Part 2: Ethical Aspects of CPR and ECC
Introduction
CPR and ECC have the same goals as other medical interventions: to preserve life, restore health, relieve suffering, and limit disability. One goal unique to CPR is the reversal of clinical death, an outcome achieved in only a minority of patients. The performance of CPR, however, may conflict with the patient's own desires and requests or may not be in his or her best interest [1], [2]. Decisions concerning CPR are complicated and often must be made within seconds by rescuers who may not know the patient or know of the existence of an advance directive. Resuscitative efforts may be inappropriate if goals of patient care cannot be achieved. In some instances resuscitation may not be the best use of limited medical resources. Concern about costs associated with prolonged intensive care, however, should not preclude emergency resuscitative attempts in individual patients.
The purpose of this section is to guide ECC healthcare professionals in making difficult decisions to start or stop CPR and ECC. These are general guidelines. Each decision must be made for the individual, with compassion, based on ethical principles and available scientific information.
Section snippets
Ethical Principles
When beginning and ending resuscitation attempts, differences in ethical and cultural norms must be considered. Although the broad principles of beneficence, nonmaleficence, autonomy, and justice appear to be accepted across cultures, the priority of these principles may vary among different cultures. In the United States the greatest emphasis is placed on individual patient autonomy. In Europe a greater emphasis on the autonomy of healthcare providers and their duty to make informed decisions
Withholding CPR at the Start Versus Withdrawing CPR at the End?
Basic life support training urges the average citizen responding first to a cardiac arrest to perform CPR. Healthcare professionals are expected to provide BLS and ACLS as part of their professional duty to respond. There are, however, several exceptions:
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When a person lies dead, with obvious clinical signs of irreversible death
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When attempts to perform CPR would place the rescuer at risk of physical injury
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When the patient or surrogate has indicated that resuscitation is not desired
Neither
Resuscitation in the Hospital
Hospitalized patients should be periodically evaluated to determine the appropriate level of care. Levels of care are usually defined as (1) aggressive emergency resuscitation; (2) intensive care monitoring and prolonged life support; (3) general medical care, including medication, surgery, artificial nutrition, and hydration; (4) general nursing care; and (5) terminal care. Selection of the appropriate level of care is a medical decision made in accordance with information from the patient or
Notifying Survivors of a Loved One's Death
Despite our best efforts, most resuscitations fail. Survival to discharge after an in-hospital cardiac arrest has seldom been reported at rates >15%. People would not be in the hospital unless they were already ill. In some out-of-hospital reports the survival rate from out-of-hospital arrest has been as high as 20% to 25% for specific subsets of patients (usually witnessed ventricular fibrillation/ventricular tachycardia arrest with immediate bystander CPR).
Notifying family and friends of the
Conclusions
Clear institutional guidelines and mechanisms are needed to address and guide the management of these sensitive issues. The work of hospital ethics committees, made up of representatives of several disciplines, has been particularly beneficial. All advance directives should be entered into the patient's record and should be subject to routine review. The newly dead should be treated with respect and their known wishes followed. It is important to consider cultural and religious factors.
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Cited by (21)
End-of-life decisions for extremely low-gestational-age infants: Why simple rules for complicated decisions should be avoided
2014, Seminars in PerinatologyCitation Excerpt :Resuscitation should be offered to all patients who want it unless there is clear evidence of quantitative futility. Quantitative futility implies that survival is not expected after CPR under given circumstances.”21 It has been claimed that life-sustaining interventions for ELGANs are “an uncontrolled experiment.”22
Moral Moments at the End of Life
2006, Emergency Medicine Clinics of North AmericaCitation Excerpt :One report found that a majority of emergency physicians had recently attempted resuscitations despite expectations that they were futile. Nonetheless, it is generally agreed that physicians should not offer or provide treatments to patients that have no chance of benefiting a patient [32]. This is based on the principles of beneficence and nonmaleficence [33,34].
Medical end-of-life decisions in Norway
2002, ResuscitationProlonged resuscitation: A case report
2001, Resuscitation