Editor's Note <\/p>\n\n\n\n
January 27, 2025<\/p>\n\n\n\n
Cardiopulmonary resuscitation (CPR) algorithms generally begin with clear instructions: in the absence of a pulse, begin CPR. When to end resuscitative efforts, though, is much less obvious. Current guidelines and clinical algorithms do not offer specific guidance on when to stop resuscitation for in-hospital cardiac arrest. Resuscitation may be prematurely terminated when survival is possible, or alternatively, may be continued when futile. Among patients who receive CPR for 30 minutes or longer, about 1.8% survived to hospital discharge.1<\/a><\/sup> At the same time, among those who survived to hospital discharge after return of spontaneous circulation, 3% received CPR for longer than 30 minutes, indicating that in some cases, patients can survive even after very long resuscitations.1<\/a><\/sup><\/a><\/p>\n\n\n\n In this issue of JAMA Internal Medicine<\/em>, Holmberg and colleagues2<\/a><\/sup> report on the development and validation of decision rules to guide termination of resuscitation among those with in-hospital cardiac arrest. The proposed decision rules were designed with the goal of being sensitive enough to identify a substantial subset of patients unlikely to survive (defined as at least 10% of the population) while having a high specificity (defined as <1% survival rate among those for whom the decision rule would recommend stopping resuscitation). Using these targets, the authors identified simple criteria for stopping resuscitation and proposed several decision rules. The best-performing rule incorporated 4 variables (with associated criteria for poor survival): whether the arrest was witnessed (unwitnessed), whether it was monitored (unmonitored), the initial rhythm (asystole), and duration of resuscitation (>10 minutes).1<\/a><\/sup>The best-performing rule met the proposed targets of identifying at least 10% of the population who were unlikely to survive, with a survival rate of less than 1% among those identified by the rule.<\/a><\/p>\n\n\n\n What do these decision rules mean for clinical practice? In the US, the median resuscitation time among patients with in-hospital cardiac arrest who do not achieve return of spontaneous circulation is 20 minutes. However, 25% of unsuccessful resuscitations last less than 14 minutes, suggesting that relatively short resuscitations are not uncommon.1<\/a><\/sup> The best-performing rule proposed by Holmberg et al2<\/a><\/sup> would recommend that even an unmonitored, unwitnessed, asystolic arrest, resuscitative efforts should not be terminated before 10 minutes. Under this rule, termination before 10 minutes would only apply to cardiac arrests that meet these criteria, and arrests not meeting these criteria would not be proposed for early termination. Thus, the decision rule might help avoid premature termination of resuscitation.<\/a><\/p>\n\n\n\n Recognizing that clinicians often consider the totality of a patient\u2019s clinical picture when making decisions on when to stop resuscitation, clinicians may be reluctant to apply a population-based rule to any one individual. Despite their limitations, these data may provide support for stopping resuscitation in situations where prolonged resuscitation is highly unlikely to result in survival. Importantly, data-driven stopping rules may reduce stress on clinical staff and family present during resuscitation as the termination of resuscitation efforts is an emotional decision for both. Data that support cessation of resuscitation can provide a basis for communication with families and care team members around expectations for survival and functional recovery that facilitate shared decision-making on the duration of extreme treatment measures.<\/a><\/p>\n\n\n\n