Geriatric Case 3: Termination of Resuscitation

This case is the third in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

Deciding when to terminate CPR is a very delicate moment in a patient’s care. It is literally the determination of possible life vs. certain death. There are clear guidelines for when to terminate resuscitation in certain contexts, but for patients who are brought to the ED by EMS, there is no true objective measure of when to terminate CPR. This is where determination of quality of life is important. In the elderly, the likelihood of a meaningful quality of life after a CPR-requiring event is quite low. Recognizing this futility is an important and challenging skill to learn. Being able to debrief with your team and discuss these events further is another essential skill that is often not practiced. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

ED RN to inform team prior to patient’s arrival: “We have an out of hospital cardiac arrest coming in with an unknown downtime and unknown past medical history. He is an 89-year-old male coming from home. He has had no shocks and CPR is in progress. They are one minute away.”

Case Summary

An elderly male is brought in by ambulance from home with CPR in progress. He collapsed in front of his son/daughter who commenced CPR. His rhythm has been PEA throughout and his downtime is 20 minutes. Participants should assess the patient, gather information about his background and determine that CPR is futile. They should decide to cease CPR and inform his son/daughter in a sensitive manner that their father has died. They will also debrief the team following the termination of resuscitation.

Download the case here: Geri EM Termination of Resuscitation

U/S for the case found here:

(U/S courtesy of McMaster PoCUS Subspecialty Training Program)

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