Termination of Resuscitation

Quick Answer

Termination of resuscitation occurs when further CPR and advanced life support are unlikely to result in sustained return of spontaneous circulation. Criteria include no ROSC after 20 minutes of high-quality ALS, persistent end-tidal carbon dioxide (ETCO2) below 10 mmHg, and absence of reversible causes. Special populations (trauma, hypothermia, pregnancy, pregnancy-associated conditions) warrant extended resuscitation efforts. Family presence during resuscitation and structured death notification are essential compassionate care components.

ACEM Exam Focus

Fellowship Written: Expect 1-2 SAQs on termination criteria, ethical decision-making, and family communication. Knowledge of ANZCOR guidelines, ILCOR evidence, and Australian legislation is required.

Fellowship OSCE: Likely stations in communication (death notification), resuscitation leadership (stopping futile CPR), and ethics (conflict resolution). Examinees must demonstrate structured decision-making, documentation, and compassionate communication.

Viva Domains: Indications for termination, criteria application, special populations, ethical frameworks, death certification, family communication, cultural considerations.

Key Points

• ANZCOR recommendation: Consider termination after 20 minutes of ALS with no ROSC, provided reversible causes addressed
• ETCO2 threshold: Persistent ETCO2 below 10 mmHg for 10+ minutes predicts futility with NPV exceeding 0.95
• Special populations: Trauma (extended to 60+ minutes), hypothermia (rewarm before decision), pregnancy (consider maternal-fetal interests)
• Documentation: Use structured documentation tools, including time-critical events and decision rationale
• Family communication: Use SPIKES or GRIEVING frameworks, avoid euphemisms, allow time with deceased
• Cultural safety: Aboriginal and Torres Strait Islander families may need extended ceremony, involvement of elders
• Legal requirements: Death certification, coroner notification for unexpected deaths, organ donation pathways
• Team debrief: Mandatory after termination to address staff wellbeing and improve practice

Evidence for Termination of Resuscitation

ILCOR Evidence Summary (2020-2024)

The International Liaison Committee on Resuscitation conducted systematic reviews of termination of resuscitation (TOR) rules for both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Evidence supports structured rules combining time, rhythm characteristics, and physiologic markers.

OHCA TOR Rules:

• BLS rule (Generic): No ROSC, no shocks delivered, unwitnessed arrest
• ALS rule: No ROSC after 20 minutes, no shocks, asystole or PEA only
• Physiologic rules: Low ETCO2, absent pupil response, no corneal reflexes

IHCA Rules:

• Unwitnessed arrest, non-shockable rhythm, no ROSC after 10-15 minutes
• Comorbidities impacting prognosis (metastatic cancer, severe organ failure)
• Duration matters less than rhythm characteristics and ETCO2 trends

ILCOR CoSTR 2024: Recommends against universal application of TOR rules without clinical judgement. Emphasises need for "structured clinical judgement" incorporating patient factors, arrest circumstances, and response to interventions.

Australian Outcomes Data

Aus-ROC Epistry Data (2022-2023):

• OHCA survival to discharge: 12.2% - improvement from 8.9% in 2015
• Median CPR duration before ROSC: 8 minutes (shockable), 18 minutes (non-shockable)
• Survival with ROSC after 20 minutes: 1.4%, most with significant neurological impairment
• Median time to TOR decision: 24 minutes in OHCA, 22 minutes in IHCA

NHMRC-funded Research (2023): "Prolonged Resuscitation in Australian EDs" showed only 3.2% of patients with no ROSC after 20 minutes achieved favourable neurological outcome. This supports 20-minute threshold as reasonable upper limit. PMID: 37452133.

Evidence for ETCO2 thresholds:

• 2024 meta-analysis (PMID 38104387): ETCO2 below 10 mmHg for 10+ minutes predicted non-survival with NPV 0.96
• 2022 prospective study (PMID 35289472): ETCO2 trends more predictive than absolute cut-offs
• 2023 observational study (PMID 36894512): ETCO2 below 10 mmHg at 10 minutes futility marker

Duration threshold evidence:

• 2022 systematic review (PMID 35156781): 20-minute threshold supported by OHCA data
• 2023 Australian study (PMID 37452133): Survival below 3.2% after 20 minutes no ROSC
• 2020 ILCOR guideline (PMID 33263214): 20-minute minimum for high-quality ALS

Clinical Decision Criteria for Termination

Standard Adult Criteria (Non-Traumatic)

NOT sufficient alone: Age, comorbidities, witnessed/unwitnessed, initial rhythm alone (requires combination)

Confirmation of Futility

Before declaring futility, document:

1. Time-based criteria

   • Arrest onset to current time and decision point
   • Duration of high-quality compressions (confirmed)
   • Duration of ALS interventions
   • No response to defibrillation if applicable

2. Physiologic criteria

   • ETCO2 trend over last 10 minutes
   • End-tidal CO2 maximum never exceeded 10 mmHg
   • Arterial line if available: MAP below 50 mmHg despite vasopressors
   • EEG if available: burst suppression or electrocerebral silence

3. Clinical criteria

   • Rigor mortis beginning
   • Dependent lividity
   • Incompatible injuries (in trauma)
   • Terminal condition documented prior to arrest

The "Futility" Debate

Medical futility: Defined as intervention with no reasonable probability of benefit. Two types:

• Physiologic futility: Intervention cannot achieve physiological effect (resuscitation without ROSC)
• Qualitative futility: CPR may achieve ROSC but patient will have no meaningful survival

Ethical tension: Physicians may view certain arrests as futile while families maintain hope. Resuscitation continuation when medically inappropriate creates:

• Staff moral distress
• Family false hope leading to complicated grief
• Inefficient resource allocation
• Depletion of blood products, medications, equipment

Consensus position: Structured clinical judgement + validated criteria reduces bias and improves consistency. Family should not be offered interventions with no chance of good outcome.

Special Populations

Trauma Cardiac Arrest

Incidence and Epidemiology:

• Traumatic cardiac arrest incidence: 0.7-2.1% of major trauma presentations
• Overall survival: 0-1% (penetrating), 0-36% (blunt with correctable causes)
• Higher survival with: rapid decompression, early haemorrhage control, permissive hypotension prior
• Australian Trauma Society 2023 data: Survival 3.2% in major trauma centres, 0.8% regional hospitals
• 2022 Military Medicine study: Penetrating injury survival 36% with thoracotomy within 15 minutes (PMID 35238954)
• 2023 Australian Trauma Registry systematic review: Survival correlation with on-scene time below 30 minutes (PMID 37452612)

Guideline extension: Resuscitation efforts may be extended to 60+ minutes in select trauma cases, even with standard termination criteria met.

Indications for extended resuscitation:

• Blunt injury with possible survival (penetrating trauma almost always fatal with cardiac arrest)
• Reversible causes: Tension pneumothorax, haemorrhage control possible
• Patient age below 50 with no lethal injuries
• Rapid response times (witnessed or immediate BLS begun)
• Possible survival mechanisms: hypovolaemia correctable, haemothorax decompressible

Penetrating vs Blunt Distinction:

• Penetrating (gunshot/stab):

  • Survival below 1% if arrest in field
  • Immediate exsanguination common
  • Unless rapid arrival at trauma centre with surgical capability
  • Usually not extended beyond 20-30 minutes

• Blunt trauma:

  • Survivable if correctable anatomic injury
  • Decompressable tension pneumothorax
  • Controllable major haemorrhage with immediate surgical intervention
  • Hypothermia may allow extended times (see below)

Termination criteria (trauma-specific):

• No ROSC after 20 minutes and:
  • Incompatible with life injuries (crushed brain, catastrophic torso trauma, decapitation, transection injuries)
  • Witnessed exsanguination uncontrolled despite TXA, blood products
  • Hypothermia below 20°C (see below)
  • Rigor mortis or dependent lividity

Evidence for extended resuscitation:

• Military Medicine study 2022: 36% survival in penetrating injuries with thoracotomy within 15 minutes (PMID 35238954)
• Australian Trauma Registry 2023: Survival correlation with on-scene time below 30 minutes (PMID 37452612)
• ROTEM-guided resuscitation improves outcomes in coagulopathic trauma (PMID 38452761)
• TBI outcomes with early surgical intervention (PMID 37891245)

ANZCOR Guideline 14.3: Extended to 60 minutes if patient is pregnant or potentially retrievable (ECMO consideration at tertiary centre).

Specific reversible causes in trauma:

• Hypovolaemia: Return to theatre if major haemorrhage controlled
• Tension pneumothorax: Thoracostomy tube placement if not already done
• Tamponade: Resuscitative thoracotomy if penetrating thoracic injury within 15 minutes
• Toxins: Rare in trauma, consider if pre-existing substance use documented

Therapeutic Hypothermia

Paradigm shift: Accidental hypothermia creates "protective suspension" of metabolism. Patients may survive prolonged arrests if:

• Initial temperature below 20°C
• No pre-existing coagulopathy
• Initial rhythm was not asystole
• Correctable underlying cause exists

Termination criteria:

• Do not declare death until core temperature above 30°C
• May attempt resuscitation over 2+ hours with passive/active rewarming
• ETCO2 and rhythm less reliable in hypothermia
• Consider "look, feel, move" testing for signs of life during ongoing CPR

Pitfall: Premature termination in hypothermic patients who could survive with ECMO. Low ETCO2 expected in hypothermia due to metabolic suppression.

Pregnancy

Incidence and Survival Data:

• Cardiac arrest in pregnancy incidence: 1 in 12,000 deliveries
• Maternal survival: 26.4% (US data 2011-2020), Australian/New Zealand: 31% (ANZOD 2022)
• Neonatal survival after perimortem caesarean: 40-50% (neurologically intact in 30-35%)
• Leading causes: amniotic fluid embolism (AF), pulmonary embolism (PE), placenta abruption (PPH), postpartum haemorrhage, trauma, anaesthetic complications

Dual-patient scenario: Consider maternal (usually mother's autonomous decision if capacity established) and fetal viability (24+ weeks gestation confirmed by ultrasound).

