Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest

Key Points Question Can termination of resuscitation (TOR) rules accurately identify patients who will not survive an out-of-hospital cardiac arrest? Findings This systematic review and meta-analysis identified 43 studies describing the performance of TOR rules, but evidence concerning the ability of TOR rules to discriminate between those patients who will die and those who will survive was lacking. The available studies provided low-certainty evidence suggesting that the universal termination of resuscitation (UTOR) rule has the best performance; however, even the UTOR rule may not be suitable for use in systems in which transport rates are low and the survival rate is higher than 8%. Meaning These findings suggest that there is insufficient robust evidence to support widespread implementation of TOR rules in clinical practice.

Adults and children with out-of-hospital cardiac arrest, where resuscitation is attempted, but return of spontaneous circulation (ROSC) is not achieved.

Intervention:
Termination of resuscitation (TOR) rule predicted outcome.

Comparison: True outcome
Outcomes: Ability of TOR rule to predict death.Economic implications of application of TOR rules.
No language restrictions were placed.
We excluded studies predicting poor neurologic outcome rather than death.
Although favourable neurologic outcome is critically important to patients, we were unable to identify any EMS systems that advocated termination of resuscitation where poor neurologic outcome was predicted.
We excluded studies addressing outcome for post-ROSC patients.Although it would be possible to transpose the data such that death becomes the true positive, the populations included in such studies comprise only ROSC patients, thus they are different to the cardiac arrest population.

Timeframe:
The initial search was conducted from database inception to mid-July 2019.Covid-19 resulted in the project being paused.The final update occurred in January 2024.

eTable 9 . 10 . 11 . 2 . 3 .
Clinical Studies Paired Sensitivity and Specificity eTable Summary of Included Studies eTable Description of Termination of Resuscitation (TOR) Rules eFigure 1. QUADAS-2 Summary Risk of Bias and Applicability eFigure Study Risk of Bias eFigure Deeks Funnel Plot Asymmetry Test eFigure 4. Bivariate Summary Receiver Operating Characteristic (SROC) Curves eReferences This supplementary material has been provided by the authors to give readers additional information about their work.eTable 1. PICOST Criteria Population:
Derivation Studies Paired Sensitivity and Specificity eTable 8. External Validation Studies Paired Sensitivity and Specificity (terminat* or cease or cessation or stop or withdraw* or withheld or withhold* or TOR or futile or futility or rule* or algorithm* or decease* or decision* or prognosis or predict*) External Validation Studies Paired Sensitivity and Specificity External Validation Studies Paired Sensitivity and Specificity True positive (TP) means TOR rule indicates stop and patient dies, False positive (FP) TOR rule indicates stop but patient survives (missed survivors) True negative (TN) TOR rule indicates continue and patient survives, False negative (FN) TOR rule indicates continue but patient dies (futile resuscitations) Sensitivity is proportion of cases where the TOR indicates stop out of all deaths.Specificity is proportion of cases where the TOR rule indicates continue out of all survivors.Summary of Included Studies © 2024 Smyth MA et al.JAMA Network Open.True positive (TP) means TOR rule indicates stop and patient dies, False positive (FP) TOR rule indicates stop but patient survives (missed survivors) True negative (TN) TOR rule indicates continue and patient survives, False negative (FN) TOR rule indicates continue but patient dies (futile resuscitations) Sensitivity is proportion of cases where the TOR indicates stop out of all deaths.Specificity is proportion of cases where the TOR rule indicates continue out of all survivors.©2024SmythMAet al.JAMA Network Open.eTable 8. External Validation Studies Paired Sensitivity and Specificity © 2024 Smyth MA et al.JAMA Network Open.eTable 8. © 2024 Smyth MA et al.JAMA Network Open.eTable 8. eTable 9. Clinical Studies Paired Sensitivity and Specificity True positive (TP) means TOR rule indicates stop and patient dies, False positive (FP) TOR rule indicates stop but patient survives (missed survivors) True negative (TN) TOR rule indicates continue and patient survives, False negative (FN) TOR rule indicates continue but patient dies (futile resuscitations) Sensitivity is proportion of cases where the TOR indicates stop out of all deaths.Specificity is proportion of cases where the TOR rule indicates continue out of all survivors.eTable10. © 2024 Smyth MA et al.JAMA Network Open.© 2024 Smyth MA et al.JAMA Network Open.
-termination of resuscitation, ROSC -return of spontaneous circulation, ** -these studies incorrectly report efficacy of BLS TOR; they should have reported efficacy of the uTOR as the participating EMS providers functioned above BLS level, VF -ventricular fibrillation, BLS -basic life support, ALS -advanced life support, OHCA -out of hospital cardiac arrest, EMS -Emergency Medical Services, ED -Emergency Department, EMT -Emergency Medical Technician, AED -automated external defibrillator, LMA, laryngeal mask airway, IV -intravenous, IO -intraosseous, ETIendotracheal intubation, ACLS -advanced cardiac life support, tCPA -traumatic cardiopulmonary arrest, NAEMSP -National Association of Emergency Medical Services Physicians, DNAR -do not attempt resuscitation order, TOR © 2024 Smyth MA et al.JAMA Network Open.