CONCEPTS resuscitation, ethics
Ethical Aspects of Resuscitation From the Ethics Committee, American College of Emergency Physicians, Dallas, Texas. Received for publication April 3, 1992. Accepted for publication April 14, 1992.
James G Adams, MD Arthur R Derse, MD, JD, FACEP William E Gotthold, MD, FACEP Joyce M Mitchell, MD, FACEP John C Moskop, PhD Arthur B Sanders, MD, FACEP
[Adams JG, Derse AR, Gotthold WE, Mitchell JM, Moskop JC, Sanders AB: Ethical aspects of resuscitation. Ann EmergMedOctober 1992;21:1273-1276.] Emergency medicine is a specialty often confronted with ultimate crises; patients frequently present near death or in cardiac arrest. At the time of c a r d i o p u l m o n a r y arrest, the emergency physician mobilizes all available resources to attempt to resuscitate the patient. This struggle is itself challenging. In addition, medical crises may raise difficult moral questions. A conflict is present when the resuscitation team questions whether the attempted resuscitation is warranted. The physician may believe that the potential for a successful outcome is remote, or the p r e m o r b i d condition of the patient precludes any possibility for an acceptable quality of life, or that resuscitation attempts are possibly c o n t r a r y to the wishes of the patient. Emergency physicians should have reliable mechanisms to recognize those patients who want no resuscitation attempts. While do not resuscitate (DNR) orders (or more precisely, do not attempt resuscitation [DNAR] orders) are well accepted in the inpatient setting, they present a challenge in emergency medicine. Emergency physicians rarely have the benefit of a p r i o r relationship with the patient to clarify- preferences regarding resuscitation. Without clear knowledge of the values and desires of the patient, full effort must be put forth. An important exception to this rule is that resuscitation attempts are not r e q u i r e d if the effort would be futile. Futility of CPR, however, is only beginning to be defined. The emergency physician must be knowledgeable about c u r r e n t ethical issues and be p r e p a r e d to stay abreast of new developments.
E L E M E N T S OF R E S U S C I T A T I O N DECISIONS When determining whether to attempt resuscitation, emergency physicians must first recognize factors that should not enter into resuscitation decisions. Gender, age, race, economic or social status, or the presence of infectious disease must not alter the decision to attempt resuscitation or influence the degree of resuscitative effort. The personal values of the resuscitation team must not interfere with the patient's right to full effort. The only considerations that should generally dictate care are the patient's preferences and sound medical
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indications. There may be ambivalence regarding resuscitation when a "successful" resuscitation threatens to produce only a severely impaired survivor. Such considerations, though, should not influence the resuscitative effort put forth in the emergency department. Only actions that have clear scientific support or are guided by patient preference should be carried out. Emergency physicians also are aware that resuscitation and post-resuscitation intensive care are expensive. Although cost of health care is a major social concern, emergency physicians must remain patient advocates. Cost containment should not play a role at times of life-threatening crisis. Triage, resource allocation, and rationing decisions are separate concerns. When large-scale decisions regarding allocation of resources or rationing are made, they must be equitable and not unfairly penahze any individual or group. Physicians must then honor these larger decisions. Concerns regarding cost should not influence the decision to attempt resuscitation or the extent of resuscitation efforts for an individual patient. ADVANCE
"Advance directive" is the general term for a mechanism designed to give patients some control over the treatment decisions that will be made when they are unable to participate directly. The two main types of advance directive, living wills and durable powers of attorney for health care, can be used to identify a patient's wishes regarding resuscitation. Living wills express the wishes of patients regarding lifesustaining procedures in the event of terminal illness. Living wills are legally recognized by more than 45 states. In the emergency situation, the existence of a living will may be u n k n o w n or the patient's hving will may be difficult to interpret. When the patient's wishes are clear, however, the emergency physician has an obligation to respect the living will or provide for another physician to care for the patient. The patient can revoke a living will at any time, even during a time of crisis in the ED. It is