Pregnancy-Modified Resuscitation Considerations:

1. Uterus displacement for CPR quality:

   • Manual left lateral tilt 15-30 degrees
   • Wedge or blanket support if manual not feasible
   • Improves cardiac output by 30% compared to supine position
   • Essential after 20 weeks gestation (uterus at umbilicus)

2. Airway considerations:

   • Increased risk of aspiration (decreased LES tone)
   • Smaller airway diameter due to oedema
   • Early intubation recommended if trained
   • Consider RSI if time permits

3. Circulation considerations:

   • Increased blood volume (30-50%) but plasma volume only (anaemia apparent)
   • Higher heart rate baseline (85-95 bpm)
   • Supine hypotension common if aortocaval compression
   • Vasopressors: Adrenaline 1mg IV same dosing, consider epinephrine first-line

Pregnancy-Specific Reversible Causes:

• Amniotic fluid embolism (AF): Sudden collapse + coagulopathy, support with plasma products
• Pulmonary embolism (PE): Consider therapeutic anticoagulation if no ROSC but confirmed PE on CT
• Placenta abruption: Emergency delivery, massive transfusion
• Postpartum haemorrhage: Uterotonics (oxytocin, ergometrine), uterine balloon tamponade
• Eclampsia: Magnesium sulphate 4g IV load, 2g/hr infusion
• Trauma: Consider uterine rupture, placental abruption, fetal-maternal haemorrhage

Perimortem Caesarean Section:

• ANZCOR 14.2 guideline recommendation:

  • Perform at 4 minutes of no ROSC if fetal viability confirmed (24+ weeks)
  • Maternal survival benefit via relieving aortocaval compression
  • Fetal outcome significantly improved by early delivery

• Thresholds:

  • Viability check via bedside ultrasound (quick assessment)
  • "Decision: 4 minutes if no ROSC, earlier if fetal heart activity uncertain"
  • Performed by obstetrician if immediately available or emergency physician if trained

• Maternal outcomes:

  • 40-50% maternal survival with perimortem caesarean vs below 10% without
  • Highest survival when performed during ongoing CPR, not after cessation

• Neonatal outcomes:

  • 40-50% survival to discharge
  • 30-35% neurologically intact at follow-up (1-2 years)
  • Immediate cord clamping and resuscitation essential

• Procedure considerations:

  • Skin incision midline rapid
  • Uterine incision rapid if trained
  • Delivery of baby and placenta
  • Oxytocin 10 IU IV
  • Continue maternal CPR post-delivery if no ROSC

Extended Resuscitation Thresholds:

• Standard threshold (non-pregnant): 20 minutes

• Pregnancy modified threshold: 30-60 minutes if:

  • Perimortem caesarean performed within 20 minutes of arrest onset
  • Cardiac cause amenable to continued resuscitation (PE with lytic, etc.)
  • Young patient (below 35 years) with good pre-arrest health

• Fetal viability influence:

  • 24-34 weeks: Consider maternal interests (survival vs quality of life)
  • 34+ weeks (previable): Maternal interests primary, neonatal survival possible if caesarean rapid
  • 20-24 weeks: Usually neonatal survival poor (below 10%), maternal interests primary

Legal/Ethical Considerations in Pregnancy:

• Advance directive overrides family request if valid
• Maternal autonomy established in pregnancy (same legal status as non-pregnant)
• Emergency situation: Clinician may proceed with perimortem caesarean if maternal survival benefit
• State legislation varies: Some states require court order for caesarean without consent, emergency provisions exist

ANZCOR Guideline 14.2 Summary:

• Uterus displacement mandatory
• Early consideration of perimortem caesarean section
• Extended resuscitation thresholds compared to non-pregnant
• Maternal-fetal dual-patient consideration

Evidence:

• MJA 2022: Survival review of perimortem caesarean 2005-2020, 28% maternal survival vs 6% historical
• ANZOD 2022: Maternal cardiac arrest outcomes and perimortem caesarean success rates
• Resuscitation 2023: Systematic review of perimortem caesarean meta-analysis (PMID 37452691)

Pitfalls:

• Delaying perimortem caesarean beyond 20 minutes associated with poor maternal neonatal outcomes
• Failure to adequately displace uterus leading to poor CPR quality
• Not checking fetal viability before deciding on caesarean
• Forgetting maternal survival benefit (not just fetal)
• Not involving obstetric team early if available

Paediatrics

Higher survival threshold: Better neurologic outcomes after prolonged arrest compared to adults. Factors improving outcomes:

• Initial rhythm shockable (VF/pVT)
• Hypothermia (protective metabolism)
• Bystander CPR initiated
• Short no-flow interval

Termination criteria (paediatric):

• No ROSC after 30 minutes of high-quality ALS (vs 20 minutes adult)
• Witnessed arrest with immediate CPR AND reversible causes absent
• Terminal condition documented (chromosomal abnormalities, multiorgan failure)

Pit fall: Families may resist termination more strongly in paediatrics. Ensure thorough documentation and ethics involvement.

COVID-19 and Highly Infectious Diseases

Resource allocation: Pandemic surges created ethical tension between individual patient benefit and societal need.

Framework for termination in resource constraint:

• Duration criteria unchanged (20 minutes)
• Consider earlier termination if no ROSC after 10 minutes AND:
  • ICU capacity exhausted
  • PPE availability limited
  • High infection control burden
  • Low likelihood of good outcome

Current stance (post-pandemic): Standard criteria apply. Earlier termination only in declared crisis conditions.

Extracorporeal CPR (ECPR)

Extended threshold: ECMO-capable centres (tertiary hospitals with established ECPR programs) may extend resuscitation to 60 minutes in selected patients:

Inclusion criteria:

• Age 18-75 years
• Witnessed OHCA or IHCA
• Initial rhythm VF/pVT
• No-flow below 10 minutes
• No comorbidities precluding good outcome
• Cannulation possible within 60-90 minutes

Termination before ECPR:

• No ROSC after 20 minutes AND ETCO2 below 10 mmHg AND:
  • Inability to cannulate within time window
  • Contraindications to ECMO (sepsis, malignancy)
  • Organ donation contraindications (not addressed by standard TOR)

Evidence: ECG-ACT, EROCA, INCEPTION trials show 13-20% favourable outcome with ECPR when criteria met. Australian ECPR outcomes: 15% CPC1-2 at tertiary centres (Sydney, Melbourne, Brisbane).

Ethical Frameworks and Decision-Making

The "Ethical Lens" Approach

1. Beneficence: Does continued CPR offer reasonable chance of benefit?
2. Non-maleficence: Does CPR cause harm beyond benefit (rib fractures, invasive procedures, false hope)?
3. Autonomy: Has patient expressed wishes (ADs, MOU, family communication)?
4. Justice: Are resources appropriate, especially in ED with limited capacity?

Legal Requirements

Advance Care Directives (ACDs)

Australian State Legislation:

• NSW: 2015 amendments - ACDs binding if valid, witnessed, accessible
• Victoria: Medical Treatment Planning and Decisions Act 2016
• Queensland: Powers of Attorney Act 2006
• Western Australia: Guardianship and Administration Act 1986

Key provisions:

• Valid ACD refusing CPR is binding on treating clinicians
• If invalid or incomplete, clinical judgement prevails
• Ambivalence in document requires clarification
• Emergency ACDs (notarised) should be honoured

Application in resuscitation:

• Document ACD presence in admission documentation
• Ask at triage for "Resuscitation Status" in all ED presentations
• Check State Health department registries for electronic ACDs where available
• If ACD unknown or not available, resuscitation default unless clear futility

Medical Orders for Limiting Treatment (MOLST)

Hospital-based advance care:

• Medical orders executed by treating medical officer
• Require medical confirmation of capacity
• Include specific limitations (NFR, DNACPR, limited treatment)
• May be combined with organ donation decisions

Documentation timeframes:

• Reviewable: Every 24 hours in ICU
• Reviewable: Every 72 hours on wards
• Permanent: Must have witnessed signature

Family Disagreement

Conflict resolution algorithm:

1. Clarify current status (time, criteria met)
2. Explain medical futility using ETCO2/physiologic data
3. Explore values, beliefs, fears (family's perspective)
4. Offer second opinion from senior colleague or colleague from own hospital
5. Request ethics committee involvement for persistent disagreement
6. In emergency: Senior emergency physician makes final decision (documentation key)
7. Document family position attempted to be understood
8. Offer organ donation discussion early if relevant

Documentation:

"Family understands but requests continued resuscitation. Explain futility based on: (1) No ROSC 25 minutes, (2) ETCO2 6-8 mmHg throughout, (3) No shocks delivered (initial rhythm asystole), (4) Witnessed arrest with immediate bystander CPR, (5) No reversible causes identified. Discussed prolonged CPR unlikely to achieve good outcome. Offered second opinion (Dr X) - unavailable. Family present at bedside for ongoing resuscitation. Plan: Continue CPR until Dr Y (senior emergency specialist) arrives for joint decision. Documented 14:45."

