Determination of Death (ALS)

History Of Present Illness

Our crew is called to a private residence for a 50-year-old man found unresponsive
by his brother. He was last seen yesterday. He is lying on the floor. There was no
recent illness or known trauma. Our patient is non-responsive.

Past medical history :  Unknown

Medications:  Unknown

Allergies:  Unknown

Social history:  Smokes 3 packs per day. History of both alcohol and drug

abuse.

Vital  signs :  

 Temp:  not taken,

 Resp:  0

 Pulse:  0

Physical Exam
General:  Our patient is unresponsive, cool, pale, and blue. There is evidence of rigor
mortis and lividity. No evidence of trauma.
HEENT:  Pupils are fixed and dilated. No JVD.
Lungs:  Lung sounds are absent.
Cardiac:  Heart sounds are absent.
Chest:  No wounds, lesions, or swelling.
Abdomen:  Soft, no masses, no swelling.
Back:  Livor mortis is noted.
Extremities:  No pedal edema.
Skin:  Cool and dry, no evidence of trauma. Rigidity and livor mortis are present.
Neuro:  Unresponsive, GCS 3.

Dr. Katz's Assessment Of This Case

In the scenario you have just witnessed, our crew is dispatched to the scene of a 50-
year-old man in cardiac arrest with obvious signs of prolonged death.
 
As there are no signs of life, and the patient has obvious signs of death, the patient is
not placed on a monitor. If there is any doubt, the patient should be placed on a
monitor with the initiation of BLS and ACLS. In a scenario like this one, history of the
patient is to be determined by interviewing family and/or bystanders, and by any clues
left on scene.
 
Whether you are a BLS or ALS provider, the protocols for CPR and ACLS typically are
straightforward. However, what if the patient is dead, or presumed dead? If your
agency has a protocol allowing the EMS provider to declare someone dead in the field,
how should you proceed? Would your approach be different now?
 
Determination of death is serious business. Death is something we all face, but it is a
diagnosis that you definitely want to be really sure about. End-of-life issues are not
simple matters in the pre-hospital environment. Although these cases are sometimes
straightforward, they can be challenging and stressful to the EMS professional.
Sometimes
your challenge will be to accurately determine death in the pre-hospital environment.
Sometimes your primary focus will be supporting the family of the deceased. It is also
important to be aware of the many challenges and local variations in handling do not
resuscitate orders (DNRO) and other advanced directive issues. Reviewing your local
“Education to the Rescue” 4 protocols and practicing your patient assessments in a
consistent and organized manner each time can prevent omission of important steps or
procedures. This is especially important with cases involving determination of death.

The Diagnosis Of Death

The diagnosis of death must be made carefully. Do not make hasty assumptions. The
deciding factor will be determined using the facts found during the physical exam and
the vital signs of the patient. The most important treatment, for the patient that you
believe to be dead, is to determine if the patient is truly dead.

Dr. Katz Reflects

“I remember a case in the Emergency Department where 30 minutes after a woman
was declared dead by a physician, the grieving husband notices that his wife was
showing signs of occasional spontaneous breathing. I can think of no error more serious
than declaring someone dead that is still alive. I would personally prefer to see a
thousand dead patients with extensive resuscitation attempts than to see a single
patient accidentally declared dead that was later determined to be alive.” Bottom line:
death is a serious diagnosis. In addition to documenting the absence of breath sounds
and pulses, it is also useful to document that the patient’s pupils are fixed and dilated.
Also, documenting a 12-lead EKG showing asystole in more than one lead is sometimes
helpful if the patient is not exhibiting obvious signs of death.  “Education to the Rescue”
5 

When all is said and done about the different points, counter-points, algorithms,
protocols, policies, and procedures, the bottom line is do not declare someone dead
unless you are 100% sure. Determination of death is not the diagnosis you want to
take a chance on being wrong.

In a letter to the editor titled “Termination of CPR in the Prehospital Arena” published in
Annals of Emergency medicine in November 1985, Drs. Mickey S. Eisenberg and
Richard O. Cummings wrote, “And how many times have you been involved in a
prolonged resuscitation and everything seemed hopeless and suddenly a palpable pulse
was detected? Probably rarely. But therein lies the problem.” Twenty-five years later we
still are faced with the same challenge: How do we accurately declare someone dead in
the pre-hospital environment?  

If you are going to declare someone dead, make sure to carefully document according
to your department’s policies and protocols. Common items that should be documented
are “pupils fixed and dilated, absent breath sounds, no palpable pulses, asystole in two
contiguous leads, and no signs of life.”

Protocols
Why do some agencies have protocols that allow for determination of death in the field
and discontinuance of CPR?

Part of it is practicality. Most patients in cardiac arrest that fail to respond to initial
CPR/ACLS on scene do not survive. Published data from Los Angeles Fire Department
showed that for non-traumatic cardiac arrests, the rate of termination of EMS efforts in
the field increased from 9% in 2000 to 27% in 2007. Patients were found pulseless and
apneic without immediate criteria for determination of death in the field (i.e.,
decapitation or other obvious death situations).

Challenges With Determination Of Death In The

Field, Or The Decision To Withhold CPR
 What if the patient has a DNR on scene, but the DNR is not completed properly
and the patient’s family tells you that the patient does not want to be
resuscitated?

 What if the patient appears to meet your protocol for determining death in the

field, you explain this to the family, and they ask you to please work on the
patient anyway?

 What if the patient has obvious signs of death (i.e., decapitation) and the family
is screaming, crying, and begging you to perform CPR?

 What if your protocols state CPR is not indicated, but resuscitative efforts were
already started on scene by bystanders? Will you discontinue those efforts?

 What if your protocols clearly allow for determination of death in the field, but
you are surrounded by 500 distraught and hostile bystanders screaming for you
to “do something”?
Remember, there will be an unlimited number of possible scenarios that you may face
when dealing with the dead or possibly dead patient. At the end of the day, no two
situations are completely alike, and in many cases you will need to make a fairly quick
decision, often based on limited information. To make matters more complicated,
families are often hysterical and irrational when dealing with the impending death of a
family member.
How Do You Determine Death?
It depends on who you ask. According to the Uniform Determination of Death Act
(UDDA), death is determined when an individual sustains either irreversible cessation of
circulatory and respiratory functions, or irreversible cessation of all functions of the
entire brain, including the brain stem. This Act was approved by the National
Conference of Commissioners of Uniform State Laws in cooperation with the American
Medical Association, American Bar Association, and the President’s Commission for the
Study of Ethical Problems in Medicine and Biomedical and Behavioral research. This act
has been adopted by most states in the United States. So that should help us, right?
We now have a clear definition that almost everyone agrees to? The answer is no. We
still have a problem. In fact, we have a few problems.  

We cannot determine brain death in the back of an EMS vehicle. Determining brain
death requires complex testing that must be done in a healthcare facility, typically a
hospital, and typically by a neurologist. The good news, however, is that we all agree
that death is defined by irreversible cessation of circulatory and respiratory functions,
right? Well, no. How do we reliably determine that the cessation of circulatory and
respiratory functions is irreversible? How can we be sure that our patient who has
no signs of respiration with absent pulses will not regain signs of life after we declare
them dead? How devastating would it be to declare someone dead in the field that
regains a pulse or respiratory effort after we drive away and say they are dead? These
are not easy questions, but we will try to provide some guidance with this challenging
issue.

Key Points
 Follow your protocols and carefully document your adherence to your protocols.

 If there is any question, that the patient may not be dead, don’t declare them
dead.

 Use good sound judgment, and always provide maximal care unless there are
compelling reasons to terminate your efforts.

 If there is overwhelming evidence that the patient is dead (i.e., decapitation), do

not attempt resuscitation.

 Remember that every death, or possible death, is a potential crime scene.

Maximize care, but minimize disturbance of the scene, if possible.

 Call for help with difficult situations. Your chain of command and online medical
control may be useful resources.

 Do not make assumptions.

Remember
Remember, there are scenarios where patients may seem dead, but may still require aggressive
resuscitation.

Hypothermia: Always remember the caveat that “they are not dead until   they are
warm and dead.” Efforts to resuscitate should continue until core temperature is at
least 86–89.6°F (30–32°C). Patients have been known to recover after being found
apneic, rigid, with fixed and dilated pupils. There has been a documented “Education to
the Rescue” 7 hypothermic recovery with core temperature at 56.7°F (13.7°C) and with
cardiac arrest for 6.5 hours. The classic example of hypothermic cardiac arrest is cold
water drowning.
 Barbiturate overdose: Barbiturate overdose can be associated with prolonged
comatose state, and some protocols recommend prolonged resuscitative
attempts.

