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Ethical Aspects of Resuscitation

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					                                                                                                           15
                                                                                                CHAPTER

Ethical Aspects of
Resuscitation
                                                                       this will involve attempting resuscitation but on occasion it
   Objectives                                                          will mean withholding CPR. Beneficence may also include
  To understand:                                                       responding to the overall needs of the community, such as
                                                                       establishing a programme of public access to defibrillation.
     When not to start resuscitation attempts.
     When to stop resuscitation attempts.                              Non-maleficence means doing no harm. Resuscitation
                                                                       should not be attempted in futile cases, and should not be
     Decision-making by non-physicians.                                attempted when it is against the wishes of a patient with
     Advance decisions to refuse treatment                             capacity.
     (formerly known as living wills).
                                                                       Justice implies a duty to spread benefits and risks equally
                                                                       within a society. If resuscitation is provided, it should be
Throughout this chapter the term ‘relatives’ includes close            made available to all who will benefit from it within the
friend/significant other.                                               available resources.

Introduction                                                           Autonomy relates to the patients making their own
                                                                       informed decisions rather than the medical or nursing
Successful resuscitation attempts have brought extended,               professions making the decisions for them. This principle has
useful and precious life to many individuals. However,                 been introduced particularly during the past 30 years arising
rates of survival and complete physiological recovery                  from legislature such as the Helsinki Declaration of Human
following cardiac arrest are poor. There are occasions                 Rights and its subsequent modifications and amendments.
when resuscitation attempts have merely prolonged                      Autonomy requires that the patient is adequately informed,
suffering and the process of dying; in some cases                      has capacity, is free from undue pressure, and that there is
resuscitation has left the patient in a persistent vegetative          consistency in the patient’s preferences.
state. It is not an appropriate goal of medicine to prolong
life at all costs. Ideally, decisions about whether or not it          Advance decisions to refuse CPR
is appropriate to start cardiopulmonary resuscitation (CPR)
should be made in advance, as part of the overall concept              Advance decisions to refuse treatment have been
of advance care planning. Detailed guidance on such                    introduced in many countries and emphasise the
decisions has been published by the British Medical                    importance of patient autonomy. Resuscitation must not
Association, Resuscitation Council (UK) and Royal College              be attempted if CPR is contrary to the recorded, sustained
of Nursing (“Decisions relating to Cardiopulmonary                     wishes of an adult who had capacity and was aware of the
Resuscitation”. October 2007. www.resus.org.uk)                        implications at the time of making that advance decision.
                                                                       However it is important to ensure that an advance decision
Decisions about CPR raise sensitive and potentially                    is valid and that the circumstances in which the decision is
distressing issues for patients and relatives. These decisions         applied are those that were envisaged or defined at the
may be influenced by individual, international and local                time that it was made.
cultural, legal, ethical, traditional, religious, social and
economic factors. Some patients with capacity decide that              The term “advance decision” may apply to any expression of
they do not want treatment and express their wishes in an              patient preferences. Refusal does not have to be in writing
advance decision to refuse treatment or “living will”.                 in order to be valid. If patients have expressed clear and
Therefore it is important that healthcare professionals                consistent refusal verbally, this is likely to have the same
understand the ethical and legal principles as well as the             status as a written advance decision. Patients should ensure
clinical aspects involved before they encounter a situation            that the healthcare team and his or her relatives are aware
where a resuscitation decision must be made.                           of their wishes if they are to be implemented.

Discussion of the legal status of those who attempt CPR is             In sudden out-of-hospital cardiac arrest those attending
not included in this chapter. Information on this topic can            usually do not know the patient's situation and wishes,
be found at www.resus.org.uk.                                          and an advance decision is often not readily available. In
                                                                       these circumstances resuscitation is begun immediately
Principles                                                             and questions addressed later. There is no ethical
The four key ethical principles are beneficence, non-                   difficulty in stopping a resuscitation attempt that has
maleficence, justice and autonomy.                                      started if the healthcare professionals are later presented
                                                                       with a valid advance decision refusing the treatment that
Beneficence implies that healthcare professionals must                  has been started.
provide benefit while balancing benefit and risks. Commonly



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Chapter 15 Ethical Aspects of Resuscitation