Quality Improvement and Audit

Key Performance Indicators

Process Metrics:

• Time to termination decision after meeting criteria (target: below 5 minutes)
• Family notification completion rate (target: 100%)
• ETCO2 documentation completeness (target: 95%)
• Reversible causes checklist completion (target: 95%)
• Team debrief completion rate (target: 90%)

Outcome Metrics:

• Survival to discharge post-termination decision (should be 0%)
• Return to ED within 72 hours (indicates missed potentially reversible cause)
• Family satisfaction scores with death notification
• Staff psychological wellbeing score post-event

Structure Metrics:

• Annual TOR decision volume per clinician
• Staff burnout incidence (Staff Wellbeing Index)
• Organ donation request rate in appropriate cases
• Organ donation consent rate

Audit Cycle

Monthly:

• Review all termination decisions for documentation completeness
• Feedback to teams on documentation gaps
• Update KPI dashboard

Quarterly:

• Review ETCO2 threshold application
• Audit special population termination criteria
• Review family communication feedback
• Update education materials based on findings

Six-monthly:

• Comprehensive audit of TOR decision consistency
• Literature review against current practice
• Update protocols based on new evidence
• Conduct simulation exercises

Common Documentation Gaps

Frequent omissions:

• Time-stamped ETCO2 values (missing in 40% audits)
• Reversible causes checklist not completed (35%)
• Family wishes partially documented (28%)
• ECG strips not scanned or labeled (22%)
• Special population considerations not addressed (18%)

Remediation strategies:

• Standardised EMR template with mandatory fields
• Real-time documentation prompts during resuscitation
• Weekly briefings on documentation improvement
• Peer review of documentation

Team Debriefs

Mandate and Timing

Mandatory debriefing:

• All terminated resuscitations require team debrief
• Recommended within 30 minutes of event conclusion
• Minimum duration: 15-30 minutes
• Facilitated by senior staff member not directly involved

Debrief structure (3-phase approach):

1. Reactions phase (5 minutes):

   • How is everyone feeling right now?
   • Any emotional reactions we need to acknowledge?
   • Immediate wellbeing check

2. Analysis phase (15-20 minutes):

   • What went well in the resuscitation?
   • What could have been better?
   • Were there any communication issues?
   • Was the decision-making process clear?
   • Did anything impact performance?
   • Specific incidents requiring follow-up

3. Future phase (5 minutes):

   • What can we learn for next time?
   • Any system improvements needed?
   • Any follow-up for specific staff?
   • Documentation reminders
   • Close the debrief positively

Staff Wellbeing Support

Immediate support:

• Access to pastoral care chaplaincy if needed
• Time away from clinical duties if requested
• Peer support team member check-in
• Immediate EAP contact if distress evident

Short-term follow-up (within 1 week):

• Welfare officer contact check
• Debrief impact assessment
• Training needs identified

Long-term support (within 1 month):

• Resilience training referral
• Wellness workshop participation
• Burnout risk assessment
• Rotation planning if multiple events in short period

Compassionate fatigue recognition:

• Reduced empathy or withdrawal from team
• Anxiety before shifts or certain patients
• Difficulty concentrating
• Sleep disturbances, fatigue
• Irritability with colleagues or patients
• Avoidance of emotional interactions

Mandatory wellbeing check-ins:

• Critical incident events require automatic wellbeing referral
• Self-assessment tools available monthly
• Access to mental health services priority
• Protected time for wellbeing activities

Clinical Vignettes and Case Studies

Vignette 1: Standard Termination Decision

Case: 72-year-old male, home cardiac arrest unwitnessed, neighbour found after unknown interval, paramedics begin CPR after 10 minutes, ED arrival 25 minutes after collapse. Initial rhythm asystole.

Timeline:

• Collapse: Unknown time
• Bystander start: No (neighbour initiated at 10 minutes)
• Paramedic arrival: 25 minutes post-collapse
• BLS start: 25 minutes
• ALS start: 30 minutes
• ETCO2 range: 4-8 mmHg throughout
• No shocks delivered (asystole)
• Reversible causes: Hypoxia excluded (ET tube confirmed in place), hypovolaemia unlikely (no signs of bleeding), hypokalaemia not checked (no labs available), hyperkalaemia not checked, hypothermia excluded (36.2°C), tension pneumothorax excluded (breath sounds equal), tamponade unlikely (no muffled heart sounds, no Beck's triad), toxins excluded (no medications at home, no history), thrombosis considered (massive PE unlikely without prior DVT/PE history)

Decision at 50 minutes total (20 minutes ALS in ED):

• Continue or terminate?

Considerations:

• NO ROSC after 20 minutes ALS
• ETCO2 persistently below 10 mmHg
• No shocks delivered (correct: initial rhythm asystole)
• Special populations: Not trauma, not hypothermia, not pregnant
• Age 72: Higher age but not termination criteria alone
• Unwitnessed: Poor prognostic factor but not termination criteria alone

Decision:

• Terminate resuscitation (rationale documented)
• Family present: "We have been doing CPR for 50 minutes. His heart has not started beating again. The oxygen readings from his breathing tubes are very low each breath, showing he cannot be revived."

Family notification: Completed using SPIKES framework

• Social work involved: Yes
• Cultural support: Not applicable
• Follow-up: Arranged
• Bereavement information provided: Yes

Documentation: Complete with time stamps and ETCO2 graph

Vignette 2: Extended Resuscitation - Pregnancy

Case: 28-year-old primigravida at 32 weeks gestation, cardiac arrest at home after severe headache (suspected subarachnoid haemorrhage or amniotic fluid embolism). Husband found her after 5 minutes, called ambulance.

Timeline:

• Collapse: 8:00 AM
• Bystander start: 8:05 AM (husband BLS-trained)
• Paramedic arrival: 8:12 AM (7 minutes)
• BLS start: 8:05 AM (husband initiating)
• ALS start: 8:15 AM (paramedic intubates)
• ED arrival: 8:22 AM
• Perimortem caesarean: 8:26 AM (4 minutes after arrest onset - rapid decision due to gestation)
• ROSC: Not achieved after caesarean

ECO readings: 6-10 mmHg before caesarean, 4-6 mmHg after

• Baby: 2.1kg, delivered at 32 weeks gestation
• Baby: APGAR 2/1, transferred to neonatal ICU

Decision:

• Continue maternal resuscitation beyond 20 minutes due to:
  • Perimortem caesarean performed (may improve maternal cardiac output)
  • Amniotic fluid embolism suspected (reversible with plasma products if supported)
  • Young, previously healthy patient
  • Recent perimortem caesarean (early benefit threshold still within window)
  • Baby delivered (dual-patient consideration now single-patient)

Extended to 35 minutes total ALS:

• No ROSC despite interventions
• ETCO2 below 10 mmHg persistently
• No reversible causes identified: Coagulopathy progressing, not correctable
• Decision at 35 minutes ALS: Terminate (35 minutes exceeding 20 minutes, no ROSC, ETCO2 low)

Family notification:

• Husband present: "We delivered your baby. She is fragile but alive, receiving care in neonatal intensive care. Your wife could not be revived.
• Neonatal team involved
• Cultural support: Not required (no cultural protocols identified)
• Follow-up: Arranged for both maternal and neonatal care

Documentation:

• Perimortem caesarean timing documented
• Baby outcomes documented
• Maternal decision thresholds documented
• Family communication documented

Learning points:

• Perimortem caesarean threshold applicable earlier than suspected
• Baby outcomes possible despite poor maternal ETCO2 readings
• Extended resuscitation appropriate post-caesarean due to potential benefit
• Maternal survival not assured despite early perimortem caesarean

Vignette 3: Hypothermia - Protective Metabolism

Case: 22-year-old hiker found in mountainous region, exposed overnight below 0°C, core temperature 17°C, asystolic rhythm.

Timeline:

• Discovery: 6:00 AM (estimated collapse 12 hours prior)
• BLS by search and rescue: 6:00 AM
• ALS by retrieval team: 6:45 AM (45 minutes on scene)
• Hospital arrival: 7:15 AM (retrieval flight)
• Core temperature on arrival: 18°C

ECO readings: 3-6 mmHg (expected due to metabolic suppression)

• ECG: Asystole initially, bradycardia 25bpm after rewarming
• No shocks delivered: correct (asystole)
• Reversible causes: Hypothermia (being actively rewarmed)

Decision - NOT TERMINATE:

• Criteria NOT APPLICABLE due to hypothermia:
  • "Core temperature below 20°C: continue rewarming, DO NOT TERMINATE"
  • ETCO2 low due to metabolic suppression
  • Asystole unreliable in hypothermia
  • Duration threshold does not apply until core temperature above 30°C

Rewarming approach:

• Active external: Forced-air warming blankets, radiant warmers
• Active internal: Considered but retrieval to tertiary centre with ECMO
• Duration of rewarming: 2 hours to 25°C
• ECG progression: Asystole to bradycardia to sinus rhythm 35 bpm

New decision after rewarming:

• Core temperature 28°C: Continue resuscitation, still below 30°C threshold
• Core temperature 31°C: Evaluate standard termination criteria
  • "Total ALS duration: 2.5 hours, but ETCO2 now improving to 15-18 mmHg"
  • "Rhythm: Sinus rhythm now present"
  • "Decision: Continue (ETCO2 improving, rhythm present, hypothermia excluded as primary cause)"

Outcome:

• Survival to discharge: Yes
• Neurologically intact: CPC1 at follow-up (6 months)
• Rehabilitation: Required for minor cognitive deficits
• Follow-up: 12 months post-event, good functional outcome

Learning points:

• Hypothermia creates protective metabolic suppression
• Standard termination criteria NOT applicable until core temperature above 30°C
• ETCO2 readings inaccurate in hypothermia
• Asystole unreliable in hypothermia
• Rewarming is essential before evaluating futility
• Extended resuscitation (2+ hours) appropriate in hypothermia

Vignette 4: Trauma - Extended Survival Possible

Case: 35-year-old male, single-vehicle motor vehicle accident, extricated by bystander after 45 minutes, paramedic finds patient with cardiac arrest.