 Electrocution: Patients struck by lightning have been known to recover after

prolonged cardiac arrest.

 Pearls Of Wisdom
There are many different protocols around the country for determination of death and
discontinuance of CPR. It is extremely important that you are very familiar with your
agency’s protocols.

Review your local protocols and practice your patient assessments in a consistent and
organized fashion each and every time. This can prevent the omission of important
steps or procedures. This is especially important with determination of death issues.

Example Of Criteria For Determination Of Death

Criteria for determination of death by EMTs or paramedics in LA County as stipulated by Los Angeles
County EMS agency:

Absence of respirations, cardiac activity, and neurologic reflexes, in addition to one or

more of the following criteria for determination of death include:

 Decapitation

 Massive crush injury

 Penetrating or blunt injury with evisceration of the heart, lung, or brain

 Decomposition

 Incineration

 Blunt traumatic arrests without organized EKG activity or with extrication times
exceeding 15 minutes

 Drowning victims with submersion time estimated greater than one hour

 Rigor mortis

 Post-mortem lividity
Additional Criteria
Paramedics are authorized to make determination of death for patients found to be
in asystole when the estimated time from collapse to the beginning of CPR efforts is
more than 10 minutes.  

For decades, the issue of determination of death by EMS professionals has received
much debate and discussion. In a JAMA article published in September 1993 titled
“Distinct Criteria for Termination of Resuscitation in the Out-of-Hospital Setting,” Drs.
Bonin, et al. concluded that “Excluding patients with persistent ventricular fibrillation,
resuscitative efforts can be terminated at the scene when normothermic adults with
unmonitored, out-of-hospital, primary cardiac arrest do not regain spontaneous
circulation within 25 minutes following standard advanced cardiac life support.”

What Is Rigor Mortis?

Rigor mortis is a sign of long-term death defined by chemical changes causing stiffness
in the muscles and limbs making the body difficult to move.  Rigor mortis starts to
occur 3–4 hours after death with maximum rigidity at 12 hours, and will start to decline
until 2–4 days after death. This timeline can vary with temperature and humidity
conditions.

What Is Livor Mortis (Or "Postmortem Lividity")?

Postmortem lividity or livor mortis is one of the signs of death. Livor mortis is when
blood settles in the lower portion of the  body, causing a purplish red discoloration of the
skin. This is from the action of gravity and red blood cells separating from the serum.
Livor mortis is usually most obvious 12 hours after death.

Scene Survey
On this call, the lead medic immediately calls for a scene survey to find any dangers
that may cause harm to the crew. Our crew is all wearing appropriate personal
protective equipment (i.e., eye protection and gloves). The patient’s brother is
interviewed about the patient’s history, as he may be able to provide essential
information. Our lead medic performs a complete head-to-toe exam while doing his
best to minimize disturbance of the scene. Taking time to explain to the family what
you are doing and why you are doing it will go a long way to make a difficult call run
smoother.

ABC's
As soon as the crew arrives on the scene the lead medic immediately calls for a scene
survey to find any dangers that may cause harm to the crew. He also asks that law
enforcement be dispatched to the scene. Our crew is all wearing appropriate personal
protective equipment (i.e., eye protection and gloves) and initiates the ABCs.

Airway: Airway is clear without signs of obstruction.

Breathing: Breathing is absent.
Circulation: Pulses are absent. There are no lung or heart sounds with auscultation.

There Is Evidence Of Both Rigor Mortis And Post-

Mortem Lividity
As there are no signs of life, and the patient has obvious signs of death, the patient is
not placed on a monitor.  As soon as the ABCs are completed, our lead medic performs
an abbreviated head-to toe exam in order to support his conclusion that resuscitative
efforts are not indicated on this call. He is careful not to disturb any clues on the scene
that could be helpful in diagnosis. Simultaneously, in the other room, our patient’s
brother is being interviewed about his brother’s medical history, as he may be able to
provide additional information.  Taking time to explain to the family what you are doing
it and why you are doing it will go a long way to make a difficult call run smoother.

 What Is Your Immediate Treatment?

