Cardiopulmonary resuscitation (CPR) is an emergency procedure that combines chest compressions with rescue breaths to manually maintain blood circulation and oxygen supply to a person whose heart or breathing has stopped. CPR sustains life and prevents irreversible brain damage until professional medical help arrives. While CPR significantly increases the chances of survival for victims of sudden cardiac arrest, it is important to understand when starting CPR may be inappropriate, unsafe, or medically futile. Knowing when to withhold resuscitation involves ethics, safety, and recognizing a definitive biological endpoint.
Irreversible Physical Signs
Clear physical signs indicate that biological death has already occurred, rendering CPR medically futile. Recognizing these markers prevents unnecessary intervention.
Rigor mortis, the stiffening of the body’s muscles, typically begins a few hours after death. Dependent lividity (livor mortis) is another clear indicator, appearing as a reddish-purple discoloration of the skin on the lowest parts of the body. This color change is due to blood settling after circulation has stopped.
Massive, non-survivable trauma, such as decapitation or complete transection of the body, contraindicates the initiation of CPR. Signs of advanced decomposition or incineration also indicate that the person has been deceased for a prolonged period. In these cases, the person providing aid should prioritize contacting emergency services and securing the scene.
Scene Hazards and Rescuer Safety
The primary directive in any emergency response is to ensure the safety of the rescuer, operating under the principle that one should never become a second victim. If the environment poses a direct threat, approaching the person to perform CPR must be avoided until professional responders secure the area.
Environmental hazards that necessitate withholding CPR include active fire, unstable structures, toxic gas or fumes, and live electrical wires. Active violence also requires waiting for law enforcement to secure the scene before rendering aid.
The potential for physical danger, such as a major traffic hazard or a precarious height, outweighs the need to immediately begin CPR. In these instances, the most helpful action is to immediately call emergency services, provide clear details about the scene, and wait for professional personnel to arrive.
Valid Medical Orders Not to Resuscitate
A person has the right to refuse life-sustaining measures, typically documented through advance directives. A Do Not Resuscitate (DNR) order, or similar documents like a Physician Orders for Life-Sustaining Treatment (POLST) form, legally instructs medical professionals not to attempt CPR if the person’s heart or breathing stops. These forms reflect the person’s wishes regarding end-of-life care.
For the general public, verifying a DNR order in an emergency is often impossible and should not delay life-saving efforts. Good Samaritan laws protect lay rescuers who attempt CPR in good faith. Professional emergency medical services (EMS) personnel are trained to identify and honor these documents, which may be present at the scene or indicated by a specialized bracelet.
If a family member or caretaker is aware of a valid DNR order, they should communicate this information clearly to the 911 dispatcher and arriving responders. Honoring a DNR order shifts the focus from resuscitation to providing comfort care, respecting the person’s autonomy.
Criteria for Terminating Resuscitation Efforts
Once CPR has been started, a rescuer should generally continue compressions and ventilations until professional help arrives. However, there are specific, limited circumstances where a lay rescuer may discontinue their efforts. One clear reason is the return of spontaneous circulation (ROSC), indicated by the person showing signs of life, such as purposeful movement or normal breathing.
The rescuer becoming physically exhausted and unable to continue effective compressions is another valid reason to stop, particularly if no other trained person is available to take over. Additionally, the scene may become unsafe after CPR has begun, requiring the immediate withdrawal of the rescuer.
In most cases, the termination of resuscitation efforts is a medical decision made by professional EMS personnel or a physician. Once professional responders take over care, the lay rescuer should stop CPR and follow the medical team’s instructions. Professionals apply established protocols, which may include stopping resuscitation after a specified period of advanced medical care without ROSC.