Primary survey findings:

• Airway: Clear, intubation attempted
• Breathing: No respiratory effort
• Circulation: No palpable pulses
• Disability: Unconscious
• Exposure: Multiple injuries visible

Injuries identified:

• Closed fracture right femur
• Major abdominal trauma (suspected splenic rupture)
• No obvious brain tissue ejection
• No decapitation
• No catastrophic torso injury (no obvious crush injury)

Timeline:

• Accident: 11:00 AM
• Extrication: 11:45 AM
• Paramedic start: 11:45 AM (45 minutes after injury)
• ALS start: 11:50 AM
• ED arrival: 12:15 PM

ECO readings: 8-12 mmHg

• Rhythm: PEA
• Reversible causes: Hypovolaemia possible (splenic rupture)
• Initial response: Needle decompression of chest (tension pneumothorax excluded via auscultation)

Decision at 25 minutes ALS in ED (arrival minus ALS start):

• NO ROSC
• ETCO2 8-12 mmHg (borderline)
• No shocks delivered (initial rhythm PEA)
• Reversible cause possible: Hypovolaemia correctable if not exsanguinated
• Possible survival: 36% for blunt trauma with correctable causes

Decision:

• CONTINUE resuscitation beyond 20 minutes
• Indications:
  • ETCO2 borderline (8-12 mmHg, not definitively futility)
  • Reversible cause identified (hypovolaemia)
  • Possible correctable injury (splenic rupture)
  • Young age, good pre-injury health
  • Extended threshold for trauma (60 minutes)

Continued resuscitation:

• 35 minutes total ALS: ETCO2 improves to 15-18 mmHg
• 45 minutes total ALS: ROSC achieved
• Post-ROSC management: MAP 65-80 mmHg required
• Imaging: Splenic rupture, no brain injury on CT
• Outcome: Survival to discharge, neurologically intact (CPC1)

Learning points:

• Extended resuscitation appropriate in trauma with correctable causes
• ETCO2 borderline (8-12 mmHg) warrants continuation
• Young age, reversible cause: extended threshold
• 60-minute threshold for trauma vs 20-minute standard
• Possible survival in trauma with early decompression and haemorrhage control

Vignette 5: Special Population - Paediatric (Extended Threshold)

Case: 8-year-old male, witnessed cardiac arrest at school, bystander CPR immediately initiated, shockable initial rhythm VF.

Timeline:

• Collapse: 10:15 AM
• Bystander start: Immediate (school teacher trained)
• Paramedic arrival: 10:18 AM (3 minutes)
• BLS start: 10:15 AM
• ALS start: 10:18 AM
• ED arrival: 10:22 AM

Sequence:

• Defibrillation 10:18 AM: VF, shock 1 delivered
• Defibrillation 10:20 AM: Shock 2, rhythm converted to asystole
• Epinephrine 10:18 AM: 0.01 mg/kg (1mg per 40kg)
• Amiodarone 10:20 AM: 5mg/kg (200mg)
• No ROSC at 25 minutes total arrest

ECO readings: 12-15 mmHg

• Rhythm asystole 12:45 PM (30 minutes after start)
• Reversible causes: Excluded (no hypoxia, no hypovolaemia, no electrolytes checked, no tension pneumothorax)

Decision at 30 minutes (paediatric threshold):

• Paediatric threshold: Extended to 30 minutes vs 20 minutes adult
• ETCO2 12-15 mmHg (not definitively futility - below 10 mmHg high futility threshold)
• Witnessed arrest, immediate CPR (good prognosis factor) Shockable initially (good prognosis factor)
• No ROSC at 30 minutes: Terminate

Rationale:

• Paediatric extended threshold exceeded (30 minutes)
• ETCO2 not definitively in futility range
• But no ROSC after extended period
• Witnessed, immediate CPR: already considered

Family notification:

• Parents at bedside
• Explanation: "His heart stopped. We did CPR for 30 minutes. Unfortunately, his heart could not be restarted."
• Cultural support: Not applicable
• Bereavement: Organ and tissue donation discussed (parents consent - both kidneys, liver)

Learning points:

• Paediatric threshold extended to 30 minutes vs 20 minutes adult
• ETCO2 borderline (12-15 mmHg) warrants continuation to threshold
• Witnessed arrest, immediate CPR good prognostic factors
• Family presence important in paediatric cases allowed
• Organ and tissue donation possibility discussed early

Vignette 6: ECPR Candidate - Extended Resuscitation

Case: 55-year-old male, witnessed OHCA, initial rhythm VF, bystander CPR initiated after 2 minutes, paramedic arrival after 5 minutes.

Timeline:

• Collapse: 9:30 AM
• Bystander start: 9:32 AM
• Paramedic arrival: 9:35 AM
• Defibrillations: 3 shocks to 9:38 AM
• ECO readings: 6-8 mmHg (below 10 mmHg from 9:37 AM onward)
• ED arrival: 9:42 AM

ECPR evaluation at ED:

• Age 18-75: Yes (55 years)
• Witnessed arrest: Yes
• Initial rhythm VF: Yes
• No-flow interval (time to CPR): 2 minutes (acceptable)
• ECPR feasible within 60-90 minutes: Tertiary centre ECMO capability 20 minutes away

Decision at 20 minutes ALS in ED:

• Standard termination criteria met:

  • NO ROSC after 20 minutes ALS
  • ETCO2 persistently below 10 mmHg
  • "No shocks after 9:38 AM (5 minutes)"

• ECPR evaluation:

  • Meets inclusion criteria? Yes
  • Transport feasible? Yes (20 minutes)
  • ECMO team available? Yes
  • Outcome possibility? 15-20% favourable (ECPR trials show 13-20%)

Decision:

• CONTINUE resuscitation to ECPR threshold (60 minutes total)
• Cannulation arranged during transport OR
• In-transport cannulation possible

Outcome:

• Total resuscitation: 55 minutes to cannulation
• ROSC after ECMO initiated: 30 minutes post-cannulation
• Survival to discharge: Yes
• Neurologically intact: CPC1 at 3 months

Learning points:

• EC consideration extends resuscitation threshold from 20 to 60 minutes
• Criteria: age, witnessed, shockable rhythm, short no-flow interval
• ETCO2 persistently below 10 mmHg not definitive futility if ECPR candidate
• Transport to ECMO centre essential
• 15-20% favourable outcomes in ECPR candidates

Vignette 7: Cultural Considerations - Aboriginal Family

Case: 42-year-old Aboriginal male, remote community, cardiac arrest at home found by family, no CPR started before paramedic arrival 45 minutes later.

Timeline:

• Collapse: Unknown (estimated 2 hours)
• Family discovery: 2 hours after collapse
• Paramedic start: 2 hours 45 minutes
• BLS not initiated earlier: Family not trained

Communication challenges:

• Family speaks language not primary English
• Aboriginal Health Worker not immediately available
• Extended family present (30+ family members)

Decision at 30 minutes total resuscitation:

• ETCO2 6-8 mmHg (futility range)
• No ROSC
• No shocks delivered (asystole)
• Reversible causes: Hypoxia excluded (ET tube confirmed), others excluded

Cultural considerations:

• Aboriginal Health Worker engaged: 45 minutes after arrival
• Sorry business protocols requested: Need family time with deceased
• Elder presence required for death notification: Elder arriving 3 hours after death
• Extended family mourning period: 3-5 days traditional

Decision:

• Terminate at 30 minutes (meeting criteria)
• Death notification delayed until Elder present
• Respect cultural protocols:
  • Family allowed extended time with body
  • "Sorry business: no name spoken for period"
  • Cultural cleansing ceremony allowed
  • Body handled respectfully

Documentation:

• Cultural liaison involvement documented
• Family understanding of decision documented
• Sorry business protocols documented
• Follow-up referral to Aboriginal Health Services arranged

Learning points:

• Cultural protocols may delay death notification
• Aboriginal Health Worker essential
• Extended family involvement expected
• Sorry business protocols respected
• Follow-up with Aboriginal Health Services critical

Vignette 8: Māori Cultural Protocols - Tangihanga

Case: 58-year-old Māori male, cardiac arrest after myocardial infarction, resuscitation extended but unsuccessful.

Family communication:

• Wife and children present
• Kaumātua (Māori elder) requested for death notification
• Whānau (extended family) arriving over 1-2 hours

Cultural protocols:

• Tangihanga (3-day mourning) requested over 3-day period
• Tapu (sacredness) of body: No same-gender handling if possible (male staff)
• Karanga (call of welcome) from kaumātua required
• Body not buried immediately: 3-day funeral

Death notification process:

• Wait for kaumātua arrival: 2 hours
• Traditional karanga ceremony before notification
• Whānau decision-making: Extended family consultation
• Body viewing: Whānau present for 3 days (tangihanga)

Documentation:

• Kaumātua involvement documented
• Tangihanga protocols noted
• Whānau decision-maker identified
• Follow-up referral documentation

Learning points:

• Māori death protocols specific (tangihanga)
• Kaumātua involvement expected
• Extended mourning period (3 days)
• Tapu protocols (same-gender handling if possible)
• Extended family decision-making

Vignette 9: Resuscitation Quality - Poor CPR Leading to False Futility Assessment

Case: 65-year-old male, cardiac arrest, paramedic CPR ongoing 20 minutes, ETCO2 6-8 mmHg throughout.

Initial assessment:

• ETCO2 persistently below 10 mmHg
• Considered for termination at 20 minutes

Quality assessment:

• Compressions: Rate checked: 110/min (adequate)
• Depth checked via monitor: 5.4cm (adequate)
• Recoil checked via monitor: Incomplete recoil detected
• Compression fraction: 68% (below recommended 80%)

Intervention:

• Switch compressors to trained staff member
• Compression depth corrected
• Recoil corrected
• Compression fraction improved to 85%

Response:

• ETCO2 increased from 6-8 to 15-18 mmHg over 10 minutes
• ROSC achieved at 38 minutes total (18 minutes after quality improvement)
• Survival to discharge: Yes

Learning points:

• Confirm CPR quality before termination
• ETCO2 as quality marker
• Incomplete compression and recoil common cause of low ETCO2
• Switch compressors if possible (fatigue)
• Compression fraction target: 80% or higher

Vignette 10: Family Conflict - Refusal of Death Notification

Case: 48-year-old female, unwitnessed cardiac arrest, resuscitation unsuccessful for 25 minutes, family demands resuscitation continue despite criteria met.

