CPR is an emergency procedure performed when a person’s heart stops beating. It involves chest compressions and rescue breathing to circulate oxygenated blood to the brain and vital organs until professional medical help arrives. Deciding when to stop these efforts is complex and depends on the rescuer’s training and the specific circumstances.
Practical Endpoints for the Lay Rescuer
A lay person, or bystander, who initiates CPR should maintain continuous compressions until a specific, practical endpoint is reached. These endpoints are based on safety, effectiveness, and the transfer of responsibility. The first reason to stop is the immediate return of signs of life, such as the person beginning to move, speak, or breathe normally again. Once these signs are present, mechanical assistance is no longer necessary.
Conditions for Cessation
The lay rescuer should also cease efforts under the following conditions:
- Transfer of care, which occurs when trained Emergency Medical Services (EMS) personnel or another rescuer of equal or higher training takes over the resuscitation effort.
- The scene becomes unsafe for the rescuer to continue, such as in the event of fire, explosion, or other imminent danger.
- The rescuer is physically exhausted and can no longer deliver effective compressions, particularly if no one else is available to assist.
Medical Termination Protocols
Once medical professionals assume control, the decision to terminate resuscitation shifts from practical limitations to clinical judgment guided by specific protocols. In the pre-hospital setting, EMS teams often follow established termination of resuscitation (TOR) rules to identify when continued efforts are likely futile. These criteria often include a combination of factors, such as the patient’s cardiac rhythm, the amount of time CPR has been performed, and whether the arrest was witnessed.
For instance, many protocols support terminating efforts after a minimum of 20 minutes of Advanced Cardiac Life Support (ACLS) without the Return of Spontaneous Circulation (ROSC). This is especially true if the initial electrical rhythm was asystole (a flat line) or Pulseless Electrical Activity (PEA) and did not respond to standard interventions. A persistently low End-Tidal Carbon Dioxide (ETCO2) reading, often below 10 mmHg after prolonged resuscitation, can also indicate extremely poor prognosis and support the decision to stop.
In the hospital setting, the decision to stop CPR is made by the physician leading the resuscitation team. This clinical determination is based on the patient’s underlying condition, the duration of the arrest, and the failure of advanced interventions, such as defibrillation and medication administration, to restore a functional heartbeat. The medical team will also consider the presence of irreversible conditions, like catastrophic trauma or terminal illness, which would preclude a meaningful recovery even with ROSC. A shared decision-making process with the patient’s family or surrogate is often initiated after a period of aggressive, yet unsuccessful, resuscitation attempts.
Legal Directives and CPR Cessation
In some cases, the decision to withhold or stop CPR is dictated by a patient’s pre-existing legal instruction rather than clinical failure. A Do Not Resuscitate (DNR) order is a legally binding medical order that instructs healthcare providers to refrain from initiating or continuing CPR. This order is based on the patient’s right to autonomy and refusal of unwanted life-sustaining treatment.
Other portable medical orders, such as Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST), serve a similar function outside of a hospital environment. If a valid DNR or similar document is presented or known to be in effect, resuscitation efforts must cease immediately. Failing to honor a valid DNR order can result in legal consequences for the healthcare provider, as it constitutes performing an unwanted medical procedure.