When to STOP Resuscitation by Roger Harris
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When to stop resuscitation in probably the biggest question challenging Critical Care and it's a challenge that many of us face virtually every clinical shift. The main problem is that there is little good data to guide us, leaving us to navigate this situation with few coordinates to plot a path forward. When to stop resuscitation explores this problem and suggests some landmarks we can use to navigate by. It examines the inter-relationship between the pillars of our medical ethics Autonomy, Beneficence, Non-Maleficence and Justice. To better understand the clinical challenges we face, the talk also uses a framework provided by modern physics and the 'Space Time Continuum' theorem. Hence the title might more appropriately be – “The will to Live – The courage to die and the space-time continuum”. If the thought of how Einstein’s theorem on ‘General Relativity’ can help us answer the question of, when to stop resuscitation interests you then don’t miss this.
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Editor's Notes
- When should we stop resuscitation is probably the most challenging question facing critical care – And it’s a challenge that most of us face every clinical shift
- So I’m going to tell you a story – A story which demonstrates the will to live and the courage to die. And to help us answer the question of when to stop resuscitation – We are going to utilise a framework proposed by Albert Einstein at the turn of the last century, a model based on General relativity and the space time continuum Hermann Minkowski 1908 “The views of space and time which I wish to lay before you have sprung the soil of experimental physics, and therein lies their strength.They are radical. Henceforth space by itself and time by itself, are doomed to fade away into the mere shadows, and only a kind of union of the two will preserve an independent reality.
- Before I start with the case – a little historical perspective The inspiration for this talk was a talk with the same title presented by Cliff Reid at smacc GOLD last year and I took away three messages from that talk 1: There is very little hard data to give us any firm guide as to when we should stop resuscitation. 2: In the absence of good data, anecdotal case reports provide the best evidence and Cliff went on to describe some case of extreme resuscitation survivors – Cases where during heroic resuscitation it seemed all hope was lost and the team was ready to call the code but instead continued and the patient miraculously survived. In these cases n=1 was a very powerful statistic. 3: And finally Cliff reminded us that we were attracted to medicine by our love of life and humanity. He reminded us that life is precious and it should be cherished. So in Cliff’s words it was a talk more about NOT Stopping resuscitation!
- and let me be very clear about my own views – I LOVE resuscitation… I was attracted to Critical Care because I love being part of a resuscitation team. We all love resuscitating RIGHT! You know that adrenaline rush you get when your patient is coding, the alarms are sounding, the defib is charging and POW – you snatch them back from the brink – You save a precious human life …… Makes me just want to get down and do a VICTORY “Fist strike” like my hero in ER used to do – You all remember that ER promo don’t you? But - all that said I have a confession to make – Kneel In my 25 years of clinical practice (And that’s not the confession) In my 25 years of resuscitating patients – It has taken till very recently for me to realise the importance of knowing when to stop resuscitation – Importance to our patients / Their families and ourselves!
- So let me tell a bit about this story The case begins with a middle aged man found face down in the water next to his surf board He’s dragged to the beach by another surfer who commences CPR Some passing medicos render assistance And when the ambulance arrives he is in a non-shockable rhythm ALS continues and he receives several rounds of adrenaline and is intubated on the beach. Finally after more than 25 minutes he is shocked into ROSC He is taken to the nearby metropolitan hospital where he is stable and investigations as to the cause of his collapse are undertaken – A CT scan of his cervical spine shows a fracture dislocation at C2-3. He remains stable and is transferred intubated to the tertiary trauma hospital where I work for further assessment of his spinal injury. In the trauma unit an MRI scan of his cervical spine shows a catastrophic injury to his cervical spine at C2-3
- So the patient arrives I the ICU and This is probably the first moment in this patients resuscitation where we could pause and consider where all this is headed???!!!! We’ve started the resuscitation with clear indications to go all-out – The patient is a young man, manifestly very adequate (surfing) and this patient is likely a Partner, Father, Brother and unequivocally someone’s child…. But with a modicum of time the facts have evolved and there are some very worrying prognostic factors… 1: The patient is in fact 60 not 40 2: He had an unknown down time prior to being found 3: His initial rhythm was non-shockable (Likely assystole) 4: It was at least 25 minutes until there was return of spontaneous circulation 5: Perhaps most importantly – His cardiac arrest was likely secondary to hypoxia rather than a primary cardiac cause AND on top of all this subsequent CT and MRI scans have shown evidence of a severe Spinal Cord injury at C2 Can I ask for a show of hands who thinks we should stop resuscitation now???
- So in these difficult cases where we are unsure where to go to next, we need some coordinates to Navigate by – These coordinates are the pillarsof our medical ethics – Autonomy / Beneficence / non-Malneficince / and Justice What intrigues me here is that I personally find the the relative importance of each of these pillars varies with my spacial proximity to the patient – Its almost like the patient exerts a gravitational pull that warps my perspective on the relevant ethics. When I stand in the room at the patient’s bedside – The presence of this unique individual, this precious life is overwhelming and my concern for AUTONOMY dominates my thoughts But if I can take a few steps back and get outside the room – I see a bigger picture – I might see a broader picture of the patients life, I see their family and friends and this might change my perspective on the ethical situation. Here I might be more concerned with Befeficience and Non- Maleficence
- And if I can take steps away – even get out of the hospital and into the surrounding community I see an even bigger picture where Justice might dominate!!
- And its now just my spacial relationship to the patient that changes the perspective on the ethical landscape its also the patients own journey through space. As the patient is on the beach all indications clearly suggest aggressive resuscitation – but as they arrive in Emergency the clinical picture evolves and the Emergency room environment has its own perspective on triage – Finally as the patient jorneys through ICU there is another environment again and the story evolves further.
- So back to our case Incredibly over the first few days in the ICU the patient wakes and despite our concerns for an anoxic brain injury it becomes clear that he is cerebrally intact! However our worst fears for his spinal cord injury are realised and he is clinically behaving as a ventilator dependent quadriplegic at C2. Does anyone think we should stop now????
- I think at this stage we need more time to ascertain what all this means. And again its interesting that its not just the patients travel through space that influences our perspective but also TIME. As the patient travels through time from the beach to the ICU the clinical situation is gradually revealed in more detail. The decisions made in seconds on the Beach, evolve over minutes to hours in the emergency room and Days to Weeks in the ICU. The patient and their relatives may also
- When should we stop resuscitation is probably the most challenging question facing critical care – And it’s a challenge that most of us face every clinical shift