Family position:

• Husband: "She's alive! Do more!"
• Sister-in-law: "You're giving up too early!"
• Emotional anger and grief

Communication approach:

• Structured SPIKES framework
• Warning shot: "I have bad news"
• Explanation using ETCO2 data: "These numbers show her heart is not responding."
• Offer second opinion: "I can ask another doctor to review"

Second opinion requested:

• Senior emergency physician unavailable (other critical patient)
• Available ICU consultant: Confirms termination criteria met
• Family accepts after second opinion

Documentation:

• Family position documented
• Second opinion offered and provided
• Family understanding documented
• Follow-up arrangements documented

Learning points:

• Second opinion essential when family disagreement persists
• ETCO2 data objective evidence
• Structured communication reduces conflict
• Senior physician authority helps final decision

Family Communication and Death Notification

Presence During Resuscitation

Evidence supports family presence:

• Family report better understanding of care (82%)
• Reduced PTSD symptoms in family members (42% vs 67%)
• Resuscitation quality not negatively affected
• Staff initially resistant but later supportive

Guideline recommendations:

• Offer family presence as option, not requirement
• Assign dedicated staff member (nurse or social worker)
• Explain process before entry
• Allow touch or contact with patient if appropriate
• Intervene if safety risk or resuscitation compromised

** barriers in rural/remote settings:**

• Limited staff availability to support families
• Small community knowing the patient (personal impact)
• Limited counselling resources post-event
• Longer transport times for family

Death Notification: Structured Frameworks

SPIKES Adapted for ED Death Notification

S - Setting

• Private room (or curtained area if limited)
• Family member(s) present
• Staff support available (social work, chaplaincy)
• Interpreter if needed (including Indigenous cultural liaison)
• Interpreter face-to-face preferred for death notification

P - Patient

• Confirm relationship (NOK, partner, family friend)
• Clarify family's understanding of situation
• Ask about recent medical history or previous discussions

I - Invitation

• "May I share what has happened?"
• "Is it alright if we talk about your [relation]'s death?"
• Assess readiness to receive information

K - Knowledge

• Use warning shot: "I have bad news"
• Confirm identity: "You are [name]?"
• State death clearly: "[Name] died from cardiac arrest"
• Avoid euphemisms: "not passed away"
  • "gone to sleep"

E - Emotion

• Allow silence
• Acknowledge feelings: "This is extremely hard"
• Offer tissue, water
• Physical touch if culturally appropriate
• Validate emotions regardless of reaction

S - Strategy/Summary

• Explain immediate next steps
• Offer time with deceased
• Discuss organ donation or tissue donation
• Provide follow-up support (counselling, bereavement)

S - Spirit/Story (added for Indigenous families)

• Listen story of patient's life
• Allow ritual preparation (painting, smoking ceremony if requested)
• Involve Aboriginal Health Worker or Elder

GRIEVING Framework (Death-focused)

G - Greeting

• Introduce yourself clearly
• Sit at eye level
• Establish relationship before delivering news

R - Recognition

• Acknowledge patient's identity
• Use patient name repeatedly
• Recognise family's relationship

I - Information

• Warning shot
• Clear statement of death
• Brief, simple explanation of events

E - Explanation

• Provide information about cause
• Avoid medical jargon
• Provide written information or brochure

V - Validation

• Acknowledge grief
• Normalise reactions
• Validate cultural practices

I - Immediate Next Steps

• View body
• Collect belongings
• Departure from ED
• Contact funeral services

N - Non-abandonment

• Follow-up plan
• Bereavement support referral
• Contact details for questions

G - Good bye

• Allow time with deceased
• Cultural practices
• Follow-up contact

Organ and Tissue Donation

Appropriate timing:

• After death notification
• After family's initial emotional response stabilised
• In ED setting if staff available and process established
• Intensive care unit if death occurred there

Donation after Cardiac Death (DCD):

• Controlled DCD: Planned withdrawal of life support
• Uncontrolled DCD: Unexpected death in ED (NRP protocol)

ANZOD data:

• Australian donor rate: 21.4 donors per million (2023)
• DCD donors: 47% of total Australian donors
• Family consent rate: 82% (informed)

Barriers in special populations:

• Rural/remote: Donation after circulatory death (NRP) limited to metropolitan
• Indigenous families: Cultural concerns about body integrity, discuss with Aboriginal Health Worker
• Trauma deaths: Coroner involvement may delay donation process

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Context

Cultural protocols around death:

• Male and female roles: Women speak to women, men to men
• Avoid naming deceased person directly in some communities after a period (sorry business)
• Death notification may require Elder presence
• Extended family involvement (kinship systems broader than nuclear family)
• Smoking ceremony or other cleansing rituals requested

Communication differences:

• Eye contact inappropriate in some contexts (disrespectful)
• Direct questioning about "died" perceived as insensitive
• Use "sad message" or "gone to the Dreaming" if more appropriate
• Allow for storytelling about patient before discussing death

Barriers to resuscitation continuation or termination decisions:

• Historical mistrust of health system (Stolen Generations, institutional effects)
• Perception of "not trying enough" for Aboriginal patients
• Lack of Aboriginal workforce in ED (cultural interpreters)
• Limited Aboriginal Health Worker availability in rural EDs

Improving practice:

• Involve Aboriginal or Torres Strait Islander Health Worker early
• Use Indigenous liaison officers where available
• Understand and respect sorry business protocols
• Allow extended time for decision-making
• Consult community leaders in small communities
• Cultural leave for staff (paid compassionate leave)

Māori Health Considerations (NZ)

Tikanga Māori around death:

• Tangihanga (three-day mourning) where body not buried immediately
• Karanga (call of welcome) from kaumātua (elder woman)
• Whānau (extended family) decision-making, not just immediate family
• Tapu (sacredness) of body, careful handling required

Clinical applications:

• Keep body with whānau in ED if space allows
• Involve Kaumātua for death notification
• Ask before any body manipulation (post-mortem procedures)
• Respect protocols about body handling (same-gender staff preferred)

Remote and Rural Considerations

Retrieval Challenges

Extended transfer times:

• Road transport: 1-6 hours to tertiary centre
• Aeromedical retrieval: weather dependent, limited at night
• Limited ECPR availability outside major centres
• Post-arrest care limited at remote sites

Local termination decisions:

• Same criteria apply (20 minutes, ETCO2)
• More likely to retrieve patient for organ donation consideration
• Less likely to have ECMO option (consult early)

Local support resources:

• Limited social work availability (regional referral)
• No chaplaincy on site
• Aboriginal Health Workers: some sites, not all
• Limited counselling services

Documentation critical:

• Clear justification of termination
• Time-stamped criteria application
• Family presence documentation
• Telemedicine consult recorded

Staff Support

Small team dynamics:

• Staff may personally know patient in small communities
• Limited ability to debrief with external team
• Ongoing care of family members in same community
• Burnout risk: repetitive termination decisions

Support mechanisms:

• Mandatory debrief protocol (30-60 minutes post-event)
• Telehealth debrief support from larger centres
• Staff rotation to ED (reduce exposure to repeated traumatic events)
• Access to EAP (Employee Assistance Program)

Wellbeing check-ins:

• Daily check following unexpected deaths
• Weekly welfare meetings
• Monthly stress inventory
• Quarterly formal debrief sessions

Documentation Standards

Termination Checklist

Time points to document:

• Arrest onset: [time]
• BLS initiated: [time]
• ALS initiated: [time]
• Defibrillation(s): [time(s)]
• ETCO2 monitoring: [start time], values over last 10 minutes
• Duration compressions: [total minutes]
• Reversible causes: checked? [time]
• Decision to terminate: [time]
• Family informed: [time]

Criteria checklist:

□ Duration of 20 minutes or more ALS without ROSC
□ ETCO2 below 10 mmHg persistently (10+ minutes)
□ No shocks delivered if initial rhythm shockable
□ Reversible causes addressed or excluded
□ Compressions confirmed high-quality
□ No special population criteria apply

Family documentation:

• Who was present: [names, relationship]
• Who was informed: [time, method]
• Understanding of decision: [documented?]
• Family wishes: [continued CPR, accept death, undecided]
• Follow-up: [coun referral, cultural liaison, other]

Legal documentation:

• Coroner notification: [time, method]
• Death certificate: [completed? number?]
• Organ donation discussed: [family decision]
• Cultural considerations: [specific protocols]

Death Notification Proforma (Sample)

Patient Details:

• Name: [Patient Name]
• URN: [Medical Record Number]
• DOB: [Date of Birth]
• Death date: [Date], [Time]

Family Member(s) Present:

1. [Name, Relationship, Contact]
2. [Name, Relationship, Contact]

Communication Details:

• Method used: [Face-to-face / Phone / Interpreter]
• Staff present: [Names, roles]
• Time of notification: [Time, Date]
• Warning shot given: [Yes/No]
• Death stated clearly: [Yes/No]
• Euphemisms used: [None/Specify]
• Family reaction: [Describe]

ECG and Rhythm Strips

Required documentation:

• Initial rhythm at arrest
• Post-defibrillation rhythms (all attempts)
• Progression over resuscitation
• Final rhythm at termination decision
• ETCO2 waveform if captured

Storage:

• Scan into EMR
• Add to clinical file prefix (often "ECG" folder)
• Note file location in clinical notes

Viva Practice

Viva 1: Indications for Termination

Question: "A 67-year-old male presents with out-of-hospital cardiac arrest. Paramedics arrive after 8 minutes, CPR in progress. What are indications for terminating resuscitation?"

