Derivation of a clinical decision rule for the discontinuation of in-hospital cardiac arrest resuscitations

Abstract

Background: Most patients undergoing in-hospital cardiac resuscitation will not survive to hospital discharge.

Objective: To derive a decision rule permitting the discontinuation of futile resuscitation attempts by identifying patients with no chance of surviving to hospital discharge.

Patients and methods: Patient, arrest, and outcome data for 1077 adult patients undergoing in-hospital cardiac resuscitation was retrieved from 2 randomized clinical trials involving 5 teaching hospitals at 2 university centers. Recursive partitioning was used to identify a decision rule using variables significantly associated with death in hospital.

Results: One hundred three patients (9.6%) survived to hospital discharge. Death in hospital was significantly more likely if patients were older than 75 years (P<.001), the arrest was unwitnessed (P = .003), the resuscitation lasted longer than 10 minutes (P<.001), and the initial cardiac rhythm was not ventricular tachycardia or fibrillation (P<.001). All patients died if there was no pulse 10 minutes after the start of cardiopulmonary resuscitation, the initial cardiac rhythm was not ventricular tachycardia or fibrillation, and the arrest was not witnessed. As a resuscitation rule, these parameters identified all patients who survived to hospital discharge (sensitivity, 100%; 95% confidence interval, 97.1%-100%). Resuscitation could have been discontinued for 119 (12.1%) of 974 patients who did not survive, thereby avoiding 47 days of postresuscitative care.

Conclusions: A practical and highly sensitive decision rule has been derived that identifies patients with no chance of surviving in-hospital cardiac arrest. Prospective validation of the rule is necessary before it can be used clinically.