival at the hospital. Provisions of the California Penal Code make it unlawful to willingly fail or refuse to comply with any lawful order, signal or direction of any peace officer.

C. Hypothermia can mask the positive neurological reflexes which indicate life, so it is imperative to be certain no contributing environmental factors exist, such as cold water submersion or cold exposure, especially in children. If there exists any possibility that either of these could be a factor, resuscitation should be started immediately.
  1. Resuscitative efforts may be extended despite apparent death, at the discretion of the Base Hospital Physician, to facilitate Organ Donation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved: Date:

Approved as to Form: Date: