When to consider stopping CPR in a 92-year-old patient with multiple co-morbidities, persistent asystole, significant low-flow time, and low end-tidal CO2 (EtCO2)?

When to Consider Terminating CPR in an Elderly Patient with Multiple Comorbidities

In a 92-year-old patient with multiple comorbidities, persistent asystole, significant low-flow time, and end-tidal CO2 <1.3kPa, it is reasonable to consider terminating resuscitation efforts as these factors collectively indicate an extremely poor prognosis for survival with good neurologic outcome.

Key Prognostic Factors for CPR Termination

End-Tidal CO2 Measurement

• In intubated patients, an ETCO2 <10 mm Hg (1.3 kPa) after 20 minutes of CPR is a strong predictor of mortality 1
• The 2015 AHA guidelines state that failure to achieve an ETCO2 >10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts 1
• Studies have shown that ETCO2 values during CPR correlate with the likelihood of ROSC and survival 2, 3
• Important caveat: ETCO2 should not be used in isolation for termination decisions and applies only to intubated patients 1

Cardiac Rhythm

• Persistent asystole despite appropriate ACLS interventions carries an extremely poor prognosis
• The absence of a shockable rhythm (such as persistent asystole) is associated with significantly worse outcomes compared to VF/VT

Patient Factors

• Advanced age (92 years) combined with multiple comorbidities significantly reduces the likelihood of successful resuscitation and neurologically intact survival
• The decision to terminate resuscitation must consider the patient's premorbid state, including quality of life and comorbidities 1

Low-Flow Time

• Prolonged low-flow time (duration of CPR) is strongly correlated with poor survival and neurological outcomes 4, 5
• The interplay between advanced age and prolonged low-flow duration is particularly important, with studies showing virtually no favorable neurologic outcomes in patients >75 years with low-flow times >60 minutes 5

Decision-Making Algorithm for CPR Termination

1. Initial Assessment (0-10 minutes)

   • Confirm cardiac arrest and initiate high-quality CPR
   • Establish advanced airway and monitor ETCO2
   • Evaluate for reversible causes (Hs and Ts) 6
   • Consider patient's age, comorbidities, and premorbid functional status

2. Intermediate Assessment (10-20 minutes)

   • Evaluate response to initial resuscitation efforts
   • Monitor ETCO2 trends (particularly important if <10 mm Hg/1.3 kPa)
   • Reassess rhythm and response to interventions
   • Consider low-flow time in context of age and comorbidities

3. Decision Point (≥20 minutes)

   • If ETCO2 remains <10 mm Hg (1.3 kPa) in an intubated patient after 20 minutes of optimal CPR
   • AND persistent asystole despite appropriate interventions
   • AND significant low-flow time in a 92-year-old with multiple comorbidities
   • THEN it is reasonable to consider termination of resuscitation efforts 1

Important Considerations and Caveats

• The decision to terminate resuscitation should be made by a senior clinician with as much information as possible about the patient's premorbid state 1
• No single factor should be used in isolation to terminate resuscitation 1
• The patient's wishes (if known) and those of close relatives should be considered 1
• The principle of futility should be applied when there is clear evidence that continued resuscitation would be unlikely to result in meaningful survival 1
• Termination decisions should be documented thoroughly, including the rationale based on the prognostic factors discussed above

Pitfalls to Avoid

• Relying solely on ETCO2 in non-intubated patients (unreliable measurement) 1
• Making termination decisions based on age alone without considering other factors
• Continuing futile resuscitation that may prolong suffering without reasonable chance of meaningful recovery
• Failing to consider the patient's premorbid quality of life and wishes
• Terminating too early before addressing potentially reversible causes

In this specific case, the combination of advanced age (92 years), multiple comorbidities, persistent asystole, significant low-flow time, and ETCO2 <1.3kPa collectively indicates an extremely poor prognosis, making termination of resuscitation efforts a reasonable clinical decision after appropriate consideration of all factors.