“Okay team, we’ve been following the APLS algorithm for 30 minutes and have considered all reversible causes. This child has been in cardiac arrest for at least an hour and none of the interventions we have carried out have made a difference. The blood gas is incompatible with life. I think we should stop resuscitation. Does anyone have any objections?”
“Erm…. I think I can feel a pulse?”
APLS makes everything sound straightforward. Follow the algorithm and aim for a return of spontaneous circulation (ROSC). If ROSC is obtained, stabilise the patient and admit for further care. If not, then the team, led by the team leader, makes a decision to stop. Parents are given the awful news if they haven’t been present, and SUDIC (Sudden Unexpected Death in Childhood) protocols begin.
But what if you get ROSC when you know the situation is still unsurvivable? When the likelihood of multiorgan failure and hypoxic brain injury is less a likelihood and more a certainty?
How long should you try to resuscitate?
There are no hard and fast rules as to how long a resuscitation attempt should be carried out. Of course, we want to continue long enough to ensure we’ve tried everything, considering all the Hs and Ts. We might consider how long the child has been in cardiac arrest – the longer the time, particularly if there was any time without CPR, the less likely they are to regain circulation.
We might consider the clinical assessment of the child, particularly their core temperature and any signs of rigor mortis or livor mortis, and we might consider the results of a blood gas and bedside echocardiogram. We might consider information about their medical history, particularly if they have an advanced care plan, DNACPR or ReSPECT form.
We will also consider the child’s family. Are they present? Do they know and understand what is going on? We might continue resuscitation attempts longer than usual to allow family members to arrive and hold the child’s hand or be at the bedside when we stop.
We might also be waiting for someone else to decide to stop, particularly if things are complicated or the team is less experienced and senior help has been called. For many reasons, we may continue resuscitation beyond the period when we hope for a good outcome. The longer we carry on, the more we know that the child is unlikely to survive whatever we do.
In those situations, stopping resuscitation is tremendously sad but feels like the right thing to do.
Getting ROSC can feel wrong. As if we’re prolonging the agony of the family and the child – and I mean “agony” in a variety of ways. Of course, the agony of a child dying is overwhelming, but it is also final – the family can begin to grieve. The agony of the unknown, a mix of hope and despair, is different. Maybe it’s better than the agony of loss? I don’t know. The agony of impending loss and the agony of loss cannot be compared unless you’ve lived through it. There’s also potential agony for the child – it’s very unlikely, physiologically, that a child with severe hypoxic brain injury and multi-organ failure will be in pain. Still, we don’t really know, do we? Life in PICU, on maximal support, is not what anyone wants for their child. And are we just delaying the inevitable?
But what if that delay allows a family to process, plan and prepare for the death of their child? Relatives from further away might have a chance to arrive to say goodbye and support each other. Things can be explained to siblings. Death can be quiet, calm and relatively private, instead of the noise, the chaos and the clinical coldness of a crowded resuscitation room. Maybe that’s still a good outcome.
So what do we do? How do we handle it? Not just the situation, but the confusion of feelings and emotions that run through us as healthcare professionals? It might help to consider all the relevant people separately.
Of course, the patient always comes first. We need to stabilise the child as best we can. That’s out of the scope of this blog but will likely involve intubation, if not already performed, setting up a ventilator, inserting lines, starting inotropes, planning investigations, and assessing and managing organ damage. We must consider pain and distress and the use of sedation and analgesia. We must minimise suffering – probably our most important role as healthcare professionals.
We need to make sure the family know and understand the situation. Yes, their child’s heart is now beating for itself, which is a good thing, but their child is still critically unwell. There may be organ damage, including unsurvivable organ failure.
We need to update them as and when we get further information from investigations and assessments, and we need to be honest. They need to know which treatments and interventions are appropriate and possible and which are not. We mustn’t give false hope.
Be clear, don’t use jargon, and don’t guess or make assumptions.
When the time is right (and that varies for every case), we need to consider what to do if the child arrests again and involve the family in that process. If the situation is truly unsurvivable, they need to know. We need to offer support in dealing with their horrendous situation, which might include specialist nurses or the hospital chaplain, for example.
In some situations, it might be worth considering organ donation. Knowing that something good has come out of the death may help families through the grieving process. Again, this is not something we’ll cover here, but something to remember. The SNOD (specialist nurse in organ donation) team are particularly good at navigating this situation.
The police might already be aware of the situation. They are often called when a child has a cardiac arrest in the community and may have been present for resuscitation. They have a role to play in the SUDIC process, and although that process cannot formally begin until the child dies, they should be informed when it becomes clear that the child will die.
Similarly, the designated doctor for child death should also be informed so they can start to prepare for the SUDIC process calmly and sensitively.
The resuscitation team is often a mix of staff with various experience levels and clinical knowledge. Do your team know the situation? It’s difficult to convey, particularly in the busy post-ROSC time, when everyone is focused on their particular role, especially with the family nearby.
It’s important, however, when the time is right, to ensure everyone knows that the child is unlikely to survive. Finding out, days later, that a child you thought you had saved had died can be very traumatic, and the team must prepare themselves.
Look after the more junior or more inexperienced members of the team in particular. Don’t forget students, HCAs, porters or reception staff, who may all have been involved in their own way. The team must know they did their job well and that they’ve given the family precious time with their child, even if the outcome will still be bad. The same goes for any ambulance staff, who may have left the resus room before the outcome was known.
Last but absolutely not least, you need to look after yourself. Be kind to yourself, whether you are the team leader or a team member. It’s okay to have mixed emotions and to feel confused about the outcome. It’s okay to feel sad and grieve for someone, even if you never met them. You did your job, and you did your best. Remember that. And, even if the outcome is not the one we expected, nor the outcome we wanted, you’ve helped to give the family a chance to spend time with their child, say goodbye, prepare to grieve, and support each other.