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Time of Death?

Jeffrey M. Taekman, MD; Melanie C. Wright, PhD | September 1, 2005
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The Case

An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was called, which involved intubation, the administration of several parenteral medications, and prolonged chest compressions. The “final rhythm” was deemed agonal and the code was “called” after approximately 15 minutes. Virtually all the members of the code team left the room, leaving behind only a single nurse to clean up. Not 3 minutes later, the nurse emerged from the room, breathlessly declaring that the patient had a strong pulse and was now breathing spontaneously. After initially dismissing her observations as representing agonal respirations, clinicians reevaluated the patient and found her to be in a perfusing rhythm with spontaneous breathing. She was transported to the ICU, where she languished for several days before supportive efforts were discontinued because of her poor neurologic prognosis.

The nurse had seen numerous codes, but never participated in one until that night. She was trained and certified in cardiopulmonary resuscitation (CPR) but had never trained with the other team members and didn’t recall being trained in how to “call” the end of codes. She commented on how difficult it had been to squeeze the Ambu bag toward the end of the code, a fact she did not raise with the code team leader during the code itself.

The code team never came together to discuss this error (the premature pronouncement of death); rather, at the end of the code they all wandered off and resumed their usual jobs.

The Commentary

Between 370,000 and 750,000 hospitalized patients suffer a cardiac arrest and undergo resuscitation each year in the United States.(1) Although delivery of CPR, a subset of skills within advanced cardiac life support (ACLS), improves survival in patients in cardiac arrest (2), many health care workers cannot perform the lifesaving skills in keeping with the evidence-based guidelines (3). Many of the errors in ACLS relate to deficiencies in communication and/or leadership (1).

This case vividly illustrates shortcomings in the educational process of resuscitation skills, including (i) high prevalence of untrained providers, (ii) overly complex treatment algorithms, (iii) inefficient and inconsistent training methods, and (iv) infrequent application of learned behaviors even by trained providers.

The case also brings to light several issues of team performance, including (i) problems of situation awareness, (ii) lack of team assertiveness, (iii) hierarchy power differentials, (iv) the lack of proper team communication, and (v) the impact of time stress.

Let’s first focus on some of the issues in ACLS education.

High Prevalence of Untrained Providers

About 700,000 physicians and 1.2 million nurses currently practice in the United States. In 2003, 667,932 ACLS providers and 10,224 advanced ACLS providers were trained in American Heart Association (AHA)-approved courses (AHA, unpublished communication). Given the AHA’s 2-year re-certification requirement, we estimate that approximately 30% of physicians and nurses lack current ACLS certification. Clearly, the penetration of ACLS training in the United States is incomplete.

Inefficient, Inconsistent, and Incomplete Training Methods

Safe and effective performance of resuscitation depends on competent team members. In general, competency is acquired through repetition of action or experience; the competent provider is generally midway on the continuum from novice to master (4). One maintains competence through frequent application of learned behaviors, since skills not practiced frequently are lost (5).

The nurse in our case attended an ACLS course, yet her psychomotor, affective, and cognitive skills were insufficiently developed to be a competent member of the resuscitation team.(6) Although she may have understood the material, she never had a chance to practice or apply that knowledge in a clinical setting. A number of studies have demonstrated that her situation is common: documentation of improper CPR technique (2,3,7), lapses in adherence to ACLS algorithms (5), and loss of CPR skills and knowledge over time (8,9) have all been well documented.

“Calling” Codes

Very little information in the AHA training materials is focused on the question of when one should “call” (ie, terminate) a code. The discussion of when to discontinue CPR fills less than one-third of a page of the ACLS Provider Manual.(10) Reasons to discontinue CPR in the ACLS manual include the following:

  • The victim responds, regains an adequate pulse, and begins to breathe
  • A trained professional provider assumes responsibility
  • The rescuers are too exhausted to continue
  • A medical professional decides it’s time to stop, or
  • Obvious signs of death are apparent.