First, make sure the scene is safe and secure. Perform a scene survey to look for any
clues. Assess the ABC's and look for additional clues during a head to toe evaluation.
Remember that every death, or possible death, is a potential crime scene. Maximize
care, but minimize disturbance of the scene, if possible. If paramedic care is available,
“Education to the Rescue” 10 and obvious signs of death are absent, place the patient
on a monitor to determine if there is asystole in two or more leads. Perform continuous
re-evaluations.
Most importantly, follow your protocols and carefully document your adherence to your
protocols.  If there is any question, that the patient may not be dead, don’t declare
them dead. Use good sound judgment, and always provide maximal care unless there
are compelling reasons to not initiate or terminate your efforts. If there is
overwhelming evidence that the patient is dead (i.e., decapitation or massive crush
injury), do not attempt resuscitation.  Call for help with difficult situations. Your chain
of command and online medical control may be useful resources. Do not make
assumptions.

What Is The Preliminary Diagnosis?

Our patient presents with clinical evidence of cardiac arrest and obvious signs of death.
All efforts are focused on supporting the family and treating the body of the deceased
with dignity.

Logistical Problems For EMS Providers

  Patient is determined to be dead while in the back of an ambulance and your
local hospital refuses to accept patients that are already declared dead.  

 Patient meets criteria for determination of death, but the EMS crew decides to
initiate resuscitation efforts due to scene safety issues (i.e., hostile scene, gang
related violence, etc.).

 Possible Solution
Each of these scenarios needs to be reviewed by every individual EMS agency before
initiating determination of death protocols for their EMS providers.  End-of-life issues
are not simple matters in the pre-hospital environment. Although these cases are
sometimes straightforward, more frequently they are challenging and can be quite
taxing to the EMS Professional. It is also important to be aware of the many challenges
and local variations in handling DNR and other advanced directive issues.

What About Advance Directives?

Advance directives are the patient’s wishes being defined in advance, before life and
death decisions need to be made. Their validity in the pre-hospital environment is not
uniform. In fact, some states do not allow EMS professionals to honor certain types of
advance directives in the pre-hospital environment. Advance directives are completely
controlled by state laws, so it is of paramount importance that you are familiar with
your state’s policies, laws, and limitations when making decisions about advance
directives.  As these policies and procedures can have tremendous impact with life and
death decisions, this is an area you want to be very familiar. Every EMS agency has
written policies and procedures and protocols for handling advance directives. With
difficult cases, many agencies have a chain of command or online medical control that
can help with handling these difficult patient scenarios.

Dr. Katz's Comments

“It is always difficult to see families stress about decisions regarding end-of-life issues,
even with patients that are terminally ill. You would be surprised how many people do
not discuss this issue, and avoid this issue, even when they are terminally ill. Having an
open discussion with your family, and putting your wishes in the form of a legal
document, can be very helpful to you and your family.”

Types Of Advance Directives

 Living Wills

 Do not resuscitate (DNR) orders

 Organ donation orders

Durable Power Of Attorney/Healthcare Surrogate
A person pre-appointed by a patient to make healthcare decisions in the event they
become incapacitated. Decisions may include discontinuation of life support in the event
of a terminal illness or injury, discontinuation and removal of life-sustaining equipment,
and termination of artificial nutrition and hydration.

Living Will
A type of advance directive, generally requiring a precondition for withholding
resuscitation when a patient is incapacitated.

DNR Or "Do Not Resuscitate" Order

A DNR order is an advance directive that describes which life-sustaining procedures
should be performed in the event of sudden deterioration in a patient’s condition.

Dr. Katz's Comments On Caring For The Family

“One area that merits discussion is the scenario that 911 is called, a patient is either
obviously dead or has a valid DNR on scene, and a patient is in cardiac arrest. Caring
for the family at the scene of a death can be complex. There are many cases when a
family or a nursing home will call 911 to the scene of a cardiac arrest despite the fact
that there are clear DNR orders in place. These scenarios take sensitivity and patience.
Many times, the person has called 911 in a panic because they are not familiar or not
experienced in handling death and simply don’t know what else to do. Remember, you
are the EMS professional that has experience dealing with life and death issues. The
bystander or family member on scene may be experiencing extreme
emotional distress with the impending death of a loved one and may not be acting
rationally. Be calm, be professional, and be patient. Sometimes the primary job of EMS
is to be a calming source of reason, and to take care of the family of the dying patient,
rather than the patient.”

