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Identifying Who Is in Charge

All CPR teams should have well-understood protocols about who is in charge. This should be based on skill and availability. In addition to the usual members of the team, there should be a person with the sole duty of documenting every action taken by the team. This should be a chronologic record and should be kept to the second. This record keeper need not be a physician or RN but must understand the procedures of a CPR and the drugs that are used. This record will document the CPR for the medical record. More important, it will allow the physician in charge to determine what drugs were given and when. Since 2 minutes can seem like 20 in an emergency, this is critical information when assessing the effect of drugs that have been given.

If the patient's attending physician is present, this physician should defer to the head of the CPR team. In teaching hospitals, this may mean that a professor is deferring to a resident. But the resident who has spent every third day for the last three years on CPR duty is likely to be more skilled than an attending physician who participates in a CPR a few times a year. The physician who is there must be in charge. No one can do CPR over the telephone.

Attending physicians do not give up their responsibility for their patients. They should monitor the progress of the resuscitation and make decisions about the types of supportive therapy that are appropriate. For example, a CPR team will normally put a patient on a respirator if the patient is unable to breathe without external support. If the attending physician considers a patient not a candidate for a respirator, this should be in the orders. Decisions about the conduct of the CPR are made by the team leader. Decisions about the advisability of CPR and the extent of ongoing care should be made by the attending physician.

Drawing the line between life and death is a medical decision. Anyone who undertakes to do CPR should make a good-faith effort to revive the patient. This does not mean that every possible procedure must be done or drug given. When there is little hope of response and the patient appears to be dead, the physician in charge or the attending physician should stop the resuscitation, document the absence of vital signs, and pronounce the patient dead. The record of the resuscitation efforts should be completed and the reason for pronouncing the death recorded immediately by the physician.

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