Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

Abstract

To the Editor: We do not believe that Morrison et al. (Aug. 3 issue)1 focused on the right question in the Termination of Resuscitation (TOR) trial. If saving lives is the issue, the question is: What can early, adequate advanced cardiac life support achieve? Basic life support — as provided in this study — will never result in “good” cardiopulmonary resuscitation, and transportation of the patient to the emergency department during basic life support is thus futile. With physician-staffed advanced cardiac life support systems, 40 to 50% of patients with out-of-hospital cardiac arrest have a return of spontaneous circulation, and 10 to 15% survive with good neurologic outcomes.2-4 In the study reported by Morrison and colleagues, the rates of return of spontaneous circulation and hospital discharge were substantially lower — by a factor of 10 and 5, respectively — than those associated with physician-staffed systems.1 Thus, implementation of the proposed rule may result in Russian roulette for patients with out-of-hospital cardiac arrest. Would anyone ask about survival after motor vehicle accidents involving patients without safety belts in their cars? Why not just use cars with safety belts, even if doing so is more expensive? Let’s think differently and send the advanced cardiac life support know-how of the emergency department — that is, experienced physicians — to our patients undergoing out-of-hospital cardiac arrest. Education and organization, not termination, make the difference.2-4