Many of these reasons are ambiguous. What is an adequate pulse? What apparent signs of death should be sought? Other sources state it is acceptable to stop resuscitation after a patient has been in asystole for 10 minutes or longer.(1) Given this ambiguity, it should not be surprising that providers are often uncertain about when to discontinue CPR.

Overly Complex Treatment Algorithms

A recent editorial in JAMA (11) argued that the lack of adherence to resuscitation protocols owes more to the complexity of the CPR and ACLS algorithms than to imperfect training methods. The editorialist’s prescription: pushing the AHA and the International Liaison Committee on Resuscitation (ILCOR) to vastly simplify the CPR treatment algorithms.

Team Coordination Problems

Although this case can be framed as a procedural error—premature calling of a code—and managed through better ACLS education and protocols, it is clear that it is also reflects inadequate teamwork and communication. Failures in communication are common contributors to adverse events in medicine. JCAHO has identified communication errors as a root cause in more than 60% of events.(12) Observation of teams in the operating room suggest that as many as 30% of communications are substandard or contain a particular type of communication failure.(13,14)

We see two key problems of team coordination in this case. First, the team was unaware of the inexperience of the nurse manually ventilating the patient. Second, the nurse did not communicate either her inexperience or her perceived difficulty in squeezing the Ambu bag. Clearly, the lack of assertiveness on the part of the nurse could be cited as a potential cause of these problems. However, it is important to point out that her lack of assertiveness may stem from failure of the organization or the clinical team leaders to provide an open and supportive team environment.

The leader-subordinate nature of a doctor-nurse relationship presents a power differential that may affect an individual nurse’s willingness to speak up in cases such as this. Differing attitudes about teamwork between doctors and nurses may reflect the problems inherent in such a relationship. Thomas and colleagues found that only 33% of nurse respondents rated collaboration and communication with physicians as high or very high, compared with 70% of physicians rating their collaboration and coordination with nurses.(15) Nurses also often stated that it was difficult to speak up if they perceived a problem with patient care.

Simulation Training As a Solution

Clearly, there is room for improvement in the teaching and learning of resuscitation and teamwork skills. Until simpler algorithms are available, more efficient and frequent methods of education should be applied to CPR and ACLS certification and skills retention.

Simulation offers a potential solution for resuscitation skill acquisition and retention. Simulation ranges from low-fidelity (i.e., desktop computer simulation) to fully immersive high-fidelity environments. High-fidelity simulation allows learners to gain experience in common and uncommon scenarios without placing patients at risk.(16) Our nurse could have practiced her newly learned skills in simulation until she had the requisite competence to become an effective member of the resuscitation team. We have created a simulation (Video) of this situation—it shows the code being conducted, with the final minute demonstrating the situation as described in the case.

Despite the attractiveness of using high-fidelity simulation for ACLS and CPR training, many problems remain. It is very hard for a simulation center with a few mannequins to “scale up” an ACLS or CPR training course to the size needed to train an entire health care workforce. Conducting constant ACLS training in its current form would quickly overwhelm the available resources of a small simulation center.

HeartCode, a recent product of the AHA and Laerdal Corporation, addresses the “scalability” issue. Using Heartcode, an ACLS student can complete about 95% of the AHA course at his or her own pace on a personal computer. The user studies the ACLS written material (in Adobe Acrobat format), then is tested on the algorithms using computer desktop simulation. The desktop simulator scores their performance and gives users immediate feedback. If they fail the scenario, they can review the materials before attempting to pass the simulation once again. Once they have successfully completed 10 scenarios, they receive a certificate to bring to an AHA-approved center for a 30-minute hands-on skills check and simulated clinical scenario. After successfully completing their hands-on skills check and simulated scenario (the “MegaCode”), learners receive their ACLS certification card.