likely that the use of living wills will increase with implementation of the patient self-determination act, which became effective December 1, 1991. This federal act requires all hospitals that accept Medicare and Medicaid funds to provide information about advance directives and develop policies for their implementation. Information about advance directives will be mailed by the government to all social security recipients. As the public becomes increasingly aware of advance directives, ED staff may begin to encounter advance directives more commonly. Clarification about an advance directive may be needed, because, for example, a hying will may state that "in the event of terminal illness or persistent vegetative state," resuscitation should be withheld. However, the presence of an advance directive does not always indicate the presence of a terminal illness. The applicability of a living will may therefore not be obvious. Nor does the general term "resuscitation" specify which interventions are to be provided
and what therapies are to be withheld. Clarification may be provided by the patient's personal physician or proxy decision maker. If there is doubt regarding the patient's wishes or underlying illness, the patient's primary physician may be an important resource and, if possible, should participate in further decisions. The authority of a proxy decision maker most often belongs to the nearest relative and can be legally granted to any person through a durable power of attorney. A durable power of attorney gives to another person the authority to make decisions for a patient who becomes incapacitated. The person with durable power of attorney then becomes a legally recognized proxy decision maker for the patient. When a durable power of attorney exists, the emergency physician should allow the designated person to participate in decisions regarding the patient's medical care, as possible. Physicians must respect the wishes of the patient when they are clear. When doubt exists regarding the wishes of the patient, the emergency physician must initiate resuscitative interventions. Proxy decision makers should not base requests to initiate or withhold resuscitation on their own values, but must make decisions according to the known wishes of the patient. All states have statutes governing durable powers of attorney. In some states, additional statutes explicitly state that durable powers of attorney may apply to health care decisions. Several states, including New York, Massachusetts, and North Carolina, have implemented health care proxy laws.1 Even in states that do not have specifically defined statutes regarding health care proxies, the physician should discuss treatment options with a person who holds a durable power of attorney unless this authority is specifically hmited in the document. The health care proxy could provide verbal and written instruction regarding questions on how to proceed in circumstances not addressed in previously constructed written documents. Immunity from liability is generally granted to the physician who carries out the proxy's decision in good faith. Physicians should be aware of state law, federal guidehnes, and ethical responsibilities that dehneate policies regarding health care proxies and hving wills. EDs should have guidelines regarding advance directives. REFUSAL
OF R E S U S 0 1 T A T I O N
It is legally and ethically acceptable to withhold resuscitation attempts for terminally ill patients who have expressed clear wishes not to undergo resuscitation. Emergency physicians are challenged to honor advance directives. The specialist in the ED must attempt to obey the patient's wishes but also ensure the validity and reliahility of such requests. The legal and ethical controversies have been well outlined elsewhere. 2-4 Decisions regarding resuscitation must be made immediately at the time of crisis. If there is any doubt regarding the patient's Wishes or the validity of an advance directive document, resuscitative measures must be initiated and carried forth with effort equal to that which would be put forth for
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any other patient. "Slow codes," suboptimal effort, or delayed intervention are never medically or ethically acceptable choices. P r i m a r y care physicians should inform patients that full resuscitation will ensue unless a clear and valid directive exists to hmit resuscitative effort. Optimal directives by terminally ill patients will specify- "No C P R " and "No intubation." Phrases such as " D N R " or "No resuscitation" are not specific enough. The ED must be p r e p a r e d to accept valid requests to hmit resuscitation. The medical, ethical, and legal imphcations of living wills should be made clear to all ED personnel in o r d e r to promote a p p r o p r i a t e patient care.