Allowing The Family To Participate In The Dying

Process
When taking care of the dying patient that is not going to be resuscitated because of
advance directives, invite the family to say their goodbyes or to be with the patient.
This act of kindness is often dismissed due to our own discomfort, and it is something
to strongly consider offering the family of the dying patient. It is one of the best gifts
you can give the family of a dying patient.
What About You, The EMS Professional?
Don’t neglect your own personal response to death and dying. Even the most seasoned
EMS professionals are not immune from the effects of dealing with death and dying.
Most EMS agencies have a process, or should have a process of debriefing for EMS
professionals, after a patient death or other emotionally troubling incident.

 Critical Incident
An incident that overwhelms the ability of an EMS worker or an EMS system to cope
with an experience, either at a scene or later.

Post-Traumatic Stress Disorder (PTSD)

A delayed stress reaction to a previous incident, often the result of one or more
unresolved issues concerning the incident. Although we often think of PTSD affecting
soldiers returning from the battlefield, PTSD can occur in EMS professionals after
traumatic calls, even with well-adjusted providers.

Signs Of PTSD To Be Aware Of For The EMS

Professional
 You have trouble getting an incident out of your thoughts

 You keep having flashbacks of an incident

 You have nightmares or other sleep disturbances after an incident

 Your appetite is not the same after an incident

 You laugh or cry for no good reason after an incident

 You find yourself withdrawing from coworkers and family members after an
incident

Critical Incident Stress Management (CISM)

CISM is a resource available for emergency personnel who have been involved in
particularly traumatic calls or incidents. CISM is a process that was developed to
address stressful situations with the intent to decrease incidence of PTSD after an
incident.
Suggested Events Where Debriefing Should Be
Considered
 Serious injury or death of a fellow worker in the line of duty

 Suicide of a fellow worker

 MCI (i.e., airline crash or train wreck)

 Serious injury or death of a child

 Intense media attention to an incident

To make matters more difficult, there is significant variation from state to state about
who specifically can honor a DNR, and the authority of a durable power of attorney to
revoking valid DNR orders. These are the types of issues and discussions that should be
asked of your department and medical director before you are placed in the difficult
situation of sorting out legal issues on scene for a patient in critical condition.  

Additionally, some states allow EMS professionals to honor a DNR order in the form of a
medic alert bracelet or necklace, form, or card.

DNR Challenges
 What if the patient has appropriate DNR paperwork on scene, but the wife on
scene states that she wants everything done, even though the patient has a DNR
order signed and available on scene. Do you honor the DNR paperwork or the
wife’s wishes which are in direct conflict of each other?

 How would your EMS agency respond when a patient’s DNR form is signed, but it
has expired and it is no longer valid according to your state’s guidelines?

 Or, what if the DNR form is signed by the patient but not by the physician and
your state requires a physician’s signature for a DNR order to be valid?
These are questions that need to be answered by your department according to your
state’s protocols, and should be discussed and sorted out in advance.

Bottom Line
Know how you would handle these scenarios before they occur. Be very familiar with
your department’s policies and procedures with DNR orders and other advanced
directives.

Pearls Of Wisdom
Unless you are reasonably confident that your patient has a valid DNR order, it is better
to proceed with resuscitation, at least for the time being. You can always stop
resuscitation if a valid DNR order is later presented. Some states require a written DNR
order signed by a physician, and some states require the patient to wear a bracelet or
necklace affirming the DNR status of the patient.  Bottom line: Know your state’s rules
for DNRs and advanced directives and the authority granted to a durable power of
attorney. If it is unclear, it is better to resuscitate a patient that is later found to have
valid DNR orders, than to mistakenly assume a patient has a valid DNR when they do
not.

Many agencies have a policy to have law enforcement respond to all cardiac arrests.
Review your agency’s protocols as to when law enforcement should be called. It is
always a good idea to document if law enforcement is on scene.

Scenarios To Consider
 DNR form is signed but has expired and is no longer valid according to your
state’s guidelines.

 DNR form is signed by the patient but not by the physician and your state
requires a physician’s signature for a DNR for to be valid.

