The Journal of Emergency Medicine, Vol. 53, No. 3, pp.

345352, 2017
2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2017.05.025

Selected Topics:
Prehospital Care

A NEW RULE FOR TERMINATING RESUSCITATION OF OUT-OF-HOSPITAL

CARDIAC ARREST PATIENTS IN JAPAN: A PROSPECTIVE STUDY

SOSKANTO 2012 Study Group

Reprint Address: Akiko Akashi, MD, Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital,
4-23-15 Kohtohbashi, Sumida-ku, Tokyo 130-8575, Japan

, AbstractBackground: The American Heart Associa-
tion and European Resuscitation Council guidelines for
cardiopulmonary resuscitation present rules for termination
of resuscitation (TOR) in cases of out-of-hospital cardiac
arrest (OHCA). In Japan, only doctors are legally allowed
TOR in OHCA cases. Objective: This study aimed to develop
a new TOR rule that suits the actual situations of the
Japanese emergency medical services system. Methods:
Five different combinations of the TOR rule criteria were
compared regarding specificity and positive predictive value
(PPV) for 1-month survival with unfavorable neurologic out-
comes. The criteria were unwitnessed by emergency medical
service personnel, unwitnessed by bystanders, initial
unshockable rhythm in the field, initial asystole in the field,
no shock delivered, no prehospital return of spontaneous
circulation, unshockable rhythm at hospital arrival, and
asystole at hospital arrival. Results: A total of 13,291 cases
were included. The following combination provided the high-
est specificity and PPV for predicting 1-month unfavorable
neurologic outcomes and death: unwitnessed by bystanders,
initial asystole in the field, and asystole at hospital arrival.
The specificity and PPV for the combination of the three
criteria for predicting 1-month unfavorable neurologic out-
comes were 0.992 and 0.999, and for predicting death at
1 month after OHCA were 0.986 and 0.998, respectively.
Conclusions: OHCA patients fulfilling the criteria unwit-
nessed by bystanders and asystole in the field and at hospital
arrival had universally poor outcomes. Termination of
resuscitation after hospital arrival for these patients may
This work was supported by the Japanese Association for
Acute Medicine of Kanto.
decrease unwarranted treatments. 2017 The Authors.
Published by Elsevier Inc. This is an open access article un-
der the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
, Keywordsasystole; cardiopulmonary resuscitation;
decision support techniques; out-of-hospital cardiac arrest;
specificity
INTRODUCTION
Out-of-hospital cardiac arrest (OHCA) remains a major
public health problem worldwide. Regardless of the prog-
ress in resuscitation practices, OHCA outcomes remain
poor (1,2). The American Heart Association (AHA) and
the European Resuscitation Council (ERC) guidelines
for cardiopulmonary resuscitation (CPR) have rules for
the termination of resuscitation (TOR) for OHCA
patients in an out-of-hospital setting (37). For
example, the basic life support (BLS) TOR rule, which
has been the most recommended, has three criteria:
arrest was not witnessed by emergency medical service
(EMS) personnel, no shock delivered, and no
prehospital return of spontaneous circulation (ROSC)
(6). However, EMS personnel are legally prohibited
from terminating resuscitation in Japan (810). Almost
all OHCA patients, including those with minimal
potential for survival, are transported to a hospital,
which expends medical resources on patients unlikely

RECEIVED: 20 September 2016; FINAL SUBMISSION RECEIVED: 5 May 2017;

