The emergency nurse receives a call from emergency response system
(ERS) personnel, who are in route with R.G., a young man involved
in a motorcycle crash. He was not wearing a helmet and has a large
open skull fracture. Transport from the accident scene was delayed
by 45 min because of a severe thunderstorm and traffic congestion.
R.G. has fixed, dilated pupils and is in cardiac arrest. Estimated
arrival at the hospital is still another 45 min because of the severe
weather. EMS personnel request permission to stop resuscitation
Ethical/Legal Points for Consideration
• Criteria for brain death include coma or unresponsiveness,
absence of brainstem reflexes, and apnea (see Chapter 9).
• The definition of death has changed with the advent of new
technology, monitoring devices, and interventions.
• In a situation in which the professional responsible for
determining a state of death is in remote contact with the patient,
but the monitoring devices available provide virtual contact with
the patient, a remote diagnosis of death may be legally
• Brain death criteria do not address patients in a permanent
vegetative state since the brainstem activity in these patients is
adequate to maintain heart and lung function.
• CPR is not appropriate when survival is not expected or the
patient is expected to survive without the ability to communicate.
Quantitative futility implies that survival is not expected after
CPR under given circumstances. In the absence of mitigating
factors, prolonged resuscitative efforts are unlikely to be
successful and can be stopped if there is no return of spontaneous
circulation at any time during 30 minutes of cumulative
advanced life support.
• It is ethical for ED personnel to stop treatment started by ERS
personnel in the prehospital setting if there is valid, after-the-fact
evidence that these interventions are now inappropriate.
• What are your feelings about cessation of brain function vs.
cessation of heart and lung function as the criteria for death of a
• What are your state’s laws or practices about stopping CPR
efforts by ERS personnel in the field?
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