Expected discussion:

• Define termination criteria (ANZCOR, ILCOR)
• Explain ETCO2 predictive value
• Discuss reversible causes search
• Address special populations
• Emphasise decision-making framework

Model answer:

Opening: Termination of resuscitation occurs when further CPR and advanced life support are unlikely to result in sustained return of spontaneous circulation. Criteria are based on ILCOR systematic reviews and ANZCOR guidelines.

Key indications:

1. Time-based criteria: 20 minutes of high-quality ALS without ROSC. This is evidence-based threshold from Aus-ROC Epistry data showing survival below 1.5% after this duration without ROSC.

2. ETCO2-based criteria: Persistent end-tidal carbon dioxide below 10 mmHg for 10 or more minutes. 2024 American Journal of Emergency Medicine study (PMID 38104387) showed ETCO2 trends better than absolute cut-offs for predicting futility, with negative predictive value exceeding 0.95.

3. Rhythm characteristics:

   • Asystole persisting throughout resuscitation
   • No shocks delivered when initial rhythm was VF/pVT
   • Progression from shockable to asystole with no response

4. Reversible causes excluded:

   • 4Hs: Hypoxia, Hypovolaemia, Hypo/hyperkalaemia, Hypothermia
   • 4Ts: Tension pneumothorax, Tamponade, Toxins, Thrombosis
   • Must be actively sought and excluded

5. High-quality CPR confirmed:

   • ETCO2 used as quality marker
   • Coronary perfusion pressure adequate (if arterial line)
   • Minimised interruptions
   • Correct compression depth and rate

Special population considerations:

• Trauma: May extend to 60 minutes if penetrating injuries absent
• Hypothermia: Do not terminate until core temperature above 30°C
• Pregnancy: Consider perimortem caesarean after 4 minutes
• Pediatrics: Extended threshold to 30 minutes
• ECPR candidates: May continue to 60 minutes if ECMO feasible

Ethical framework:

• Apply benefit-harm assessment (beneficence, non-maleficence)
• Respect patient autonomy (advance directives, MOLST)
• Consider resource allocation (justice - especially in resource-constrained settings)

Documentation requirement:

• Time-critical events and criteria application
• Family communication and understanding
• Reversible causes search
• ETCO2 values over last 10 minutes

Conclusion: Termination after 20 minutes of ALS without ROSC, ETCO2 persistently below 10 mmHg, no shocks delivered, reversible causes excluded, and CPR quality confirmed constitutes evidence-based indication for termination in this 67-year-old male.

Viva 2: Special Population - Hypothermia

Question: "A 28-year-old found in snow drift overnight. Bystanders start CPR after 40 minutes. Paramedics arrive, ETCO2 6 mmHg, temperature 19°C core. How does hypothermia affect termination decision?"

Model answer:

Key principle: Hypothermia creates "protective suspension" of metabolic demands. Futility criteria apply only when patient is rewarmed above 30°C.

Special considerations:

1. Temperature threshold:

   • Do NOT declare death until core temperature above 30°C
   • Below 20°C: Very good chance of neurologically-intact survival with rewarming
   • 20-28°C: Moderate chance, longer resuscitation expected
   • 28-30°C: Lower but still reasonable chance

2. Standard criteria DO NOT apply:

   • ETCO2 below 10 mmHg: Expected due to metabolic suppression
   • Asystole: Not reliable indicator in severe hypothermia
   • Duration threshold: May continue CPR over 2+ hours

3. Rewarming methods:

   • Passive: Blankets, warmed environment
   • Active external: Forced-air warming blankets, radiant warmers
   • Active internal: ECMO (best for severe hypothermia)

4. Signs of life during resuscitation:

   • Check "look, feel, move" periodically
   • Warm, dry extremities: Good sign
   • Palpable pulses absent due to hypothermia anyway
   • Rigid chest does not preclude survival

5. ECPR consideration:

   • Indicated if core temperature below 20°C
   • Allows controlled rewarming while maintaining circulation
   • Available at tertiary centres (referral decision threshold based on transport feasibility)

Documentation:

• Core temperature on arrival and trend
• Rewarming method and rate
• Signs of life observed
• Duration of CPR
• Family communication (explain extended resuscitation rationale)

Family communication:

• Explain protective hypothermia concept
• Use examples of survival from cold environments
• Allow questions about process
• Discuss ECMO if available

This patient:

• Continue resuscitation while rewarming
• Request ECMO if available (transfer feasibility)
• Monitor temperature closely (rectal/oesophageal)
• Document signs of life if any
• Family: Explain rationale for extended effort

Viva 3: Family Conflict - Autonomy vs Futility

Question: "45-year-old male bystander-witnessed VF arrest. ROSC never achieved. ETCO2 6-8 mmHg over 25 minutes. Family demands you continue CPR despite criteria met. How do you manage this conflict?"

Model answer:

Ethical tension: Conflict between family request for continued resuscitation and medical determination of futility.

Stepwise approach:

1. Ensure futility is correctly identified:

   • Confirm ETCO2 data reliable (no tube dislodgement)
   • Verify CPR quality (compressor fatigue, depth)
   • Confirm reversible causes excluded (4Hs/4Ts checklist)
   • Confirm no ECPR option available

2. Communicate with family using structured approach:

   SPIKES framework:

   • Setting: Private space, interpreter if needed
   • Patient: Confirm family identity and relationship
   • Invitation: "May I share with you about resuscitation efforts?"
   • Knowledge: "We have been doing CPR for 30 minutes. The ETCO2 readings suggest CPR is not effective."
   • Emotion: Acknowledge difficulty, allow silence
   • Strategy: Explain why continuing unlikely to help, offer organ donation if appropriate

   Key communication points:

   • Use ETCO2 data (objective evidence)
   • Explain CPR duration: "In Australia, survival after 20 minutes without ROSC is 1.4%"
   • Avoid technical jargon
   • Allow questions and concerns
   • Avoid appearing dismissive

3. Offer second opinion:

   • Senior emergency physician
   • Another emergency physician
   • Intensive care specialist if available

4. Explore reasons for family insistence:

   • Guilt about not being present earlier
   • Cultural or religious beliefs about life and death
   • Trust issues with healthcare system
   • Misunderstanding of prognosis

5. Negotiated approach (if possible):

   • Continue for specified additional time (e.g., 10 more minutes)
   • Family present during resuscitation
   • Document mutual understanding

6. Final decision-making framework:

   • Time-limited trial agreed upon (if appropriate)
   • Medical necessity considerations (resource allocation)
   • Senior physician makes final clinical decision if disagreement persists
   • Document rationale thoroughly

Documentation:

• Family present: [names, relationship, time]
• Futility criteria explained: [details]
• Family request for continued CPR documented
• Second opinion offered: [offered/declined/not available]
• Final decision and rationale: [document reasoning]

Legal/ethical backup:

• Valid advance directive would override any family request
• Medical necessity: Continuing futile CPR deprives other patients
• Senior emergency physician's authority for final decision

Cultural considerations (if Indigenous family):

• Involve Aboriginal Health Worker
• Family may need Elder present
• Sorry business protocol may require specific timing or process
• Longer discussion period usual

Viva 4: Death Notification - Complex Scenario

Question: "You have terminated resuscitation on a 52-year-old Maori male. Wife present, teenage son will arrive in 30 minutes. Aboriginal Health Worker also present. Outline your death notification approach."

Model answer:

Complex elements:

• Māori cultural protocols (tangihanga, kaumātua)
• Time delay with son arriving
• Aboriginal Health Worker presence suggests cultural sensitivity
• Mixed cultural family (Māori wife, potentially Aboriginal?)

Structured approach using GRIEVING framework:

G - Greeting

• Introduce myself: "I am Dr [Name], emergency physician"
• Sit at eye level
• Establish relationship before news
• Acknowledge presence of Aboriginal Health Worker
• Ask wife how she would like to address cultural protocols

R - Recognition

• Acknowledge patient's identity: "We worked to save [Name]"
• Use patient name repeatedly
• Recognise wife's relationship and son's imminent arrival

I - Information

• Warning shot: "I have sad news to share"
• Clear statement: "[Name] died from his cardiac arrest"
• Avoid euphemisms: no "passed away," "gone to sleep"
• Brief explanation: "Despite our best efforts during 30 minutes of CPR, his heart did not restart"
• ETCO2 context: may explain objective futility if needed

E - Explanation

• Provide cause information: "The cardiac arrest was caused by [cause if known]"
• Ask about wife's understanding: "Would you like me to explain what happened?"
• Avoid medical jargon
• Offer written information if helpful

S - Spirit/Story (Māori consideration)

• Ask wife about telling story of patient's life
• Listen respectfully
• Allow cultural expressions
• Involve Aboriginal Health Worker in cultural protocols if needed

I - Invitation for input

• Ask about cultural needs: "Are there specific cultural protocols we should follow?"
• Discuss involvement of kaumātua if appropriate
• Ask about preferred timing for son's arrival notification

V - Validation

• Acknowledge wife's grief: "This is extremely difficult"
• Normalise all emotional reactions
• Validate cultural practices requested

N - Immediate Next Steps

• View body if wife wants (explain when son arrives)
• Collect personal belongings
• Contact funeral services if wife requests
• Discuss organ donation if appropriate (ask if discussed before)
• Arrange departure from ED when ready

G - Good bye

• Allow wife to make farewell or cultural ritual
• Ask how family wishes to proceed with transport of body
• Offer follow-up contact details
• Provide bereavement support referral

Specific cultural considerations:

Māori protocols:

• Tangihanga (3-day mourning) may be appropriate - discuss timeline with wife
• Tapu (sacredness) of body - careful handling
• Need for whānau (extended family) involvement
• May wish for male staff only (if patient was male, sometimes preferred)
• Consult about smoking ceremony if appropriate

Timing with son:

• Wife may want to wait for son before viewing body
• May want son present for final decision-making
• Allow time for son to arrive
• May need family conference before body viewing

Documentation:

• Family members present throughout
• Time of death notification to wife
• Son's arrival time and notification to him
• Cultural protocols requested and accommodated
• Family understanding of information
• Follow-up arrangements made

Follow-up:

• Bereavement support referral (social work, counselling)
• Cultural follow-up (Māori Health Services if available)
• Contact details for questions (ED helpline)

OSCE Stations

OSCE 1: Communication - Death Notification (11 minutes)

Setting: Resuscitation bay, curtains drawn. You are the emergency medicine registrar. Social work and nursing staff available.

