Recognizing and Managing Futility

     Grandpa had excused himself from the table where almost a dozen family members remained, sipping coffee and visiting after finishing up their Thanksgiving dinner. Moments later, they heard the crash and thud as Grandpa knocked over a lamp before crumpling to the bedroom floor in full arrest. When the call came in to dispatch, we had two available units in the area, so both rigs were sent to the scene.

     With four medics on the scene, things were happening quickly. The patient was intubated, vascular access was established, and our initially shockable rhythm of v-fib had unfortunately converted into asystole after two shocks. We now settled into the daunting task of trying to dig this man out of a deep pathophysiologic hole. We were just starting into our second round of drugs when one of the grandkids appeared in the bedroom door, all dressed up perfectly in his little suit and tie. He looked briefly at the four of us and then asked, "How's Grandpa doing?" For what seemed like an eternity, we all just stared blankly until, at long last Senior Medic John Kalata spoke: "Grandpa isn't doing too well today, son." Apparently satisfied with that answer, the little boy turned and bounced down the stairs, and we all let out a collective sigh and went back to work. Over the next few minutes, we saw no indication whatsoever that we were going to be able to turn this situation around, and knew that this was just another exercise in futility. At that point, John looked at us and said, "You guys keep working. I'm going down to talk to the family."

     In spite of a half-century of trying to solve the cardiac resuscitation puzzle, survivability from sudden cardiac arrest remains a single-digit event. While some scenarios do lend themselves to better resuscitation numbers, when it's all said and done on a coast-to-coast basis, only about 5% or less will return to lead a normal life. One of the most important elements of any resuscitation attempt is to recognize when your efforts are, in fact, futile. The patient won't take a breath. Periodic complexes move across the cardiac monitor, yet the patient doesn't have a palpable pulse. Capnography confirms that the patient is producing no CO₂, the primary waste product of metabolism. While the resuscitation may still be ongoing, at this point it's time to focus our attention on our next group of patients: the friends, family and loved ones at the scene.

     It's always been my belief that the bad news of resuscitation is best delivered in at least two and ideally three or four chunks. Hopefully the folks on scene have been sequestered into the family room or kitchen, so you can address them all at once. The first meeting usually goes something like this: "No, Grandpa isn't breathing, but we have a tube in his throat and are breathing for him. No, his heart still isn't beating, but we are doing CPR and moving blood around for him. I've got to get back in with my team, but I'll update you in a little while." From a practical perspective, "a little while" should be no more than about five minutes. While five minutes flies right by when you are running a code, that is forever in the minds of those who have nothing to do but wait.

     The next round of information should be more transitional, further preparing everyone for what's most likely coming. "No, Grandpa still isn't breathing. We've got a bunch of drugs on board, but his heart just doesn't want to respond so we are still doing CPR, moving his blood around for him. We are doing everything we can, but it's not looking good." While there is always the slim possibility that the situation may turn around and the patient will be resuscitated, returning with good news is always the easiest message to pass along. Unfortunately, it's just not a likely message that you'll be delivering.

     Assuming the situation remains unchanged, the next trip in to share information needs to move them toward the endpoint. "No, nothing has really changed. We are talking to a physician at the base station hospital to get his take on this, but none of the drugs are working and we just can't seem to get Grandpa's heart to start beating on its own, and we can't get him to breathe either. We are really running out of options here." At some point you just have to lay it out as gently but directly as you can. "I'm sorry, but Grandpa is dead. There is nothing else we can do."

     With the sad math being that about 95% of our patients who start dead will stay dead, this scenario plays out frequently, in spite of our best efforts, and it is certainly a given that we need to keep those friends, family and loved ones on scene informed as to what's going on with the patient.

     The simple truth remains that being told that someone you love or care for has just died is always devastating no matter how that message is delivered. But once you recognize that things aren't working and your efforts are futile, you can soften the emotional blow, at least to some degree, by offering up small, digestable chunks of bad news while still being compassionate, yet direct.

     Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.