There is still considerable international variation in the              now clear procedural requirements or guidelines in many
medical attitude to written advance decisions. In some                  countries.
countries, such as the UK, the written advance decision is
legally binding. Where no explicit advance decision has                 Who should decide not to attempt
been made and the express wishes of the patient are                     resuscitation and who should be
unknown there should be a presumption that healthcare                   consulted?
professionals will, if appropriate, make all reasonable efforts
to resuscitate the patient.                                             The overall responsibility for this decision rests with the
                                                                        senior healthcare professional in charge of the patient after
                                                                        appropriate consultation with other healthcare professionals
When to withhold a resuscitation                                        involved in the patient's care.
attempt
While patients have a right to refuse treatment, they do not            People have ethical and legal rights to be involved in
have an automatic right to demand treatment; they cannot                decisions that relate to them and if the patient has capacity
insist that resuscitation must be attempted in any                      their views should be sought unless there is a clearly
circumstance. Doctors cannot be required to give treatment              justifiable reason to indicate otherwise. However it is not
that is contrary to their clinical judgement. This type of              necessary to initiate discussion about CPR with every
decision is often complex and should be undertaken by                   patient, for example if there is no reason to expect
senior, experienced members of the medical team.                        cardiorespiratory arrest to occur, or if the patient is in the
                                                                        final stage of an irreversible illness in which CPR would be
The decision to make no resuscitation attempt raises several            inappropriate as it would offer no benefit.
ethical and moral questions. What constitutes futility? What
exactly is being withheld? Who should decide and who                    It is good practice to involve relatives in decisions although
should be consulted? Who should be informed?                            they have no legal status in terms of actual decision-making.
                                                                        If the patient has capacity then their permission will be
What constitutes futility?                                              needed prior to any discussion with the relative. Refusal
                                                                        from a patient with capacity to allow information to be
Futility may be considered to exist if resuscitation will not           disclosed to relatives must be respected.
prolong life of a quality that would be acceptable to the
patient. Although predictors of non-survival after attempted            If patients who lack capacity have previously appointed a
resuscitation have been published, none has sufficient                   welfare attorney with power to make such decisions on
predictive value when applied to an independent validation              their behalf, that person must be consulted when a decision
group. Furthermore, the outcome for a cohort undergoing                 has to be made balancing the risks and burdens of CPR.
attempted resuscitation is dependent on system factors such             There are slight differences in the law relating to patients
as time to CPR and time to defibrillation. It is difficult to             who lack capacity in England & Wales, in Scotland and in
predict how these factors will impact on the outcome of                 Northern Ireland, so it is essential to be familiar with the law
individuals.                                                            that applies in your locality.

Inevitably, judgements will have to be made, and there will             In some circumstances there are legal requirements to
be grey areas where subjective opinions are required in                 involve others in the decision-making process when a
patients with comorbidity such as heart failure, chronic                patient lacks capacity. For example the Mental Capacity Act
respiratory disease, asphyxia, major trauma, head injury and            2005, which applies in England and Wales requires
neurological disease. The age of the patient may feature in             appointment of an Independent Mental Capacity Advocate
the decision but is only a relatively weak independent                  (IMCA) to act on behalf of the patient who lacks capacity.
predictor of outcome; however, the elderly commonly have                However, when decisions have to be made in an emergency,
significant comorbidity, which influences outcome.                        there may not be time to appoint and contact an IMCA and
                                                                        decisions must be made in the patient's best interests, and
What exactly should be withheld?                                        the basis for such decisions documented clearly and fully.
Do not attempt resuscitation (DNAR) means that in the event
of cardiac or respiratory arrest, CPR should not be started -           When differences of opinion occur between the healthcare
nothing more than that. Other treatment should be                       team and the patient or their representatives these can
continued, including pain relief and sedation, as required.             usually be resolved with careful discussion and explanation,
Treatment such as ventilation and oxygen therapy, nutrition,            or if necessary by obtaining a second clinical opinion. In
antibiotics, fluid and vasopressors, is also continued as                general, decisions by legal authorities are often fraught with
indicated. If not, orders not to continue or initiate any such          delays and uncertainties, especially if there is an adversarial
treatments should be made independently of DNAR orders.                 legal system, and formal legal judgement should be sought
                                                                        only if there are irreconcilable differences between the
While DNAR orders for many years in many countries were                 parties involved. In especially difficult cases, the senior
written by individual doctors, often without consulting the             doctor may wish to consult his/her own medical defence
patient, relatives or other healthcare personnel, there are             society for a legal opinion.




