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  • A patient with an advance directive to not resuscitate (a DNR order) may be treated but not resuscitated in the ED.
  • Lacking advance directives, all children including those who are terminally ill must be provided with resuscitation. Rarely is there time or resources in the ED to initiate a conversation that would lead to a sound DNR order.
  • There is no standard of care that dictates the duration of resuscitation for infants, children, or adolescents. The duration of resuscitation is at the discretion of the treating physicians.
  • Brain death in infants and children typically cannot be determined in the ED because of the observation period required. To diagnose brain death, a set of criteria must be met that includes a compatible clinical history, a physical exam consistent with brain death, and may require supportive studies to definitively establish this diagnosis.


There are certain circumstances when resuscitation in the emergency department (ED) may be withheld. A terminally ill patient who presents to the ED with an advance directive such as a DNR order may be treated but not resuscitated. The order must be signed by the patient's attending physician and legal guardian and should be reviewed by the attending physician in the ED with the patient's guardian. The parents or legal guardian may withdraw the DNR order at any time, including shortly after arrival in the ED.


A terminally ill patient with no advance directives must be provided with advanced life support and resuscitation. Time and resources in the ED are insufficient to initiate the conversations that might result in a DNR order.


Termination of resuscitation and declaration of death is appropriate when there is no return of spontaneous circulation. There are no absolute standards of care that dictate the duration of resuscitation in the pediatric population. Survival after out-of-hospital arrest is poor and has been correlated to the number of doses of Epinephrine administered. In several studies, there were no survivors if more than one dose of epinephrine was administered, and a larger number of investigations revealed no survivors if more than two doses of epinephrine were administered. In terms of duration of resuscitation, multiple studies have demonstrated few survivors in resuscitations lasting more than 20 to 30 minutes, while other investigations have demonstrated intact survival only in patients who received less then 15 minutes of resuscitation.1 Lacking universally accepted guidelines, the physician must determine the duration of resuscitation based upon the individual case. Certainly, hypothermic patients should have resuscitation continued until they have a body temperature of at least 35°C.


A number of studies have demonstrated that family members typically prefer to be present during resuscitation, and that their grieving is less problematic if they were present during the resuscitation. There should be one staff member assigned to be present with the family to answer questions and explain what is being done; the ED staff should be sensitive to the presence of family ...

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