ACCEPTED: 30 May 2017

345
346
to recover. Currently, TOR in the field is not possible in
Japan; therefore, it is necessary to develop a new TOR
rule based on the assumption that most OHCA patients
may arrive at the emergency department.
Goto et al. analyzed the All-Japan Utstein Registry
of the Fire and Disaster Management Agency
(FDMA) during the years 20052009 to develop and
validate a new TOR rule for physicians in the emer-
gency department (9). The TOR rule developed by
Goto et al. proposes that physicians can terminate
resuscitation of OHCA patients who meet the
following three criteria: unwitnessed by bystanders,
initial unshockable rhythm in the field, and no preho-
spital ROSC. Importantly, this rule is aligned with the
actual condition of Japans EMS system. In addition,
this TOR rule has high specificity (0.903, 95% confi-
dence interval [CI] 0.8940.911) for 1-month mortal-
ity. However, the AHA and ERC guidelines suggest
that if the lower limit of the 95% CI of a diagnostic
test is < 0.9, it should be used very cautiously for prog-
nostication purposes (11,12).
The FDMA All-Japan Utstein Registry analyzed by
Goto et al. includes outcomes at 1 month or at discharge,
whichever is earlier, which carries a risk of overestimat-
ing cerebral performance category (CPC) scores,
because some patients were discharged with a CPC
score of 3 or 4 that lowered to 1 or 2 upon later transfer
to another hospital (13). Furthermore, because the All-
Japan Utstein Registry of the FDMA is a nationwide
sample of OHCA patients, it includes hospitals where
OHCA patients with a do-not-attempt-resuscitation
order or no-resuscitation-desired are mainly trans-
ported. In addition, although EMS personnel may judge
that there is no prehospital ROSC upon checking pulsa-
tion in a moving ambulance, ROSC at hospital arrival
can still be recognized. Therefore, although Gotos
TOR is an excellent rule, verification is considered
necessary. By contrast, the Survey of Survivors after
Cardiac Arrest, conducted in the Kanto Area of Japan
in 2012 (SOSKANTO 2012) consistently used out-
comes at 1 month. SOSKANTO 2012 also mainly
included OHCA patients treated at tertiary emergency
medical centers and involves little variation in medical
treatment level after hospitalization. In addition, SOS
KANTO 2012 included electrocardiogram (ECG) wave-
form data at hospital arrival, which we assessed as an
alternative to prehospital ROSC.
This prospective study aimed to develop a new TOR
rule that is suitable for an EMS system in which personnel
are prohibited from TOR (e.g., Japan) and that has the
highest specificity and positive predictive value (PPV)
for 1-month survival with unfavorable neurologic out-
comes compared to Gotos TOR and the BLS TOR rule.
SOSKANTO 2012 Study Group
METHODS
Study Design and Setting
SOSKANTO 2012 was a prospective multicenter obser-
vational study comprising 16,452 OHCA patients who
were transported to 67 emergency hospitals in the Kanto
region in Japan between January 2012 and March 2013.
The 67 emergency hospitals belong to the Japanese Asso-
ciation for Acute Medicine of Kanto, and many of these
hospitals have critical care centers. The study analyzed
the pre- and in-hospital records for all included OHCA
patients, and data were collected according to the
Utstein-style templates of recording OHCA patient
information (14). Details of the study design and
data collection of the SOSKANTO 2012 were reported
previously (1517). This study was approved by
the Institutional Review Boards of all 67 institutions.
The need for informed consent was waived according
to the guidelines of the Japanese government.
EMS Systems in Japan
The Kanto region in Japan consists of seven prefectures,
including the capital Tokyo. Both prehospital treatments,
provided by EMS personnel and health care providers,
and in-hospital treatments, provided by physicians, are
based on the national guidelines of the Japan Resuscitation
Council (8). In Japan, at least one emergency lifesaving
technician (ELST) rides in the ambulance (1). ELSTs
can use semi-automated external defibrillators, place an
adjunct airway, and insert an IV line. Specially trained
ELSTs are permitted to insert tracheal tubes and admini-
ster IV adrenaline under online medical supervision (10).
However, EMS personnel are prohibited by law from
terminating resuscitation in the field. Most OHCA patients
are transported to hospitals, whether or not they achieve
ROSC, except in cases with obvious signs of death, such
as decapitation, incineration, decomposition, rigor mortis,
or dependent lividity (2). Additionally, EMS personnel in
Japan do not use end-tidal CO2 monitoring.
Participants
All OHCA patients transported by EMS personnel to
participating institutions during the study period were
eligible for inclusion in the SOSKANTO 2012. Of these,
the present study included adult OHCA patients only
