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7 Signs That Say “Do Not Resuscitate”

It is a moment in time that you will certainly face at some point in your EMS career. Most of us will face this decision many times over throughout our tenure. Should I attempt resuscitation?

The question may be complicated by family, friends or bystanders who have, in good faith, started CPR prior to your arrival and fully anticipate that you will continue. Or perhaps other members of emergency services arrived before you and declared the patient not workable. They may advise you of their findings, without much further detail. “This guys dead.” 

Often, responders who aren’t responsible for documenting the obvious death criteria can be much more casual about the determination of death. They may decide not to try to resuscitate because the patient “looks dead.” They aren’t the ones who have to write the paperwork and meticulously document the physical findings that allowed them to make the determination of obvious death … you are.

How will you tell a family member or helpful bystander that it isn’t medically reasonable to continue CPR? How will you advise the well meaning first responder who failed to initiate resuscitation efforts that you’re going to begin them in earnest anyway? To proceed with confidence you need to know your resuscitation guidelines and you need to know your obvious signs of death. You need to know them well.

When you walk into that room and assess the patient there won’t be time to consult reference cards. People are going to want a definitive action plan quickly. protocols will vary from region to region, but I have found this list to be accurate and useful across many states and many organizations. Commit this one to memory.

EMT’s can objectively decide to withhold resuscitation in the presence of:

1.) A valid DNR order

• DNR stands for Do Not Resuscitate. It is a physicians order that the patient be allowed to expire without CPR. A DNR may be a part of a more complex advanced directive, detailing what types of comfort measures the patient does and does not want, or it can be a stand alone document.
• Valid DNR orders vary from state to state and must be present with the patient at the time of contact. The are often signed documents like the one shown here but can also take the form of bracelets or signed cards. You’ll need to reference you local policy on what can and cannot be accepted as a valid DNR.

• If family or bystanders inform you of the presence of a DNR, but are unable to produce it you will need to begin you resuscitation effort and contact your physician to consult on your findings and the families wishes.

2.) Dependant Lividity

• Dependant Lividity is the pooling of blood in the body after the heart has stopped beating. Once the heart ceasesto circulate the patients blood, the blood becomes subject to gravity and begins to settle in the lower portions of the body (dependant regions).

• Lividity can be blue, purple or black and looks similar to bruising of the skin.
• As much as I hate to state the obvious, the areas where dependant lividity will occur can vary depending on what position the body is in at the time of death.
• Lividity can also be referred to as livor mortisor post mortem hypostasis.

3.) Rigor Mortis

• Most of the lay public are familiar with the concept of rigor mortis. Not surprisingly, you’ll also find a lot of misinformation out there about the nature of rigors.
• Rigor Mortis is the stiffining of muscles due to the absence of ATP after death. Without ATP the myosin and actin bind together and the muscle fibers become rigid. This process begins 1-3 hours after death. The muscles will remain rigid until they begin to decompose 18 – 48 hours post mortem.
• Rigor begins in smaller muscle groups first and moves to larger muscles. It resolves in reverse (larger muscles relax first. Therefore, small muscle groups like the hands, wrists and jaw will begin to rigor before the biceps and legs. This is why we often assess for rigor by moving the mandible.

4.) Decapitation

• Decapitation is the removal of the head from the body. This can occur it traumatic accidents with unusual mechanisms, such as this scene. Over the course of human history, patients suffering from decapitation have demonstrated a 100% mortality rate.

5.) Decomposition

• Almost immediately after death, cells release enzymes that begin consuming the body’s tissues. Enzymes and bacteria that were aiding in digestion begin feeding on the  intestines themselves. They will eventually begin consuming abdominal organs and contents as well.
• Decomposition takes from 2 weeks to two years depending on the environment and how quickly critters find there way to the corps.

6.) Incineration

• Cardiac arrest after full thickness burns to the entire body is not considered survivable. These burns create fluid shifts that are to profound to overcome in a resuscitation scenario.

7.) Removal of a vital bodily organ (Usually including blood)

• Organs and tissues considered vital to the immediate survival of the body include the heart, the lungs the brain and the circulating blood. The complete removal of any of these is reason to forgo resuscitation attempts.

So you’ve decided that the patient does not warrant resuscitation attempts. What do you do now? In most systems you’re going to need to call medical direction and explain yourself.

The physician is going to want to know the basics of who the patient is:

 74 y/o male history of bone cancer and CHF.

When and where were they found?

Found by family in bedroom supine in bed approximately 12 minutes ago.

When were they last seen and what condition were they in?  This one is important!

Last seen last night at 2200 before bed. Patient had no unusual complaints.

What did you find?

On arrival found patient supine in bed with marked dependant lividity and rigor mortis present in the jaw and neck.

Let the physician know that you feel obvious death indicators are present and agree to a time of confirmation. Note that this is not a time of death. The coroner will determine the time of death. Document this as the time of resuscitation termination or the time of confirmation of obvious death criteria.

Remember this list and next time you walk into that pressure situation hopefully you’ll feel better equipped to make a decision fast and with confidence.

Tags: death, determination of death, dnr, do not resuscitate, doa, lividity, livor mortis, obvious death, rigor mortis