Documentation
When called to the patient that may involve determination of death issues, it makes
sense to proceed calmly and methodically, and to document that methodical process as
clearly as possible. Cardiac arrests patients are high risk cases, and you want to make
sure your documentation reflects decisions that were thoughtful, timely, and careful. If
you make a decision to treat or not to treat, make sure that the explanation for your
decision is clearly documented. If there are scene safety issues that delay lifesaving
care or an initial patient assessment, make sure that is adequately addressed in your
documentation. Also, in the middle of a stressful call, it is sometimes very easy to
overlook seemingly simple details. Make sure that all of your documentation is
complete, accurate, and corresponds to the patient that you are treating. Make sure to
accurately document all times accurately using a single time reference, like
a dispatch center’s time reference. Is the patient exhibiting obvious signs of death like
postmortem, rigor mortis or livor mortis? Is your decision to withhold CPR supported by
your protocols? Does your documentation reflect this fact? Make sure to document your
interactions with family or bystanders and their relationship to the patient. Did you
document that person’s full name in your record? Not only should you be extremely
vigilant about your sensitivity to your patient’s family, it is just as important that you
document any related actions, like covering the body, and any facilitated assistance to
the family, such as making phone calls or requesting additional community resources.
All situations involving death should have thorough documentation that will provide a
clear picture of your decision to treat or not treat, and your care and assessment on
scene.
What Happened To Our Patient?
Our patient in this scenario was determined to be in cardiac arrest by our crew, with
absent pulses, absent breath sounds, and absent heart sounds. The patient’s pupils
were fixed and dilated. Signs of post mortem rigidity and lividity were found to be
present.  Law enforcement and the Medical Examiner were contacted. The family was
adequately supported. The body was left undisturbed, but covered with a sheet to
maintain respect and dignity for the deceased. The crew showed tremendous
professionalism and concern for the family, while maintaining dignity for the patient.

Glossary
Advance Directive  : A written document that expresses the wants, needs, and desires of
a patient in reference to future medical care; examples include living wills, do not
resuscitate (DNR) orders, and organ donation.
Asystole  : The absence of ventricular contractions; a 'straight-line ECG.'
Body  : In the context of the uterus, the portion below the fundus that begins to taper
and narrow.
Brain  : Part of the central nervous system located within the cranium; contains billions
of neurons that serve a variety of vital functions.
Command  : In incident command, the position that oversees the incident, establishes
the objectives and priorities, and from there develops a response plan.
Dispatch  : To send to a specific destination or to send on a task.
Distress  : A type of stress that a person finds overwhelming and debilitating.
Ethical  : A behavior expected by an individual or group following a set of rules.
Evisceration  : Displacement of an organ outside the body.
Gravity  : The acceleration of a body by the attraction of the earth's gravitational force,
normally 32.2 ft/sec2.
Incidence  : The frequency with which a disease occurs.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG that
shows the electrical conduction in the heart.
Neglect  : Refusal or failure on the part of the caregiver to provide life necessities, such
as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal
safety.
Online Medical Control  : Medical direction given in real time to an EMS service or
provider.
Professional  : A person who follows expected standards and performance parameters in
a specific profession.
Protocol  : A treatment plan developed for a specific illness or injury.
Respiration  : The exchange of gases between a living organism and its environment.
Sensitivity  : The ability to recognize a foreign substance the next time it is encountered.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell, and
so on.
Stress  : A nonspecific response of the body to any demand made upon it.
Terminal Illness  : A sickness that the patient cannot be cured of; death is imminent.

References
1. Pollak, A.N. (ed.) (2013) Nancy Caroline’s Emergency Care in the Streets. (7th
ed.) Boston: Jones and Bartlett Publishers.

2. Tintinalli, J.E. (2011) Emergency Medicine (7th ed.) New York: McGraw-Hill.

3. Eckstein M. (2010) “Disposition of the Deceased: How to Determine Patient

Status & Prevent Futile Transports.” JEMS, MECH 3.

4. Bonnin, M.J., et al. “Distinct criteria for termination of resuscitation in the out-
ofhospital setting.” JAMA. 1993:270:1457-1462.

5. Eisenberg, Mickey S. and Cummins, Richard O. “Termination of CPR in the

Prehospital Arena.” Annals of Emergency Medicine. 1985: Volume 14, Issue
11,p.1106-1107.

6. Eckstein M, et al (2005). Termination of resuscitative efforts for out-of-hospital

cardiac arrests. Academy of Emergency Medicine. Volume 12, p.65-70.