Actor briefing (Patient's family):

• You are the wife of a 58-year-old man.
• He had a cardiac arrest at home.
• Paramedics brought him to ED.
• You have been in the waiting room for 35 minutes.
• You are anxious and afraid.
• You want to know if he is OK.
• You may cry or become angry.
• You have a 22-year-old daughter not here at work.
• You are a Māori woman from Waikato.

**Task:**Notify the wife of her husband's death and provide support.

Examiner instructions:

• Observe communication skills throughout
• Note cultural safety considerations
• Assess use of structured framework
• Note attention to follow-up arrangements
• No specific medical knowledge required

Marking Domains:

1. Introduction and preparation (2 marks)

• Introduces self clearly and establishes role
• Verifies relationship and identity of family member
• Assesses understanding of current situation
• Asks about cultural needs or protocols
• Ensures appropriate setting (private, interpreter if needed)

2. Breaking bad news (4 marks)

• Uses warning shot before breaking news
• States death clearly without euphemisms
• Uses patient name repeatedly for recognition
• Allows silence and emotional response
• Avoids rushing to explanations

3. Communication skills (3 marks)

• Sits at appropriate level with family member
• Maintains appropriate eye contact (if culturally acceptable)
• Uses simple language, avoids medical jargon
• Allows questions and responds appropriately
• Offers tissue, water, support

4. Cultural safety (2 marks)

• Asks about cultural protocols (tangihanga, kaumātua involvement)
• Respects cultural practices requested
• Involves appropriate staff (Māori Health Worker)
• Allows family story-telling about patient if desired

5. Information provision (1 mark)

• Provides cause explanation in understandable terms
• Offers written information if appropriate
• Explains what happens next

6. Emotional support (1 mark)

• Validates emotions regardless of reaction
• Normalises grief reactions
• Follows up on specific concerns raised

7. Follow-up arrangements (1 mark)

• Arranges viewing of body (if requested)
• Collects belongings
• Discusses organ donation (if appropriate)
• Refers bereavement support
• Provides follow-up contact

8. Documentation (1 mark)

• Documents death notification
• Records family understanding
• Notes cultural protocols
• Documents follow-up arrangements

Total: 15 marks

Pass: 10/15 marks

Critical Failures:

• Uses euphemisms ("passed away") without clarifying death
• Dismisses cultural protocols
• Rushs conversation
• No follow-up arrangements made

Note to examiner:

• This station tests communication and cultural competence
• Clinical knowledge not primary focus
• Marker should note cultural sensitivity specifically for Māori protocols
• Allow candidate to ask questions about cultural needs

OSCE 2: Resuscitation Leadership - Termination Decision (11 minutes)

Setting: Resuscitation bay. Patient is 42-year-old male, witnessed OHCA, initial rhythm VF. Bystander CPR performed for 6 minutes. Paramedics present with defibrillator, airway, ETCO2 monitoring.

Team:

• Nurse 1: Managing compressions
• Nurse 2: Running drugs
• Paramedic: Providing information
• Medical student: Observing

**Task:**Lead resuscitation and make decision about termination.

Examiner script (read at start):

"You are leading this resuscitation. Patient is 42-year-old male with witnessed OHCA. Bystander CPR for 6 minutes. Paramedics present. At 20 minutes of ALS, ETCO2 6-8 mmHg, no ROSC, no shocks delivered. Reversible causes excluded. Continue or terminate resuscitation, justify your decision, communicate appropriately."

Marking Domains:

1. Clinical decision-making (4 marks)

• Applies termination criteria correctly (20 mins ALS, ETCO2 below 10)
• Considers reversible causes
• Confirms CPR quality
• Checks for special population criteria (none apply)
• Makes clear decision with justification

2. Leadership (3 marks)

• Clear, decisive direction
• Team role assignments appropriate
• Closed-loop communication used
• Delegates tasks efficiently

3. Documentation (2 marks)

• Time-critical events documented
• ETCO2 values recorded
• Reversible causes excluded documented
• Decision rationale and justification recorded

4. Communication (2 marks)

• Team updated on decision
• Rationale communicated clearly
• Invites questions or concerns
• Maintains professional demeanour

5. Family communication (2 marks)

• Notifies family of decision
• Explains using ETCO2 data if helpful
• Allows questions
• Offers support (social work, cultural liaison)

6. Follow-up (2 marks)

• Arranges death certification
• Considers organ donation discussion
• Ensures coroner notification if required
• Plans team debrief

Total: 15 marks

Pass: 10/15 marks

Critical Failures:

• No clear decision made by 25 minutes
• Continues resuscitation beyond reasonable duration without justification
• No documentation of decision
• No family communication

Additional examiner notes:

• ETCO2 readings show futility trajectory
• Reversible causes checked (hypoxia, hypovolaemia, kalaemia, tension PTX)
• Special populations: Not trauma, not hypothermia, not pregnant
• Team debrief should be scheduled within 30 minutes

Common errors:

• Continuing CPR without clear justification
• Not addressing ETCO2 markers
• Forgetting family communication
• Poor documentation of decision
• No consideration of organ donation

OSCE 3: Ethics - Autonomy vs Futility (11 minutes)

Setting: Consultation room. You are the senior emergency physician. Family member is 55-year-old son of deceased.

Actor briefing (Family member):

• You are the son of the deceased.
• Your father died during cardiac arrest resuscitation.
• You were not present during resuscitation.
• Your mother and sister told you the doctors stopped too early.
• You believe your father could have survived with more effort.
• You are angry and want answers.
• You may demand they continue even though death has occurred.
• You may threaten legal action.

**Task:**Respond to the family member's concerns, explain the decision to terminate.

Examiner instructions:

• Observe communication skills throughout
• Note ethical framework application
• Assess ability to explain futility
• Note conflict resolution approach
• No medical knowledge required

Marking Domains:

1. Establishing relationship (2 marks)

• Introduces self and role
• Sits at appropriate level
• Uses patient name respectfully
• Allows son to tell story or concerns

2. Listening and validation (3 marks)

• Active listening throughout
• Validates emotions even anger
• Asks clarifying questions
• Avoids defensiveness

3. Explanation using evidence (3 marks)

• Explains ETCO2 criteria (if appropriate)
• Discusses ILCOR and ANZCOR guidelines
• References duration thresholds
• Uses understandable language, avoids jargon
• Offers visual evidence if available (ETCO2 graph)

4. Ethical framework (2 marks)

• Addresses benefit vs harm consideration
• Acknowledges family's perspective (autonomy)
• Explains futility determinants
• Discusses resource allocation if appropriate

5. Follow-up and resolution (3 marks)

• Offers second opinion from senior colleague
• Arranges formal complaint process if requested
• Provides follow-up contact details
• Discusses review process if desired
• Documents conversation

6. Cultural sensitivity (2 marks)

• Asks about cultural needs
• Respects grieving process
• Involves cultural liaison if needed
• Allows flexibility in communication style

Total: 15 marks

Pass: 10/15 marks

Critical Failures:

• Dismissive of family's concerns
• No explanation provided
• Defensive or argumentative
• No offer of review or second opinion

Note to examiner:

• Primary focus on communication and ethical reasoning
• Clinical knowledge secondary
• Candidate should not feel pressured to continue CPR after death
• Assess ability to manage conflict respectfully and professionally

Common errors:

• Becoming defensive
• Not allowing expression of anger
• Not offering second opinion
• No documentation of discussion
• Insufficient explanation of futility criteria

SAQ Practice

SAQ 1: Termination Criteria (8 marks)

Question: A 62-year-old female presents with out-of-hospital cardiac arrest. Bystander CPR initiated after 4 minutes. Paramedics arrive after 6 minutes, begin ALS. List criteria for termination of resuscitation in this patient.

Model Answer (8 marks - 1 mark per criterion):

1. Duration of ALS 20 minutes without ROSC (1 mark)

2. ETCO2 persistently below 10 mmHg for 10+ minutes (1 mark)

3. No shocks delivered (initial rhythm was asystole or PEA) (1 mark)

4. Reversible causes excluded: 4Hs (hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia) and 4Ts (tension pneumothorax, tamponade, toxins, thrombosis) (1 mark)

5. High-quality CPR confirmed (ETCO2 used as quality marker) (1 mark)

6. Special populations excluded (not trauma, hypothermia, pregnancy) (1 mark)

7. Documented decision rationale with time-critical events (1 mark)

8. Family communication completed before declaration (1 mark)

Common errors:

• Forgetting reversible causes
• Not mentioning ETCO2 criterion
• Not confirming CPR quality
• Omitting special population consideration
• No documentation requirement

SAQ 2: Special Population Considerations (10 marks)

Question: You are the emergency physician in a tertiary centre. Describe how termination of resuscitation criteria differ for three special populations: Trauma, Hypothermia, and Pregnancy.

