1. Termination of Resuscitation (TOR) By Primary Care Paramedics Implementation Trial Research by Ontario’s Base Hospitals in Collaboration with the Sunnybrook Prehospital and Transport Medicine Research Program

2. Purpose of TOR Implementation Trial To demonstrate the feasibility of TOR by PCPs in selected cardiac arrest patients

3. Why should PCPs do TOR? Fewer than 5% of patients survive prehospital cardiac arrest Emergency ambulance transport can be hazardous to motorists, pedestrians, and paramedic A TOR guideline has been developed that is by itself 99.5% accurate in identifying patients who will not survive cardiac arrest Families are comfortable with TOR in the home and support given by paramedics CPR guidelines support the concept of TOR by PCPs

4. Potential Participants in the TOR Implementation Trial Simcoe Cornwall Kitchener-WaterlooYork Muskoka Grey Bruce Peel Hamilton Peterborough Timmins Sault Ste Marie

5. TOR Medical Directive TOR medical directive structured similar to other PCP medical directives When you follow and complete the TOR form you will be following the TOR medical directive!

6. Overview of the Paramedic Role in the TOR Implementation Trial Make sure you have the following two documents in front of you : u TOR Paramedic Guide u TOR Paramedic Form The Guide describes how to fill out the Form!Use the Guide whenever you have to fill out the Form.

7. Overview of the Paramedic Role in the TOR Implementation Trial Step 1: Implement the Cardiac arrest protocol and decide whether TOR guideline can be used on your patient Step 2: Answer the TOR Guideline Questions Step 3: Interpret the TOR Guideline Step 4: Patch to the Base Hospital if needed Step 5: Record the Decision of the BHP Step 6: Record the Patient Outcome Step 7: Record Variations from the Protocol Step 8: Record your Comfort Level Step 9: Complete the Call information and submit the form along with your ACR to the Base Hospital in the TOR Implementation Envelope.

8. Step 1 - Implement Cardiac Arrest Protocol On which patients should you consider using the TOR guideline? ALL cardiac arrest patients On which patients should you actually use the TOR guideline? >18 years old No ALS procedures available during the call The cardiac arrest is of presumed cardiac cause. All these must be true to actually use the TOR guideline! If any are not true, do not use the TOR guideline.

9. Step 1 - Implement Cardiac Arrest Protocol On which patients should you complete the Paramedic Form? ALL CARDIAC ARREST CASES!!!! including trauma, Code 5, drownings etc. For these only the Form needs to be completed only to Step 1.

10. Step 2 – Answer the TOR Guideline Questions Once the Cardiac Arrest Protocols are completed: Answer each question by checking the correct “  ”  Yes OR  Uncertain OR  No Do not make any decision about TOR at this point

11. Step 3 – Interpret the TOR Guideline Check only one of the two choices depending on answers to questions in Step 2 : If you checked “  Yes OR  Uncertain” to any question in Step 2, check the top “  ” in Step 3. Continue Resuscitation and Transport. DO NOT patch to BH. Go to Step 6. If you checked “  No” to ALL questions in Step 2, check the bottom box. Continue Resuscitation. Patch to the BH for consideration of TOR

12. Step 3 Interpret the TOR Guideline Box 2 – Consider stopping resuscitation at this time. Continue resuscitation and patch to the BHP. Misleading statement

13. Step 4 – Patch to the BH (if needed) The Patch should occur from the scene but can occur during transport. If unable to establish patch check the “  ” and transport. Present your patch in the exact order outlined in Step 4. Do not deviate from this script. The BHP is filling out a form with same information. Use the exact phrases where possible. n Supply “Further Clinical Information” if asked or if you feel is relevant.

14. Step 5 – Record the decision of the BHP You must always follow the decision of the BHP! If the BHP advised TOR u Check the top “  ” u Counsel caregivers u Arrange disposition of body according to local policy (addressed shortly) If the BHP advised transport and continued resuscitation  Check the bottom “  ”

15. Step 6 – Record the patient outcome The patient outcome is recorded only when the patient was transported to the ED.

16. Step 7 – Indicate variations from protocol All questions must be answered for every case. Each describes variations from TOR guideline May have occurred in unusual circumstances and does not mean improper care actually occurred Contact the BH if you are unsure of the answers to any of these questions

17. Step 8 – Rate your comfort level Takes into account many aspects of the call Focus on how comfortable you felt using the TOR Guideline

18. Step 9 – Complete the Call Information Provide the requested information. Submit the completed Paramedic Form and your yellow copy of the ACR to the BH in the TOR envelope. Complete the information requested on the front of the TOR envelope

19. Questions? n Thanks for your participation!

20. ACPs Responding n If ACPs are responding, do not use TOR Medical Directive – initiate transportation after completion of on-scene protocols

21. Termination of Resuscitation n BHP can terminate resuscitation based on your treatment and assessment findings n Upon receiving the order to “Terminate Resuscitation” from the BHP, provide the BHP with: u your name u the name and age of the deceased. n Once pronounced, advise family n Record the name of the BHP and the time of the “Terminate Resuscitation” Order

22. Termination of Resuscitation Body Disposition: n Unexpected Death – advise police and coroner n Peterborough – call the Regional Coroner’s Office (705) 745-9887 OR request the police notify the coroner n Northumberland, Kawartha Lakes Haliburton – call CACC to have the police service notify the coroner n Remain at scene until police or coroner arrive unless directed otherwise by CACC n Complete ACR as per MOHLTC Standard – include: u BHP name, time of death u Attending police constable, name and number n Leave completed ACR with patient in a sealed envelope (addressed to the Coroner and marked Confidential)