Do We Need a Clinical Decision Rule for the Discontinuation of Cardiac Arrest Resuscitations?

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Abstract
THE GUIDELINES for the treatment of patients in cardiac arrest are probably the most successful clinical guidelines in medicine today. These include guidelines for cardiopulmonary resuscitation (CPR), advanced cardiac life support (ACLS), and pediatric advanced life support that are developed through a consensus process by the American Heart Association in cooperation with other organizations.1 These guidelines are widely used and successful because the optimal treatment for a patient in cardiac arrest requires an interdisciplinary team response with time to treatment being a key factor. In the setting of cardiac arrest, decisions must be made instantaneously and there is no time to look up the appropriate treatment. Although the body of recommendations in ACLS and pediatric advanced life support are rich and full of nuances encouraging clinicians to assess the patient for cause of the arrest and individualize the treatment based on clinical circumstances, the treatment is often reduced to a series of algorithms based on the electrocardiographic monitor rhythm. Clinicians are comfortable with the algorithms because they provide them with ready access to an accepted form of treatment without having to make complicated clinical decisions. The disadvantage of the algorithmic approach to patients in cardiac arrest is the loss of individualized treatment. Cardiac arrest is not a disease but a complex syndrome with diverse causes and prognoses based on the underlying disease factors, pathophysiological conditions of the arrest, and the resuscitation response.