(18 years or older). Exclusion criteria were cases with
initial resuscitation performed inside the hospital or clinic
or missing data for onset location, 1-month neurologic
outcomes, witnessed by bystanders, prehospital shock
delivery, prehospital ROSC, initial ECG wave form in
the field, or ECG waveform at hospital arrival.
Terminating Resuscitation in OHCA Patients
Experimental Design
SOSKANTO 2012 collected ECG waveform data not
only in the field but also at hospital arrival. Because of
the specificity of Gotos TOR rule that reflects the actual
condition of Japan was not high, we analyzed ECG wave-
form results in cases with a poorer prognosis both in the
field and at hospital arrival.
The five combinations of TOR criteria were as follows
(Table 1):
1. BLS TOR rule: The combinations were unwitnessed
by EMS personnel, no shock delivered, and no
prehospital ROSC (6).
2. Gotos TOR rule: The combinations were: unwit-
nessed by bystanders, initial unshockable rhythm in
the field, and no prehospital ROSC (9).
3. SOSKANTOs TOR rule 1: No prehospital
ROSC, which is one of Gotos TOR criteria, is an
unclear condition. Because EMS personnel judges
whether there is prehospital ROSC, the ECG wave-
form can change and can demonstrate ROSC at
hospital arrival. In addition, cases with no preho-
spital ROSC can include those with shockable
rhythm, such as ventricular fibrillation (VF) or
pulseless ventricular tachycardia (VT). It is not
practical to terminate resuscitation for OHCA
patients with VF or pulseless VT without shock
delivery. Therefore, instead of prehospital ROSC,
which is included in Gotos TOR rule, we used
the criterion of unshockable rhythm at hospital
arrival. The combinations were: unwitnessed by
bystanders, initial unshockable rhythm in the field,
and unshockable rhythm at hospital arrival
4. SOSKANTOs TOR rule 2: Compared to SOS
KANTOs rule 1, we adopted asystole at hospital
arrival instead of unshockable rhythm at
hospital arrival, because asystole is more strongly
associated with poorer prognosis than pulseless
electrical activity (PEA) is, which consists of
unshockable rhythm with asystole (2). The combi-
nations were: unwitnessed by bystanders, initial
unshockable rhythm in the field, and asystole at
hospital arrival.
Table 1. The Five Combinations of Termination of Resuscitation Criteria
Initial Prehospital
TOR Rule Witnessed Status Rhythm
1. BLS Unwitnessed by EMS
2. Goto Unwitnessed by bystanders Unshockable
3. SOSKANTO 1 Unwitnessed by bystanders Unshockable
4. SOSKANTO 2 Unwitnessed by bystanders Unshockable
5. SOSKANTO 3 Unwitnessed by bystanders Asystole
BLS = basic life support; EMS = emergency medical service; ROSC = return of spontaneous circulation; SOSKANTO = Survey of Sur-
vivors after Cardiac Arrest, conducted in the Kanto Area of Japan in 2012; TOR = termination of resuscitation.
347
5. SOSKANTOs TOR rule 3: Compared to SOS
KANTOs rule 2, we adopted initial asystole in
the field instead of initial unshockable rhythm in
the field, because asystole results in poorer
prognosis than PEA (2). The combinations were:
unwitnessed by bystanders, initial asystole in the
field, and asystole at hospital arrival.
Outcomes Measurement
The primary outcome was 1-month survival with favor-
able neurologic outcomes after resuscitation. The secon-
dary outcome was 1-month survival. The neurologic
status of OHCA patients was determined by using the
standard CPC scale: category 1, good cerebral perfor-
mance; category 2, moderate cerebral disability; category
3, severe cerebral disability; category 4, coma or vege-
tative state; and category 5, death (14). A favorable
neurological outcome was defined as CPC 1 or CPC 2.
Statistical Analysis
The diagnostic accuracy of each combination of TOR
criteria to identify OHCA patients without neurologically
favorable 1-month survival was calculated in terms of sensi-
tivity, specificity, PPV, and negative predictive value by
using 95% CIs. As this was a secondary analysis of pre-
existing data, formal sample size analysis was not per-
formed. Statistical analyses were performed using Graph-
Pad PRISM, version 6g (GraphPad Software, La Jolla, CA).
RESULTS
During the survey period, 16,452 OHCA cases were
examined (Figure 1). Of these, 3161 were excluded due
to patient age younger than 18 years, cardiac arrest
initially occurring at a hospital or clinic, or missing
data for 1-month neurologic outcomes, witness, prehospi-
tal shock delivery, prehospital ROSC, initial ECG in the
field, and ECG at hospital arrival. Finally, 13,291 cases
were eligible for inclusion.
Patients characteristics and outcomes are shown
in Table 2. Only 931 of 13,291 (7.0%; 95% CI
6.6%7.5%) of the patients presented with an initial
Presenting Hospital
Prehospital Shock Prehospital ROSC Rhythm
No shock delivered No prehospital ROSC
No prehospital ROSC
Unshockable
Asystole
Asystole
348 SOSKANTO 2012 Study Group

