Autoresuscitation after CPR Cessation: Clinical Patterns, Ethical Challenges, and Nursing Safeguarding

Background: The Lazarus phenomenon, or autoresuscitation after cessation of cardiopulmonary resuscitation (CPR), represents a rare but clinically and ethically significant event. Challenging conventional death declaration criteria, it carries profound implications for nursing surveillance, documentation practices, and end-of-life ethics. Fewer than 100 cases have been documented globally. Aim: This narrative review explores the clinical, ethical, and nursing implications of the Lazarus phenomenon. It specifically identifies practice gaps, protocol deficiencies, and evaluates nurse-led interventions aimed at mitigating premature death declarations. Design: A narrative review employing thematic synthesis of published case reports and observational studies. Setting: Analysis focused on clinical settings reporting autoresuscitation, including intensive care units (ICUs), emergency departments (EDs), and organ donation contexts. Policy frameworks from the American Heart Association (AHA) and European Resuscitation Council (ERC) were examined. Participants: The study synthesized 100 peer-reviewed cases of the Lazarus phenomenon published between 1982 and 2025. No direct human participants were involved. Methods: A structured literature search was conducted across PubMed, Scopus, and Google Scholar using Boolean operators with terms including "Lazarus phenomenon," "autoresuscitation," "post-CPR monitoring," and "nursing ethics." Inclusion criteria encompassed case reports, reviews, and guidelines related to delayed return of spontaneous circulation (ROSC). Data underwent thematic analysis across three domains: physiological mechanisms, ethical dilemmas, and nursing roles. Quality was assessed using the SANRA tool. Results: Approximately 68–75% of autoresuscitation events occurred within 10 minutes of CPR cessation, frequently attributed to delayed drug circulation or auto-PEEP. Nurses were the first to detect ROSC in 63% of cases. Documentation deficiencies were identified in 61% of cases, with ethical conflicts particularly pronounced in donation after circulatory death (DCD) scenarios. Extended observation periods, dual-monitoring approaches, and structured documentation protocols – often nurse-initiated – were associated with a 32% reduction in premature death declarations and a 41% decrease in nurse-reported moral distress. Conclusion: Despite its rarity, the Lazarus phenomenon reveals critical gaps in post-CPR care. Implementing standardized, nurse-led 10-minute observation protocols could significantly reduce premature death declarations and harmonize AHA guidance with ERC standards. Recommendations: This review recommends implementing a standardized 10-minute post-CPR observation protocol supported by continuous ECG and capnography; integrating autoresuscitation awareness into nursing curricula and simulation-based training; updating AHA guidelines to align with ERC recommendations on post-resuscitation monitoring; and empowering nurses as ethical sentinels in death confirmation and organ donation decision-making through structured protocols, institutional policy support, and interdisciplinary collaboration.