Question: I recently had my recerts and have a question concerning Medical TOR. The way it was explained to me was that a TOR was a pronouncement. It was explained to me, if we receive a TOR in the back of the unit before the vehicle is put into drive, we have stay on scene with a patient until the coroner comes. Likewise if we received the TOR while the vehicle was in motion we could continue to the hospital. I really don't understand the difference as to whether the vehicle is in gear or not. I was under the impression that if we receive a TOR, it is simply that, terminate resuscitation and continue transport (no lights and sirens) with no resuscitation. The decision on route would then be, do we go to the morgue or to the ER. I understand the delicacy of appearances and you may have to leave scene with lights and sirens but once away from the scene, judgment on activation of emergency signals would be up to the driver/crew. Could you elaborate some more on this?

My question concerning TOR is this. Is a patient deemed dead at the time of TOR or are they deemed dead when assessed either at the hospital by an ER physician or at the scene by the coroner?

 Thanks for your question. We are often asked regarding the procedure to follow operationally regarding the TOR once a TOR has been received from a Base Hospital Physician. To be clear, this is a BLS issue and direction on this comes from the Ministry of Health but we would be happy to try and navigate the decisions as to why this has been developed as such.

To answer your question, termination of resuscitation is equal to pronouncement of death. You will notice however that the BLS Standard avoids the term "pronouncement" preferring to use the terms "certify" and "terminate resuscitation".

Anyone can "pronounce" death. However, only a physician or nurse practitioner can "certify" the death. Certification is essentially the authority to fill out a death certificate. In order to certify the death you need to have sufficient knowledge of the circumstance of the death. Coroners certify the death whenever the person does not die of a "natural cause" (accident, homicide, suicide or if the manner of dying is undetermined). There are a number of circumstances of "natural causes" listed in the Coroner's Act that require reporting such as a person dying in police custody, a psychiatric facility, or an index case in a nursing home etc. Outside of those a coroner investigates a natural cause death are that it is both sudden AND unexpected (e.g. not being known to have a condition that is associated with sudden and unexpected death like known coronary artery disease). Otherwise any physician with sufficient knowledge of the circumstance of the death can certify the death.

The Base Hospital Physician will provide the paramedic with a Termination of Resuscitation Order which is effectively (by another name) a pronouncement. As for the distinction that you are referring regarding the movement of patients, this comes directly from the Deceased Patient Standard Training Bulletin and is a Ministry of Health and Coroner driven decision. A link to this bulletin can be found on our website.

Please note that on page 11 of this document, points #2 details the need to remain on scene if a TOR is received in an ambulance that is stationary on scene. This is done so to then allow the coroner to attend and investigate and then certify the death. Point #3 on page 12 details the procedure to follow if a TOR is received during the transport phase to the nearest ED. We would like to be clear, this is not a local Base Hospital decision and procedure, this is a joint consensus from the Ministry of Health and the Coroners of Ontario.

To be fair, we think it is not as simple as the distinction of having the ambulance "in gear" or not. It is our opinion that the spirit and intent of this initiative was to limit your risk on Code 4 transport as paramedics going long distances with patients who have a very low chance of survival vs limiting the ability of Coroners to access and investigate scenes vs trying to avoid transporting "dead "patients in ambulances and contravening the Ambulance Act Part VI, section 12, point 1.

A link to the Ambulance Act can be found here.

Hope this helps explaining the rationale behind this policy.

BLS,Cardiac/Circulation,Medical Cardiac Arrest,Miscellaneous

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