Some Patients Subject to Resuscitation-Discontinuation Rule Could Survive

By Will Boggs MD

June 11, 2019

NEW YORK (Reuters Health) - Some patients subject to the so-called UN10 rule to discontinue resuscitation during in-hospital cardiac arrest (IHCA) could survive, based on data from the American Heart Association Get With the Guidelines-Resuscitation-IHCA registry.

The UN10 clinical-decision rule indicates futility if all three of these criteria are met: unwitnessed arrest (U), nonshockable rhythm (N), and no return of spontaneous circulation within 10 minutes of resuscitative efforts (10).

In the original study that devised this rule, none of the patients meeting the UN10 rule survived (100% positive predictive value), and in a single-center validation cohort, 1.1% of those meeting the rule survived (98.9% positive predictive value).

Dr. Zachary D. Goldberger of the University of Wisconsin School of Medicine and Public Health, in Madison, and colleagues used registry data to determine how the UN10 rule performs in a broader sample of hospitalized patients with contemporary resuscitation care practices.

Among more than 96,000 patients with an index IHCA, 54.2% achieved ROSC, 19.4% survived to discharge and 16.7% were discharged with a favorable neurologic status.

Overall, 16.4% met all 3 UN10 criteria: 6.3% of these patients survived to discharge (93.7% positive predictive value) and 4.8% survived with favorable neurologic status, the team reports in JAMA Network Open, online May 31.

A greater proportion of patients who did not meet the UN10 rule survived to discharge (22.0%) and survived with favorable neurologic status (19.1%).

"Given that 4.8% of patients meeting the UN10 rule had favorable neurologic survival and 6.3% survived to discharge, many patients and families may not consider resuscitative efforts futile at these levels," the researchers conclude. "Given that (the rule) does identify patients whose probability of survival and favorable neurologic outcomes is significantly decreased, it could be used as an adjunct to decision making and potentially refined in the future to create a more predictive tool to aid in termination of resuscitative efforts following IHCA."

Dr. Benjamin S. Abella of the University of Pennsylvania, Philadelphia, who studies cardiopulmonary resuscitation, told Reuters Health by email, "An underlying theme in this work is that we are constantly improving our ability to treat cardiac-arrest patients and increase the opportunity for survival - therefore, we have to be cautious about decision rules to terminate care. Cardiac-arrest care is a challenging, moving target - and it's important to revisit outcomes so that we don't give up on patients inappropriately."

"While the UN10 rule has been circulated among hospital providers for years, it is unclear to me how often it is actually used in actual practice," he said. "That is, in my 20 years of experience, I have met numerous physicians and nurses caring for cardiac-arrest patients who had never heard of the rule and mostly used their own judgment to determine whether care should be continued to an arrest victim. So, while the current work is important to highlight challenges in our field, I'm not sure many providers will need to change practice if they weren't using the rule in the first place."

"One the most challenging decisions healthcare providers make in the hospital setting is terminating care for a patient in cardiac arrest - because stopping a resuscitation results in 100% mortality," said Dr. Abella, who was not involved in the new study. "The main message of this work is that this decision remains a huge challenge and needs far more research."

"There is remarkably wide variation in the quality of care given to patients suffering in-hospital cardiac arrest," he added. "We need to focus more attention on this problem; patients and their families want to trust the hospital to be a safe place for medical emergencies."

Dr. Goldberger was unable to provide comments in time for publication.

SOURCE: https://bit.ly/2IrEoJ5

JAMA Netw Open 2019.

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