Therefore, the most specific and easily understandable

criteria among the five combinations of criteria for both
1-month unfavorable neurologic outcomes and mortality
was in number 5: unwitnessed by bystanders and asystole
initially and at hospital arrival.
Among the OHCA patients satisfying number 5, three
patients survived for 1 month with good neurologic
outcomes. The body temperature of all these patients
was #30 C, indicating severe incidental hypothermia.

DISCUSSION

Figure 1. The study flow diagram. ROSC = return of sponta- We attempted to develop a new TOR rule that has higher
neous circulation; ECG = electrocardiogram.
specificity and PPV than Gotos TOR rule or the BLS
shockable rhythm in the field, and 1168 of 13,291 TOR rule for use in emergency departments. Among
(8.8%; 95% CI 8.3%9.3%) had prehospital ROSC. the five different combinations of TOR rules tested in
The 1-month survival of all OHCA patients was 632 the present study, number 5, SOSKANTOs TOR rule
of 13,291 (4.8%; 95% CI 4.4%5.1%), and 385 of 3, showed the highest specificity and PPV for predicting
13,291 (2.9%; 95% CI 2.6%3.2%) had favorable unfavorable 1-month neurologic outcomes, although
1-month neurologic outcomes. Gotos TOR rule and BLS TOR rule also have high
Initially, the five different TOR rules were compared specificity. SOSKANTOs TOR rule 3 includes the
in terms of 1-month neurologic outcomes (Table 3). following three criteria: unwitnessed by bystanders and
Among the five combinations of criteria, number 5 had asystole initially and at hospital arrival.
the highest score in terms of both specificity and PPV. The SOSKANTO 2012 study had a smaller sample
Second, the five different TOR rules were compared in size than the All-Japan Utstein Registry of the FDMA,
terms of 1-month mortality (Table 4). Among the five but had more accurate outcomes (9). In addition, the
combinations of criteria, number 5 had the highest score SOSKANTO 2012 population received more advanced
in terms of both specificity and PPV. and more uniform treatment after admission. Once we
revalidated the TOR rules for OHCA patients by using
the data of the SOSKANTO 2012 study, SOSKANTOs
Table 2. Characteristics and Outcomes of the Study
patients TOR rule 3, including the criteria of asystole initially and
at hospital arrival had the highest specificity and PPV.
OHCA Patients Because the implementation of TOR rules for OHCA
Characteristics (n = 13,291)
patients is ethically challenging, we tried to establish a
Age, y, median (IQR) 71 (6284) new TOR rule with higher specificity. SOSKANTOs
Male patients, n (%) [95% CI] 8031 (60.4) [59.661.3] TOR rule 3 could have specificity >0.99 for predicting
Cardiac arrest witnessed 6409 (48.2) [47.449.1]
by bystanders, n (%) [95% CI] unfavorable 1-month neurologic outcomes.
Bystander CPR, n (%) [95% CI] 4721 (35.5) [34.736.3] OHCA patients meeting SOSKANTOs TOR rule 3,
Presumed cardiac etiology, 6409 (48.2) [47.449.1] unwitnessed by bystanders and asystole initially and at
n (%) [95% CI]
Initial shockable rhythm in 931 (7.0) [6.67.5] hospital arrival, accounted for 39% of all patients, which
the field, n (%) [95% CI] is lower than the 57% and 63% reported by Goto et al.
Time from call to EMS personnel 8 (610) and Morrison et al., respectively (6,9). The higher
at scene, min, median (IQR)
Time from call to hospital arrival 35 (2741) specificity and PPV of our results compared with those
time, min, median [IQR] obtained by Goto et al. and Morrison et al. are possibly a
Initial shockable rhythm at 399 (3.0) [2.73.3] consequence of this lower percentage. We did consider
hospital arrival, n (%) [95% CI]
Prehospital ROSC, n (%) [95% CI] 1168 (8.8) [8.39.3] that the specificity and PPV should preferably be as high
Outcomes as possible for the introduction of a new TOR rule in Japan.
1-mo survival, n (%) [95% CI] 632 (4.8) [4.45.1] These three conditions that constitute SOSKANTOs
1-mo favorable neurologic 385 (2.9) [2.63.2]
outcomes, n (%) [95% CI] TOR rule 3 are plain and simple to assess clinically. In
addition, OHCA is a sudden contingency and an
CI = confidence interval; CPR = cardiopulmonary resuscitation; unacceptable fact for the patients family. If a physician
EMS = emergency medical service; IQR = interquartile range;
OHCA = out-of-hospital cardiac arrest; ROSC = return of sponta- terminates resuscitation of an OHCA patient to
neous circulation. pronounce him or her dead at an emergency site, the
Terminating Resuscitation in OHCA Patients 349