We believe this method of ACLS certification is much more efficient (and effective) than traditional methods. HeartCode enables the end-user to complete ACLS at his or her own pace and return to the materials as needed. HeartCode frees the high-fidelity simulation center to focus on issues of team coordination, acquisition of higher-level ACLS skills, and acquisition of certain psychomotor skills, such as depth of chest compression, that may require realistic feedback for learning.(17)

With respect to the problems of team communication and coordination, training of “non-technical skills” can also be offered as a solution.(18) The medical community, beginning with the field of anesthesia, has begun to adopt principles of crew resource management (19) from aviation to the training of team communication and coordination.(20) Such efforts use simulation to provide practice and feedback in the performance of non-technical skills such as decision making, communication, leadership, and assertiveness. In high-fidelity simulations, providers can immerse themselves in a realistic patient care environment that generates the emotional stress, time pressure, and workload that often accompany high-stakes technical tasks. By including the participation of interdisciplinary teams, individuals have the opportunity to interact as they solve realistic patient care problems. Effective debriefing, including performance feedback, provides opportunities for learners to analyze their own performance and identify areas for improvement. A recent review further describes the key components of effective team training, including management participation, a commitment to life-long training, thoughtful program design including task analysis, and interdisciplinary simulation using dynamic scenarios.(21)

Procedural or System Solutions

One solution to problems associated with the acquisition and retention of ACLS skills is the use of multi-disciplinary mock codes. Mock codes may be pre-announced or not. They usually involve a scenario presented to the code team in which the members must treat a simulated patient (either a simulator or a manikin) requiring ACLS. Facilitators may be involved in the mock codes as instructors or evaluators.(22) While we are aware of no research that shows objective improvements in ACLS proficiency, subjective ratings of both confidence in one’s own skill and the value of the mock codes support their use.(23,24) The American Academy of Pediatrics promotes the use of periodic mock codes for practitioners and provides sample mock code scenarios on respiratory distress, seizure disorder, and shock.(25)

Although mock codes involving all available providers may help, another procedural change that could improve ACLS performance is the use of dedicated resuscitation teams comprised of the same members all the time. While dedicated teams would allow members to practice, learn, and work together, they are impractical in today’s health care environment. Technology may one day offer a solution in collaborative virtual environments where the team could gather and practice regardless of their physical location and without harm to patients.

Lastly, system solutions such as the availability and use of checklists may improve performance in ACLS (17), particularly in the performance of complex algorithms. From a systems design perspective, reduction of the complexity of the algorithms is preferable to requiring the use of assistive tools such as checklists. However, checklists may be helpful as a short-term solution.

The Future of Simulation Training

One question for the future is whether or not the training of team skills really requires the use of high-fidelity patient simulations. Would tasks that incorporate requirements for similar levels of psychomotor workload, cognitive requirements, and interpersonal skills (such as are found in fully distributed and immersive computer gaming environments) be sufficient for training the necessary cognitive, psychomotor, and team coordination skills? Would teamwork skills developed in such artificial training environments transfer to actual patient care environments?

A great deal of attention is being devoted to learning in virtual three-dimensional worlds. Online collaborative environments, such as the military simulation known as America’s Army, allow players to develop team skills while completing realistic missions. As technology for the simulation of tactile or haptic feedback (eg, computerized forced feedback) matures, one could imagine the day when ACLS practice, certification, and recertification all occur in a virtual three-dimensional environment.

Take-Home Points

  • Current ACLS and CPR algorithms are too complex for use in the real world.
  • Simulation is a solution to many of the shortcomings with current ACLS training.
  • New products are available that offer more efficient means of ACLS training.
  • Future ACLS training will likely include fully or partially immersive three-dimensional environments.
  • Non-technical skills such as team communication, leadership, and assertiveness are essential for effective team performance in health care and are especially relevant in critical care situations, such as ACLS.
  • The training of non-technical team coordination skills may also benefit from the use of low- and high-fidelity simulation approaches.

Jeffrey M. Taekman, MD Assistant Professor of Anesthesiology Director, Human Simulation and Patient Safety Center Assistant Dean for Educational Technology Duke University

Melanie C. Wright, PhD Assistant Professor of Anesthesiology Human Simulation and Patient Safety Center Duke University


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Time of Death


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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