Discontinuing resuscitation efforts
Deciding when to stop cardiopulmonary resuscitation (CPR) in the emergency department is one of the most difficult clinical and ethical judgments.
The decision must combine the arrest circumstances, response to high‑quality resuscitation, premorbid status and any advance wishes, active search for reversible causes, and available escalation options. No single test, observation or fixed time‑point should be used in isolation to declare resuscitation futile.
This section summarises practical, evidence‑aligned principles for ED practice (Resuscitation Council UK ALS 2021; RCEM).
Definitions
- No‑flow time: interval during which the patient had no circulation and no CPR (collapse → start of compressions).
- Low‑flow time: interval during which CPR (manual or mechanical) was being delivered.
Both intervals strongly influence prognosis and decisions about continuation or cessation.
Guiding principles
- Use a multi‑factorial approach: integrate premorbid health and frailty, arrest circumstances (witness status, bystander CPR, no‑flow/low‑flow durations), initial rhythm and response to therapy, and presence/treatment of reversible causes.
- Check and treat reversible causes early; identification of a reversible cause usually justifies continuing and often extending resuscitation while that cause is addressed (e.g. rewarming in hypothermia, antidotes for overdose, decompression for tension pneumothorax).
- Avoid single‑parameter rules: do not stop solely because of one low ETCO2 measurement, a single POCUS finding, or an arbitrary time limit. Trends and the full clinical picture matter.