title: Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule.
abstract: BACKGROUND
  Of the proposed algorithms that provide guidance for in-field termination of resuscitation (TOR) decisions, the guidelines for cardiopulmonary resuscitation (CPR) refer to the basic and advanced life support (ALS)-TOR rules. To assess the potential consequences of implementation of the ALS-TOR rule, we performed a case-by-case evaluation of our in-field termination decisions and assessed the corresponding recommendations of the ALS-TOR rule.
  
  
  METHODS
  Cohort of non-traumatic out-of-hospital cardiac arrest (OHCA)-patients who were resuscitated by the ALS-practising emergency medical service (EMS) in the Nijmegen area (2008-2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC).
  
  
  RESULTS
  Of the 598 cases reviewed, resuscitative efforts were terminated in the field in 46% and 15% survived to discharge. The ALS-TOR rule would have recommended in-field termination in only 6% of patients, due to high percentages of witnessed arrests (73%) and bystander CPR (54%). In current practice, absence of ROSC was the most important determinant of termination [aOR 35.6 (95% CI 18.3-69.3)]. Weaker associations were found for: unwitnessed and non-public arrests, non-shockable initial rhythms and longer EMS-response times.
  
  
  CONCLUSIONS
  While designed to optimise hospital transportations, application of the ALS-TOR rule would almost double our hospital transportation rate to over 90% of OHCA-cases due to the favourable arrest circumstances in our region. Prior to implementation of the ALS-TOR rule, local evaluation of the potential consequences for the efficiency of triage is to be recommended and initiatives to improve field-triage for ALS-based EMS-systems are eagerly awaited.
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Dominique V M
authors.initials: DV
authors.lastname: Verhaert
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands. Electronic address: judithbonnes@gmail.com.
authors.forename: Judith L
authors.initials: JL
authors.lastname: Bonnes
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Joris
authors.initials: J
authors.lastname: Nas
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Wessel
authors.initials: W
authors.lastname: Keuper
authors.affiliation: Regional Ambulance Service Gelderland-Zuid, Professor Bellefroidstraat 11, 6525 AG Nijmegen, The Netherlands.
authors.forename: Pierre M
authors.initials: PM
authors.lastname: van Grunsven
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Joep L R M
authors.initials: JL
authors.lastname: Smeets
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Menko Jan
authors.initials: MJ
authors.lastname: de Boer
authors.affiliation: Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Brouwer
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000379:methods / Q000706:statistics & numerical data*; D003661:Decision Support Techniques; D004632:Emergency Medical Services; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D009426:Netherlands; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy*; D012042:Registries; D016414:Resuscitation Orders; D012189:Retrospective Studies
keywords: Clinical practice; Guidelines; Out-of-hospital cardiac arrest; Resuscitation orders; Termination of resuscitation