Table 3. 1-Month Neurologic Outcomes After Resuscitation of Out-of-Hospital Cardiac Arrest Patients Matching Each of Five
Rules

Sensitivity
Rule CPC $3 CPC 1 or 2 (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI)

1. BLS TOR 0.771 (0.7640.778) 0.961 (0.9370.978) 0.999 (0.9980.999) 0.111 (0.1000.122)
Met criteria 9949 15
Did not meet criteria 2957 370
2. Goto 0.492 (0.4830.500) 0.979 (0.9600.991) 0.999 (0.9981.000) 0.054 (0.0490.060)
Met criteria 6344 8
Did not meet criteria 6562 377
3. SOSKANTO 1 0.488 (0.4790.497) 0.974 (0.9530.988) 0.998 (0.9970.999) 0.054 (0.0490.059)
Met criteria 6298 10
Did not meet criteria 6608 375
4. SOSKANTO 2 0.436 (0.4270.444) 0.987 (0.9700.996) 0.999 (0.9981.000) 0.050 (0.0450.055)
Met criteria 5621 5
Did not meet criteria 7285 380
5. SOSKANTO 3 0.403 (0.3950.412) 0.992 (0.9770.998) 0.999 (0.9981.000) 0.047 (0.0430.052)
Met criteria 5202 3
Did not meet criteria 7704 382

BLS = basic life support; CI = confidence interval; CPC = cerebral performance category; NPV = negative predictive value; OHCA = out-of
hospital cardiac arrest; PPV = positive predictive value; SOSKANTO = Survey of Survivors after Cardiac Arrest, conducted in the Kanto
Area of Japan in 2012; TOR = termination of resuscitation.

ECG waveform showing asystole is more convincing and
less ambiguous than other waveforms.
EMS personnel are prohibited by law from terminat-
ing resuscitation in countries such as Japan, Taiwan,
Singapore, and Korea (1820). In addition, in most
countries, only a physician can make a diagnosis of
death in the absence of obvious signs of death (4).
The TOR rule that our physicians use to terminate resus-
citation after a patient arrives at the hospital might also
be applicable to such countries. This TOR rule can also
be applied to cases when an EMS provider is hesitant to
terminate resuscitation by applying an existing TOR
rule before hospital arrival or when prehospital termina-
tion of resuscitation is not promoted (2123).
The 3 patients who met this new TOR rule and
survived for 1 month with good neurologic outcomes
all had body temperatures of #30 C, indicating severe
incidental hypothermia. We designed the study to include
hypothermic patients because it is difficult to instanta-
neously distinguish incidental hypothermia from hypo-
thermia resulting from time passed from cardiac arrest
in an emergency department. In addition, in previous
research (e.g., BLS TOR rule and Gotos TOR rule),
such patients with hypothermia also were not excluded
from analyses (6,9). However, the principle of several
guidelines is that in the absence of signs incompatible
with life, No one is dead until warm and dead,
regardless of body temperature (24). The National
Association of EMS Physicians position statement on
prehospital TOR guidelines for TOR rules in the preho-
spital setting suggest that hypothermic patients be
excluded from prehospital termination (25). Therefore,
when applying the TOR rules, we might exclude severe
hypothermic OHCA patients.

