Cardiopulmonary resuscitation (CPR) is a technique performed when a person’s heart has stopped beating, aiming to maintain blood flow and oxygen delivery to the brain and other organs until definitive medical care is available. The process involves chest compressions and rescue breathing, serving as a bridge to professional help. Deciding when to stop these life-sustaining efforts is a complex situation governed by safety concerns, specific medical guidelines, and legal requirements. These criteria differ significantly based on whether the rescuer is a layperson or an experienced medical professional.
When Bystanders Should Cease Efforts
A bystander, whether trained or untrained, initiates CPR to sustain life until Emergency Medical Services (EMS) or other professional responders arrive on the scene. For a layperson, the decision to stop is dictated by practical, safety, and physical considerations. The most straightforward reason to stop is the successful handover of care to trained personnel, such as paramedics or emergency medical technicians. The bystander should continue effective CPR until professional responders are physically ready to take over and instruct the layperson to stop.
Scene safety is an overriding factor; a layperson must immediately cease CPR if the environment becomes dangerous, such as with a fire, gas leak, or collapsing structure, because the rescuer’s life must not be put at serious risk. Effective chest compressions require significant physical exertion. If the rescuer becomes exhausted and can no longer deliver high-quality compressions, it is appropriate to stop. Stopping due to fatigue is generally protected under Good Samaritan laws, as ineffective CPR is unlikely to help the patient.
The most encouraging reason to stop CPR is the patient showing clear signs of life, known as Return of Spontaneous Circulation (ROSC). Signs of ROSC include the patient waking up, beginning to breathe normally, moving purposefully, or making a sound. If these signs appear, the rescuer should cease compressions and monitor the patient closely. The rescuer must be ready to resume CPR if the signs of life disappear.
Clinical Protocols for Medical Professionals
For licensed medical personnel, the decision to stop resuscitation is highly protocol-driven and is called Termination of Resuscitation (TOR). Most protocols require a full resuscitative effort following Advanced Cardiac Life Support (ACLS) guidelines for a specific duration. This duration is typically at least 20 minutes before considering termination if Return of Spontaneous Circulation (ROSC) has not occurred. This timeframe allows advanced interventions like administering medications and attempting defibrillation to take effect.
The initial heart rhythm plays a significant role in the decision-making timeline. Patients whose rhythm remains asystole (a flatline) or pulseless electrical activity (PEA) after prolonged efforts are strong candidates for TOR. This is especially true when the arrest was not witnessed by EMS. If the patient’s heart rhythm remains a shockable rhythm, such as ventricular fibrillation (VF) or ventricular tachycardia (VT), efforts are often continued longer because these rhythms have a higher chance of responding to treatment.
Specific underlying medical factors may necessitate prolonged efforts beyond the standard duration. Patients experiencing severe hypothermia or a drug overdose may require extended resuscitation because their bodies are more resilient to oxygen deprivation. Advanced monitoring, such as capnography to measure end-tidal carbon dioxide (ETCO2), assists professionals. Persistently low ETCO2 values after 20 minutes of CPR often indicate a very poor prognosis and support the decision to terminate efforts.
In the prehospital setting, the paramedic or advanced life support provider must usually consult with an online medical control physician. This consultation is required before officially terminating resuscitation.
Legal Directives and Obvious Signs of Death
Factors external to the immediate medical situation, such as legal documentation, can mandate stopping or not initiating CPR. A Do Not Resuscitate (DNR) order or other valid Advanced Directive, like a Physician Orders for Life-Sustaining Treatment (POLST) form, legally directs medical personnel not to perform resuscitation. These documents reflect the patient’s wishes to decline aggressive life-sustaining measures. Medical staff must verify and respect their validity upon arrival.
Resuscitation should not be started if the patient displays obvious, irreversible signs of biological death. These signs indicate that the cellular damage is too extensive for recovery. These physical findings mark the difference between clinical death and biological death, which is the irreversible death of tissue.
Signs that legally preclude the initiation of CPR include:
- Rigor mortis, which is the stiffening of the body’s muscles.
- Dependent lividity, the pooling of blood that causes a purplish discoloration in the lowest parts of the body.
- Decomposition.
- Injuries incompatible with life, such as decapitation or massive crush injury.