Termination of Resuscitation Rule

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Termination of Resuscitation (TOR) Rules

In-Hospital Cardiac Arrest
- In-hospital cardiac arrest (IHCA) is a critical event with often poor outcomes.
- Resuscitation efforts are initiated immediately but deciding when to stop is challenging.
- Current guidelines lack clear, evidence-based rules for termination of resuscitation.
- Variability in practice can lead to inappropriate early termination or futile resuscitation.
- Clear guidelines are needed to balance patient care and resource allocation.

Variability in Resuscitation Practices
- Lack of clear guidelines leads to inconsistent clinical decisions.
- Risk of inappropriate early termination: stopping too soon in potentially survivable cases.
- Risk of futile resuscitation: continuing efforts with very low chance of success.
- Previous rules, like the UN10 rule, have not been reliable for widespread use.
- Both scenarios can delay care for other patients and consume resources.

New Termination of Resuscitation (TOR) Rule
- Study published in JAMA Internal Medicine developed a new TOR rules for IHCA.
- Rules were validated using a large dataset from multiple countries.
- Aim to provide consistent, evidence-based guidance for stopping resuscitation.
- Best-performing rule includes 4 key factors for decision-making.
- Rules are tools to support, not replace, clinical judgment.

The Four Key Factors of the TOR Rule
1. Unwitnessed Arrest: Arrest not directly observed by a healthcare provider.
2. Unmonitored: Patient not on continuous ECG monitoring at the time of arrest.
3. Initial Rhythm Asystole: First recorded rhythm was asystole (flatline).
4. Resuscitation Duration ≥ 10 Minutes: Efforts ongoing for at least 10 minutes.
- If all 4 factors are present, termination of resuscitation may be appropriate.

Performance and Reliability of the Rule
- False-positive rate of 0.6%: Only 6 out of 1000 cases incorrectly predict death.
- Positive rate of 11%: Rule applies to a meaningful proportion of IHCA cases.
- Low false-positive rate ensures minimal risk of stopping resuscitation in survivable cases.
- High reliability supports its use in clinical practice.
- Further research is needed to confirm findings and assess impact on outcomes.

Applying the Rules in Clinical Practice
- TOR rules are adjuncts to clinical judgment, not replacements.
- If all 4 criteria are met, probability of successful resuscitation is very low.
- Clinicians must consider patient-specific factors (e.g., underlying conditions, prior wishes).
- Rules help reduce variability and improve decision-making consistency.
- Always integrate rules with broader clinical context.

Clinical Implications and Future Research
- TOR rules improve consistency and appropriateness of resuscitation decisions.
- Reduce risk of inappropriate early termination and futile resuscitation.
- Free up resources for other patients by avoiding prolonged futile efforts.
- Potential to improve overall outcomes for IHCA patients.
- Further research is needed to validate and refine these rules.

Summary of the Four Key Factors
1. Unwitnessed Arrest: Arrest not observed by a healthcare provider.
2. Unmonitored: No continuous ECG monitoring during arrest.
3. Initial Rhythm Asystole: First rhythm was a flatline.
4. Resuscitation Duration ≥ 10 Minutes: Efforts ongoing for at least 10 minutes.
- If all 4 factors are present, termination of resuscitation may be considered.

Key Takeaways
- New TOR rules provide evidence-based guidance for stopping resuscitation in IHCA.
- Best-performing rule uses 4 easily obtainable factors with high reliability.
- Rules aim to reduce variability and improve decision-making consistency.
- Always use rules in conjunction with clinical judgment and patient-specific factors.
- Further research is needed to confirm and refine these guidelines.