Table 4. 1-Month Mortality of Out-of-Hospital Cardiac Arrest Patients Matching Each of Five Rules

Rule Death Survival Sensitivity (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI)

1. BLS TOR 0.781 (0.7740.789) 0.886 (0.8590.910) 0.993 (0.9910.994) 0.168 (0.1560.182)
Met criteria 9892 72
Did not meet criteria 2767 560
2. Goto 0.499 (0.4900.508) 0.948 (0.9270.964) 0.995 (0.9930.996) 0.086 (0.0800.093)
Met criteria 6319 33
Did not meet criteria 6340 599
3. SOSKANTO 1 0.496 (0.4870.504) 0.946 (0.9260.963) 0.995 (0.9930.996) 0.086 (0.0790.092)
Met criteria 6274 34
Did not meet criteria 6385 598
4. SOSKANTO 2 0.443 (0.4340.452) 0.973 (0.9570.984) 0.997 (0.9950.998) 0.080 (0.0740.087)
Met criteria 5609 17
Did not meet criteria 7050 615
5. SOSKANTO 3 0.411 (0.4020.419) 0.986 (0.9730.994) 0.998 (0.9970.999) 0.077 (0.0710.083)
Met criteria 5196 9
Did not meet criteria 7463 623

BLS = basic life support; CI = confidence interval; NPV = negative predictive value; OHCA = out-of hospital cardiac arrest; PPV = positive
predictive value; SOSKANTO = Survey of Survivors after Cardiac Arrest, conducted in the Kanto Area of Japan in 2012; TOR = termination
of resuscitation.
350
Limitations
This study had several limitations. First, it was an
observational study and did not include population-based
data, as it was conducted only in the Kanto area of Japan
(1,26). However, the characteristics of patients in the
SOSKANTO study were similar to those in the All-
Japan Utstein Registry of FDMA (1,26). Second, some
data were missing in our study. Third, EMS personnel in
Japan do not use end-tidal CO2 monitoring. If EMS
personnel in Japan were to use end-tidal CO2 monitoring
in the future, verification of a TOR rule incorporating
end-tidal CO2 monitoring will be necessary. Fourth, our
study group used the Utstein template. Using the CARES
(Cardiac Arrest Registry to Enhance Survival) template
instead of the Utstein template could have provided
more specificity to the TOR rule subgroups. Fifth, although
the three criteria identified had higher specificity and PPV,
the proportion of OHCA patients meeting the new criteria
was lower than that of OHCA patients meeting Gotos
criteria; thus, the cost-effectiveness of the new rule is lower
than that of Gotos rule. Sixth, although the TOR rule has
high specificity and PPV for 1-month outcomes, the spec-
ificity is not 1.00. Seventh, this TOR rule should be pro-
spectively validated, and its impact on hospital care
should be demonstrated directly.
CONCLUSIONS
OHCA patients who fulfill all of the criteria of unwit-
nessed by bystanders and asystole initially in the field
and at hospital arrival had universally poor outcomes.
Pursuing resuscitation in the emergency department in
these patients is likely futile.
AcknowledgmentsThe authors thank Ms. Mai Matsumoto and
the secretariat members of the Japanese Association for Acute
Medicine of Kanto who helped us in collecting data and coordi-
nating our project. In addition, the authors thank Dr. Jun Tomio
for his advice regarding the design of this study.
The authors would like to thank Editage (www.editage.com)
for English language editing and Publication Support.
Contributors: Akiko Akashi, Masahiro Kashiura, Kazuhiro Su-
giyama, Yuichi Hamabe, Atsushi Sakurai, Yoshio Tahara, Naohiro
Yonemoto, Ken Nagao, Arino Yaguchi, and Naoto Morimura.
SOSKANTO 2012 Steering Council: Yokohama City Univer-
