Definitive Care Phase of Resuscitation

Definitive care phase of the resuscitated patient may begin in the ED and continue in various inpatient settings (the operating room, intensive care unit, cardiac catheterization or interventional radiology suite, etc.). Transfer to another facility for specialized care may be necessary.

The importance of the family of the critically ill patient should not be forgotten. Many patients requiring extensive resuscitation in the ED may have been previously well. In the case of patients with chronic, controlled disease, family members may be quite shaken by the sudden decompensate in their loved one�s condition. It is the responsibility of the EP and other members of the primary resuscitation team (nursing staff, social services) to make themselves available to the family as soon as it is possible. Early communication with family and friends serves several purposes: to obtain additional relevant history, to explain the current condition and resuscitative efforts that are taking place, to clarify any advance directives or previously expressed wishes of the patient, and to express the concern and support of the resuscitative team. Although controversy exists as to whether family members should be permitted to view resuscitative efforts, there is little doubt that interacting with family members in these situations is a skill that requires training, practice and flexibility.

Other individuals that may become involved as indirect members of the resuscitation team include religious or spiritual counselors, organ procurement specialists, law enforcement, forensic specialists, sexual assault and domestic violence personnel. It is the responsibility of the EP to understand the reporting requirements for victims of violence, abuse, neglect and organ procurement in their respective practice jurisdictions.

Ethical and Legal Aspects of Resuscitation

Many ethical issues are magnified and intensified during a resuscitation phase. How aggressive should resuscitation efforts be when there is a low likelihood of survival? How should resources in the ED be distributed between critically ill patients with poor prognoses and less severely ill patients? Under what circumstances is a patient that is still communicating in a position to refuse resuscitative efforts when they are emergently needed? What process should be followed to obtain consent for organ donation?

There are, however, certain legal realities that the EP and other members of the resuscitation team need to be compliant with. Moreover, laws and guidelines that apply to medical emergencies differ from jurisdiction to jurisdiction. These include laws relating to Do Not Resuscitate (DNR) orders, advance directives, living wills, consent or refusal of treatment and mandatory reporting laws to police, coroner and various social agencies.

In general, resuscitative efforts should not be initiated when obvious signs of death are apparent, such as dependent lividity, rigor mortis or trauma inconsistent with life. Although statutes regarding DNR directives vary, the fundamental right of an individual to make decisions about their medical care, including end-of-life care, should be honored by medical personnel. This right was recognized in the United States by the Patient Self-Determination Act of 1991. Similar legislation exists in other countries.

The decision of when to cease resuscitative efforts once they have begun is often more difficult. Survival after prolonged loss of spontaneous circulation and, perhaps more importantly, survival with neurological function that would be acceptable to the patient, becomes less likely as time elapses, with the rare exception of miraculous survival such as sometimes occurs with victims of accidental hypothermia. Ultimately, a judgment must be made by the responsible physician, weighing the likelihood of benefit against the disadvantages of continuing aggressive resuscitative efforts.