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Who should be informed?                                                  face similar dilemmas about when resuscitation is futile
                                                                         and when it should be abandoned. In general,
Once the decision has been made it must be communicated                  resuscitation is started in out-of-hospital cardiac arrest
clearly to all who may be involved, including the patient.               unless there is a valid advance decision to the contrary or a
Unless the patient refuses, the decision should also be                  valid DNAR order or it is clear that resuscitation would be
communicated to the patient's relatives. The decision, the               futile, for example, in cases of a mortal injury such as
reasons for it, and a record of who has been involved in the             decapitation and hemicorporectomy, known prolonged
discussions should be recorded in the medical notes - ideally            submersion, incineration, rigor mortis, and dependent
on a special DNAR form - and should clearly document the                 lividity. In such cases, the non-physician is recognising that
date the decision was made. The decision should be                       death has occurred but is not certifying the cause of death
recorded in the nursing records, if these are separate. The              (which can be done only by a physician or coroner in most
decision must be communicated to all those involved in the               countries).
patient's care.
                                                                         But when should a decision be made to abandon a
When to abandon the                                                      resuscitation attempt? Should paramedics trained in
resuscitation attempt                                                    advanced life support be able to declare death when the
                                                                         patient remains in asystole after 20 min despite advanced
The majority of resuscitation attempts do not succeed and
                                                                         life support techniques? In some countries, including the
have to be abandoned. Several factors will influence the
                                                                         UK, paramedics may cease the resuscitation attempt in this
decision to stop the resuscitative effort. These will include
                                                                         situation. The strict protocol followed requires that certain
the medical history and anticipated prognosis, the period
                                                                         conditions that might indicate a remote chance of survival
between cardiac arrest and start of CPR, the interval to
                                                                         (like hypothermia) are absent. The diagnosis of asystole
defibrillation and the period of advanced life support with
                                                                         must also be established beyond reasonable doubt and
continuing asystole and no reversible cause.
                                                                         documented with ECG recordings.
In many cases, particularly in out-of-hospital cardiac arrest,
                                                                         Similar decisions about initiating resuscitation or
the underlying cause of arrest may be unknown or merely
                                                                         recognising that death has occurred may have to be made
surmised and the decision is made to start resuscitation
                                                                         by nurses in community nursing establishments for the
while further information is gathered. If it becomes clear
                                                                         aged or terminally ill. Hopefully, a decision on the merits of
that the underlying cause renders the situation futile, then
                                                                         a resuscitation attempt will have been made before it is
resuscitation should be abandoned if the patient remains
                                                                         required and advance care planning, including decisions
in asystole with all advanced life support measures in
                                                                         about CPR, should be undertaken for every patient in
place. Information, such as an advance decision refusing
                                                                         these establishments.
CPR, can also become available, which makes
discontinuation of the resuscitation attempt ethically
                                                                         Mitigating circumstances
correct.
                                                                         Certain circumstances, for example hypothermia at the
In general, resuscitation should be continued as long as                 time of cardiac arrest, will enhance the chances of
ventricular fibrillation persists. It is generally accepted that         recovery without neurological damage, and the normal
asystole for more than 20 min in the absence of a                        prognostic criteria (such as asystole persisting for more
reversible cause, and with all advanced life support                     than 20 min) are not applicable.
measures in place, is grounds for abandoning the
resuscitation attempt.                                                   Sedative and analgesic drugs obscure the assessment of
                                                                         the level of consciousness in the patient who has a return
In out-of-hospital cardiac arrest of cardiac origin, if                  of spontaneous circulation.
recovery is going to occur, a return of spontaneous
circulation is almost always established on site.                        Withdrawal of treatment after a
Normothermic patients with primary cardiac arrest who                    resuscitation attempt
require on-going CPR without any return of a pulse during
transport to hospital rarely survive neurologically intact.              Prediction of the final neurological outcome in patients
                                                                         remaining comatose after regaining a spontaneous
The decision to abandon the resuscitation attempt is made                circulation is difficult during the first three days. There are
by the resuscitation team leader, but after consultation                 no specific clinical signs that can predict outcome in the first
with the other team members. Ultimately, the decision is                 few hours after the return of a spontaneous circulation. This
based on the clinical judgement that the patient's arrest is             topic is covered in more detail in Chapter 14.
unresponsive to advanced life support.

Decision making by non-physicians
Many cases of out-of-hospital cardiac arrest are attended
by emergency medical technicians or paramedics, who




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Chapter 15 Ethical Aspects of Resuscitation




 Key learning points
 •   Resuscitation should normally be started promptly and
     effectively, but we must recognise when these
     interventions are inappropriate and when they should
     cease.



Further reading
Baskett PJF, Steen PA, Bossaert L. European Resuscitation Council Guidelines
for Resuscitation 2005. Section 8. The ethics of resuscitation and end of life
decisions. Resuscitation 2005;67 Suppl 1:S171-180.

Baskett PJ, Lim A. The varying ethical attitudes towards resuscitation in
Europe. Resuscitation 2004;62:267-73.

Lemaire F, Bion J, Blanco J, et al. The European Union Directive on Clinical
Research: present status of implementation in EU member states’ legislations
with regard to the incompetent patient. Intensive Care Med 2005;31:476-9.

Decisions relating to cardiopulmonary resuscitation. A joint statement from
the BMA, RC(UK) and the RCN. October 2007.www.resus.org.uk

Nichol G, Huszti E, Rokosh J, Dumbrell A, McGowan J, Becker L. Impact of
informed consent requirements on cardiac arrest research in the United
States: exception from consent or from research? Resuscitation 2004;62:3-23.




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