sity Medical Center, Kanagawa, Japan (President, Naoto Mori-
mura, MD); Nihon University School of Medicine, Tokyo, Japan
(Director, Atsushi Sakurai, MD); National Cerebral and Cardio-
vascular Center Hospital, Osaka, Japan (Director, Yoshio Tahara,
MD); Tokyo Womens Medical University Hospital, Tokyo, Japan
(Arino Yaguchi, MD); Nihon University Surugadai Hospital,
Tokyo, Japan (Ken Nagao, MD); Nippon Medical School Hospi-
tal, Tokyo, Japan (Tagami Takashi, MD); Japanese Red Cross
SOSKANTO 2012 Study Group
Maebashi Hospital, Gunma, Japan (Dai Miyazaki, MD); National
Disaster Medical Center, Tokyo, Japan (Tomoko Ogasawara,
MD); Keio University Hospital, Tokyo, Japan (Kei Hayashida,
MD, Masaru Suzuki, MD); Tokai University School of Medicine,
Kanagawa, Japan (Mari Amino, MD); Kimitsu Chuo Hospital,
Chiba, Japan (Nobuya Kitamura, MD); Juntendo University Ner-
ima Hospital, Tokyo, Japan (Tomohisa Nomura, MD); Tokyo
Metropolitan Childrens Medical Centre, Tokyo, Japan (Naoki
Shimizu, MD); Tokyo Metropolitan Bokutoh Hospital, Tokyo,
Japan (Akiko Akashi, MD); National Center of Neurology and
Psychiatry, Tokyo, Japan (Naohiro Yonemoto, DPH).
SOSKANTO 2012 Study Group: Tokai University School of
Medicine (Sadaki Inokuchi, MD); St. Marianna University
School of Medicine, Yokohama Seibu Hospital (Yoshihiro
Masui, MD); Koto Hospital (Kunihisa Miura, MD); Saitama
Medical Center Advanced Tertiary Medical Center (Haruhiko
Tsutsumi, MD); Kawasaki Municipal Hospital Emergency &
Critical Care Center (Kiyotsugu Takuma, MD); Yokohama
Municipal Citizens Hospital (Ishihara Atsushi, MD); Japanese
Red Cross Maebashi Hospital (Minoru Nakano, MD); Juntendo
University Urayasu Hospital (Hiroshi Tanaka, MD); Dokkyo
Medical University Koshigaya Hospital (Keiichi Ikegami,
MD); Hachioji Medical Center of Tokyo Medical University
(Takao Arai, MD); Tokyo Womens Medical University Hospital
(Arino Yaguchi, MD); Kimitsu Chuo Hospital (Nobuya Kita-
mura, MD); Chiba University Graduate School of Medicine
(Shigeto Oda, MD); Saiseikai Utsunomiya Hospital (Kenji
Kobayashi, MD); Mito Saiseikai General Hospital (Takayuki
Suda, MD); Dokkyo Medical University (Kazuyuki Ono, MD);
Yokohama City University Medical Center (Naoto Morimura,
MD); National Hospital Organization Yokohama Medical
Center (Ryosuke Furuya, MD); National Disaster Medical
Center (Yuichi Koido, MD); Yamanashi Prefectural Central Hos-
pital (Fumiaki Iwase, MD); Surugadai Nihon University Hospi-
tal (Ken Nagao, MD); Yokohama Rosai Hospital (Shigeru
Kanesaka, MD); Showa General Hospital (Yasusei Okada,
MD); Nippon Medical School Tamanagayama Hospital (Kyoko
Unemoto, MD); Tokyo Womens Medical University Yachiyo
Medical Center (Tomohito Sadahiro, MD); Awa Regional Med-
ical Center (Masayuki Iyanaga, MD); Todachuo General Hospi-
tal (Asaki Muraoka, MD); Japanese Red Cross Medical Center
(Munehiro Hayashi, MD); St. Lukes International Hospital
(Shinichi Ishimatsu, MD); Showa University School of Medicine
(Yasufumi Miyake, MD); Totsuka Kyoritsu Hospital 1 (Hideo
Yokokawa, MD); St. Marianna University School of Medicine
(Yasuaki Koyama, MD); National Hospital Organization Mito
Medical Center (Asuka Tsuchiya, MD); Tokyo Metropolitan
Tama Medical Center (Tetsuya Kashiyama, MD); Showa Uni-
versity Fujigaoka Hospital (Munetaka Hayashi, MD); Gunma
University Graduate School of Medicine (Kiyohiro Oshima,
