Determining futility of care: despite best efforts, certain injuries are not survivable in austere environments. The tactical situation, casualty clinical condition, and operational constraints (e.g., mass casualty incidents, logistics) may warrant the consideration of ceasing ongoing, aggressive resuscitative efforts.

The provider must use all their operational knowledge to determine the utility of ongoing resuscitation. As a guide only, examples of wounds with low chance of survival include:

- Cranial injuries with exposed brain matter (exception may be isolated frontal lobe injuries) or severe TBI with signs of herniation (i.e. dilated pupils, hypertension plus bradycardia) or Glasgow Coma Scale score .3–5
- Penetrating thoracic or abdominal injuries that are hypotensive or nonresponsive after:
  - two units blood transfusion
  - bilateral chest decompression (needle decompression/finger thoracostomy/tube thoracostomy)
  - assessment for pericardial tamponade
- Junctional amputations with pelvic disruption
- Out-of-hospital cardiac arrest (despite bilateral chest decompression), especially if surgical resuscitation is more than 10 minutes away.
  - Blunt trauma mechanism without organized activity on cardiac monitor
  - Cardiopulmonary resuscitation for longer than 5 minutes
  - No cardiac motion observed on FAST examination or palpated with left finger thoracostomy
  - Cardiac monitoring reveals:
    - - Asystole
    - - No organized rhythm
    - - Wide complex/idioventricular rhythm
- Cervical spine trauma with cardiovascular collapse
- Obvious massive trauma, such as total body disruption and decapitation
- Nonresponders

Before cessation of resuscitation attempts by the provider, every attempt should be made to contact medical direction for input. If contact with higher medical direction is not feasible, then the on-scene provider must use their best judgment for ongoing resuscitation attempts. This may include an assessment of available resources, timing of evacuation, and the clinical condition of all the patients requiring the attention of the provider making the decision. It will not always be possible to save all team members.

A determination that further attempts to save a life are futile does not necessarily mean cessation of clinical care for the patient. All reasonable interventions to reduce pain and suffering, short of hastening death (e.g., not giving a lethal dose of opiates) should be provided. At times, agonal respirations and bodily movement can take place in the dying process; be prepared for this in the sight of comrades and be prepared to explain this. This is not a reason to continue resuscitative efforts.

If a casualty dies, all medical interventions should be left in place if feasible. If supplies may be needed for future casualties and resources are critically limited, it may be necessary to reuse medical devices (e.g., cricothyrotomy kits, chest tubes).

After death, a casualty should not be used as a blood donor for surviving casualties. Every attempt should be made to find alternate donors for any surviving casualties. Transfusing blood from a deceased casualty may result in transfusing acidotic and hypocoagulable blood, thus worsening the surviving casualty’s hemostatic physiology and possibly causing death.

Providers facing the dilemmas around patient death and cessation of resuscitative efforts should also be cognizant of the effects on team members, other patients, and on themselves. Various strategies for coping with these challenges may be appropriate in different circumstances. A full exploration of the topic is beyond the scope of this CPG; however, some consideration of these issues should be built into individual and unit training for PFC scenarios.