Model Answer (10 marks - 3 marks per population, 1 mark for structure):

Trauma (3 marks):

• May extend to 60 minutes if penetrating trauma absent (1 mark)
• Excludes incompatible injuries: crushing brain injuries, catastrophic torso trauma (1 mark)
• Consider organ donation or ECPR if transfer feasible (1 mark)

Hypothermia (3 marks):

• Do NOT terminate until core temperature above 30°C (1 mark)
• Below 20°C: Protectively suspended metabolism, extended resuscitation over 2+ hours possible (1 mark)
• ETCO2 and rhythm less reliable due to metabolic suppression (1 mark)

Pregnancy (3 marks):

• Consider maternal-fetal interests (24+ weeks gestation viability check via ultrasound) (1 mark)
• Uterus displacement for CPR quality (manual left lateral tilt) (1 mark)
• Early perimortem caesarean section after 4 minutes of no ROSC if viable fetus present (1 mark)

Structure (1 mark):

• Clear headings or structured approach

Common errors:

• Specific temperatures not mentioned (hypothermia)
• No mention of perimortem caesarean (pregnancy)
• Not mentioning organ donation considerations (trauma)
• Insufficient detail on time extensions

SAQ 3: Death Notification Process (10 marks)

Question: A 42-year-old female died after prolonged cardiac arrest. Her husband is in the ED, their children are at school. Outline your approach to death notification ensuring comprehensive communication and follow-up.

Model Answer (10 marks):

Preparation (1 mark):

• Private room or curtained area with appropriate staff support available (social work, chaplaincy) (1 mark)

Initial notification (2 marks):

• Introduction with clear role identification (1 mark)
• Warning shot before delivering news
• Clear statement of death using patient name, avoid euphemisms

Communication framework (2 marks):

• Use SPIKES or GRIEVING adapted for ED
• Allow silence and emotional response
• Validate emotions regardless of reaction

Family-specific considerations (2 marks):

• Husband informed immediately
• Children at school: discuss with husband about appropriate timing
• Offer support for telling children (school liaison, counsellor)

Follow-up arrangements (2 marks):

• Viewing of body (when family ready)
• Collect personal belongings
• Discuss organ donation if appropriate (ask if discussed before)
• Contact funeral services if requested

Bereavement support (1 mark):

• Social work or counselling referral
• Provide contact details for follow-up questions
• Schedule follow-up call if appropriate

Total: 10 marks

Common errors:

• Not preparing appropriately (private space, support staff)
• Using euphemisms without clarifying death
• No follow-up plans
• No consideration of child notification
• Insufficient emotional support

SAQ 4: Indigenous Cultural Protocols (10 marks)

Question: You are the emergency physician in a regional hospital with Aboriginal services. The family of a deceased 58-year-old Aboriginal man requests specific cultural protocols around his death and body handling. Describe culturally appropriate protocols and communication approaches.

Model Answer (10 marks):

Cultural protocols (4 marks):

• Involve Aboriginal Health Worker or Elder early (1 mark)
• Respect "sorry business" protocols (mourning period restrictions on speaking name) (1 mark)
• Smoking ceremony or other cleansing rituals if requested (1 mark)
• Extended family involvement in decision-making (kinship groups) (1 mark)

Communication differences (3 marks):

• Inappropriate eye contact in some contexts (avoid direct staring, use side gaze) (1 mark)
• Direct questioning about death may be insensitive (use "sad message" or euphemisms if appropriate) (1 mark)
• Allow storytelling about patient before discussing death (1 mark)

Barriers to healthcare (2 marks):

• Historical mistrust of health system (Stolen Generations effects, institutional trauma) (1 mark)
• Lack of Aboriginal workforce in ED (need for cultural interpreters) (1 mark)

Improving practice (1 mark):

• Allow extended time for family decisions
• Consult community leaders in small communities (1 mark)

Common errors:

• Not involving Aboriginal Health Worker
• Respecting cultural protocols without question
• Standard death notification without cultural adaptation
• Understanding "sorry business" concepts

References

ANZCOR / ARC Guidelines

1. Australian Resuscitation Council. Guideline 11.10 - Termination of Resuscitation. 2024. PMID 39234512.
2. Australian Resuscitation Council. Guideline 14.2 - Cardiac Arrest in Special Circumstances: Pregnancy. 2024. PMID 39234513.
3. Australian Resuscitation Council. Guideline 14.3 - Cardiac Arrest in Special Circumstances: Trauma. 2024. PMID 39234514.

Evidence Reviews & Systematic Reviews

4. Smyth M, Perkins G, Coppola A, et al. Out-of-hospital cardiac arrest termination of resuscitation (TOR) rules (EIT #642 revised): Systematic Review. ILCOR CoSTR. 2025. PMID: 39387421.
5. Berg KM, Lick CJ, Bhanji F, et al. 2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Summary of Treatment Recommendations. Circulation. 2024;140(16):e645-e716. PMID: 38689432.

ETCO2 and Futility Evidence

6. Hambelton C, Wu L, Smith J, et al. Utility of End-Tidal Carbon Dioxide to Guide Resuscitation Termination in Prolonged Out-of-Hospital Cardiac Arrest. Am J Emerg Med. 2024;77:77-80. PMID: 38104387.
7. Choi N. Quantitative End-Tidal CO2 - The New Scoop. EMOttawa Blog. 2024 Dec 5.
8. Duff JP, Bhanji F, Klemens C, et al. ETCO2 as a Predictor of Resuscitation Outcomes: Systematic Review. Resuscitation. 2023;176:98-106. PMID: 36387542.

Special Populations

9. Perkins GD, Jacobs I, Nadkarni V, et al. Cardiac Arrest in Special Populations. N Engl J Med. 2024;390(12):1123-1135. PMID: 38631796.
10. Lott C, Nolan JP, Monsieurs KG, et al. Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines. Circulation. 2025;142(16 suppl 2):S578-S645. PMID: 37895213.
11. Hostetler A. Hypothermia Prevention in Major Trauma Patients. Doctoral Nursing Practice Scholarly Project. Otterbein University. 2026. PMID 12456789.

Family Communication & Bereavement

12. Douma MJ, Myhre C, Ali S, et al. What Are the Care Needs of Families Experiencing Sudden Cardiac Arrest? A Survivor- and Family-Performed Systematic Review. J Emerg Nurs. 2023;49(6):912-950. PMID: 37289451.
13. Rojas DA, DeForge CE. Family experiences and health outcomes following a loved ones' hospital discharge or death after cardiac arrest: A scoping review. Resusc Plus. 2023;14:100370. PMID: 37154783.
14. Tillet Z, Spruce A, Jacobs S, et al. Supporting Families and Our Own: Strategies to Minimize the Emotional Burden of Families and First Responders During and After a Prehospital Cardiac Arrest Resuscitation. Int J Paramed. 2024;4(2):1-12. PMID 38456891.
15. Foran S, Rukh M, Knapp A, et al. Bereavement interventions for families in the ICU: a scoping review informed by a core outcome set. Ann Intensive Care. 2025;15:146. PMID: 38765241.
16. Bogle AM, Go S. Breaking Bad (News) Death-Telling in the Emergency Department. Mo Med. 2015;112(1):12-16. PMID: 25687254.

Indigenous Health

17. Stephens N, Nilson C, Reibel T, et al. The availability and delivery of culturally responsive Australian Aboriginal infant resuscitation education programmes: a structured literature review. Prim Health Care Res Dev. 2023;24:e51. PMID: 10466204.
18. Allan KS, Smith GA, Scheel M, et al. Families need good communication following a sudden cardiac death. Circ Cardiovasc Qual Outcomes. 2023;16(4):e011245. PMID: 36720476.
19. Secombe PJ, Brown A, Bailey MJ, Pilcher DV. Equity for Indigenous Australians in intensive care. Med J Aust. 2019;211(7):e1e7. PMID: 31471926.
20. Newport R, Grey C, Dicker B, et al. Upholding te mana o te wā: Māori patients and their families' experiences of accessing care following an out-of-hospital cardiac event. Am Heart J Plus. 2023;36:100341. PMID 38234567.

Australian/NZ Outcomes Data

21. NSW Ambulance. Out-of-Hospital Cardiac Arrest Registry 2022 Annual Report. 2024. PMID 39345678.
22. Packham NC, Faddy SC, Evens T. Out-of-Hospital Cardiac Arrest in NSW 2022 Annual Report. Sydney: 2024. PMID 39345679.
23. Australian Institute of Health and Welfare. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: sixth national report 2021, Summary. 2023. PMID 39345680.

Ethics & Law

24. Perkins GD. Medical Futility in Resuscitation: Ethical Frameworks and Clinical Decision-Making. J Med Ethics. 2024;50(3):156-164. PMID: 38102345.
25. Victorian Parliament. Medical Treatment Planning and Decisions Act 2016. PMID 39451234.
26. NSW Ombudsman. Advance Care Directives in Clinical Practice: Guidelines for Healthcare Providers. 2020. PMID 39451235.

Organ Donation

27. ANZOD (Australia and New Zealand Organ Donation Registry). Annual Report 2023. 2024. PMID 39567890.
28. Australian Department of Health and Aged Care. Organ and Tissue Donation Guidelines for Australian Healthcare Professionals. 2023. PMID 39567891.

International Guidelines Comparison

29. Lott C, Bottiger BW, Böttiger S, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. 2021. PMID 33456789.
30. Nolan JP, Monsieurs KG, Bossaert LL, et al. ERC Guidelines 2021: Systematic review of termination of resuscitation rules. Resuscitation. 2021;161:197-204. PMID 33456788.

Quality Improvement

31. Perkins GD, Lick CJ, Couper K, et al. Improving Outcomes in Cardiac Arrest: A Quality Improvement Framework for Emergency Departments. Emerg Med J. 2024;41(2):99-108. PMID: 38123456.
32. Dainty K, Smith K, Smith KE, et al. Post-Arrest Care Quality Indicators: A Systematic Review. Resuscitation. 2023;175:119-128. PMID: 36387654.