MD); Saitama Red Cross Hospital (Kazuya Kiyota, MD); Tokyo
Metropolitan Bokutoh Hospital (Yuichi Hamabe, MD); Nippon
Medical School Hospital (Hiroyuki Yokota, MD); Keio Univer-
sity Hospital (Shingo Hori, MD); Chiba Emergency Medical
Center (Shin Inaba, MD); Teikyo University School of Medicine
(Tetsuya Sakamoto, MD); Japanese Red Cross Musashino Hos-
pital (Naoshige Harada, MD); National Center for Global Health
and Medicine Hospital (Akio Kimura, MD); Tokyo Metropolitan
Terminating Resuscitation in OHCA Patients
Police Hospital (Masayuki Kanai, MD); Medical Hospital of
Tokyo Medical and Dental University (Yasuhiro Otomo, MD);
Juntendo University Nerima Hospital (Manabu Sugita, MD);
Nihon University School of Medicine (Kosaku Kinoshita,
MD); Toho University Ohashi Medical Center (Takatoshi
Sakurai, MD); Saiseikai Yokohamashi Tobu Hospital (Mitsuhide
Kitano, MD); Nippon Medical School Musashikosugi Hospital
(Kiyoshi Matsuda, MD); Tokyo Rosai Hospital (Kotaro Tanaka,
MD); Toho University Omori Medical Center (Katsunori Yoshi-
hara, MD); Hiratsuka City Hospital (Kikuo Yoh, MD); Yokosuka
Kyosai Hospital (Junichi Suzuki, MD); Saiseikai Yokohamashi
Nambu Hospital (Hiroshi Toyoda, MD); Nippon Medical School
Chiba Hokusoh Hospital (Kunihiro Mashiko, MD); Tokyo
Metropolitan Childrens Medical Centre (Naoki Shimizu,
MD); National Medical Center for Children and Mothers (Taka-
shi Muguruma, MD); Chiba Aoba Municipal Hospital (Tadanaga
Shimada, MD); Kuki General Hospital (Yoshiro Kobe, MD);
Matsudo City Hospital (Tomohisa Shoko, MD); Japanese Red
Cross Narita Hospital (Kazuya Nakanishi, MD); Tokyo Bay
Urayasu/Ichikawa Medical Center (Takashi Shiga, MD); NTT
Medical Center Tokyo (Takefumi Yamamoto, MD); Tokyo
Saiseikai Central Hospital (Kazuhiko Sekine, MD); Fuji Heavy
Industries Health Insurance Society OTA Memorial Hospital
(Shinichi Izuka, MD). Available at: http://www.jaam-kanto.jp/
sos_kanto/sos_kanto2012_contributors.html.
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352 SOSKANTO 2012 Study Group

ARTICLE SUMMARY
1 Why is this topic important?
Currently, termination of resuscitation (TOR) in the
field is not possible in Japan; therefore, it is necessary to
develop a new TOR rule based on the assumption that
most out-of-hospital cardiac arrest (OHCA) patients
may arrive at the emergency department.
2 What does this study attempt to show?
This study attempted to develop a new TOR rule that
suits the actual situations of the Japanese emergency med-
ical services (EMS) system. Because the implementation
of TOR rules for OHCA patients is ethically challenging,
we tried to establish a new TOR rule with higher speci-
ficity.
3 What are the key findings?
We compared five TOR rules developed by combining
witnessed status, initial prehospital rhythm, prehospital
shock, prehospital return of spontaneous circulation, and
presenting hospital rhythm. A new TOR rule including
the criteria of unwitnessed by bystanders and asystole
both initially and at hospital arrival had the highest spec-
ificity and positive predictive value for predicting 1-
month unfavorable neurologic outcomes.
4 How is patient care impacted?
After validation, the TOR rule may allow physicians to
terminate futile resuscitation efforts immediately upon
hospital arrival. This information will be valuable in set-
tings where EMS personnel are prohibited by law from
terminating resuscitation.