ToR and VoD
Rapid Recap is distributed each month using suggested topics or topics on trend (seasonal/disease trends). NWAS-wide clinicians, irrespective of grade, are invited to contribute towards writing content in future issues in a supportive process. Please get in touch with rapid.recap@nwas.nhs.uk.
This month's Rapid Recap looks at Termination of Resuscitation (ToR) and Verification of Death (VoD).
A plain-text version can be found at the bottom of this page.
ToR and VoD
JRCALC have updated the Termination of Resuscitation (ToR) and Verification of Death (VoD) guidelines for 2026. Key points have been highlighted for your reference; however, read the full guidelines found on JRCALC PLUS.
ToR
Extended resuscitation time from 30 minutes to 45 minutes for adults, and 60 minutes for children (<18).
The clock starts for resuscitation when the first ambulance service dispatched resource confirms cardiac arrest.
Resuscitation management and termination decisions are then based on the initial presenting cardiac rhythm.
For adults, clinicians can terminate after 45 minutes of total resuscitation time with no sustained ROSC (a sustained ROSC is defined as ROSC lasting >10 minutes).
Clinicians may terminate resuscitation before 45 minutes if new information of futility and/or frailty becomes available.
There are occasions when some interventions cannot be provided by paramedics; consider what specialist interventions may be indicated (e.g. thrombolysis, thoracotomy, resuscitative hysterotomy). Resuscitation should always be continued with minimal on-scene time for hypothermic patients, drug overdose/poisoning, pregnancy, penetrating trauma, suspected PE, possible electrolyte disturbance, children (under 18-years).
ToR Children
The default with children is to begin resuscitation and continue to the hospital. In theory, resuscitation of children could be terminated after 60 minutes with no sustained ROSC, but not advised. See JRCALC for further details.
VOD
For VoD (formerly diagnosis of death), clinicians must examine and document findings for the following VoD criteria:
A/B: apnoea, absence of breathing?
C: absent circulation.
D: disability, unresponsive (GCS3).
E: 5 minutes of asystole on ECG.
This process is for presentations other than those unequivocally associated with death (i.e. massive cranial or cerebral destruction, decapitation, hemicorporectomy or similar massive injury, burns >95% full thickness or extensive incineration, decomposition).
Remember: Hypostasis, rigor mortis, burns and submersion still require the VoD procedure to be followed with examination of ABCDE (as above).
ToR and VoD are two distinct times; both must be individually recorded. ToR is the time when resuscitation is terminated. VoD time is only confirmed following continuous monitored asystole for 5 minutes after ToR.
VoD Children
For VoD in children, all of the following must be present:
Hypostasis, Rigor Mortis, and Asystole. Together, these are conditions unequivocally associated with death.
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