EMERGENCY MEDICAL SERVICES CONSIDERATIONS The legal, medical, and ethical difficulties of limiting resuscitation of the terminally ill patient in the prehospital setting are significant. 2 There is, nevertheless, a clear need for emergency medical services personnel to honor DNR orders. 5 At present, there is great variability in legal authorization for prehospital DNR orders. Some emergency medical services systems can honor no l)NR o r d e r in the prehospital setting, 6 while others have developed legally and ethically acceptable prehospital mechanisms to withhold CPR and intubation. 7 Living wills should generally not be used to limit prehospital resuscitation. Because there is no s t a n d a r d format for living wills, the applicability of the document may not be clear. It may not specifically address issues of resuscitation or guarantee the presence of a terminal disease. It is often not possible to confirm the applicability in the prehospital setting. ReCognizable, s t a n d a r d "No CPR/No intubation" orders should identify those patients with terminal illnesses who wish to have no resuscitation attempts. DNR orders have generally been written by a physician in a hospital c h a r t p r i o r to the time of a patient's demise. These orders provide clear guidance to those caring for the patient. Some emergency medical services have extended the role of DNR orders to the out-of-hospital setting. While it is ethically appropriate to honor such orders in the prehospital setting, a number of operational, legal, medical, and ethical challenges must first be overcome. The emergency medical service must be sure that the directive reflects the wishes of the patient. The patient's wishes must be informed, based on an understanding of his or her illness. Emergency medical services rely on the patient's personal physician to discuss such matters. The prehospital "No CPR/No intubation" document might therefore be signed by a physician who attests to the patient's wishes. The form used for such orders must be acceptable to the emergency medical service and the legal jurisdiction. It must be easily recognizable to the emergency medical service personnel and be clear regarding those interventions to be implemented and those, to be withheld. Finally, mechanisms must be in place to ensure that the document reflects the current wishes of the patient. This can
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be accomplished by requiring periodic renewal of the order. The American College of Emergency Physicians has developed guidelines for DNR orders in the prehospital setting. 8 "No CPR/No intubation" orders can be constructed to be operationally, legally, and ethically effective in the prehospital setting, although a great deal of effort must be expended to design and implement them. Such instruments must be clear and should minimize uncertainty regarding their applicability under unusual or unpredictable medical circumstances. Prehospital advance directives should be portable so that the directive can be honored equally in the hospital, nursing home, private home, or public setting.9,1° An ideal system would possess s t a n d a r d communication and authorization procedures that are easily recognizable and do not demand interpretation or cause confusion. The document should be familiar to the family, the private physician, and the personnel of the emergency medical service, the El) and nursing homes, if applicable.
THE IMPORTANCE OF PROGNOSIS: RECOGNITION OF FUTILITY Emergency medicine continues to seek to define the medical indications and prognosis for resuscitative measures. S t a n d a r d p r o c e d u r e in emergency medicine is to attempt resuscitation. In the absence of patient wishes to the contrary, full resuscitative attempts are carried out, even if the potential for meaningful recovery is remote. Physicians and ethicists continue to discuss how to proceed when it is believed that attempts at resuscitation would be futile. If a medical intervention is of no benefit, then it should not be applied. If a medical intervention ~ result in a permanent vegetative state, should it be continued? Should CPR be performed on a cachectic patient with advanced metastatic cancer? Some physicians and ethicists argue that when a medical determination is made that CPR would be futile, patient or family input is unnecessary.il, 12 Others argue that any decision of futility may entail a value judgment, especially when it is based on assessments of quality of life. Resuscitation decisions, therefore, should proceed according to the patient's wishes. Relying on poorly defined notions of futility may diminish patient autonomy. 13 W h a t is the significance of this debate about futility and decision-making authority? Emergency physicians do make decisions to cease resuscitative efforts or not initiate efforts in medically hopeless circumstances.14 These are p r o p e r l y medical decisions that should not require family consent. The indications for terminating or not initiating resuscitation attempts are, however, conservatively drawn. They establish a strong presumption in favor of resuscitation in doubtful cases. Thus, the scope of medical futility in resuscitation decisions is narrow; it does not include estimates of future quality of life, for example. Ongoing research into outcomes of resuscitation should help determine more precisely the expected outcome of intervention and thereby indicate more clearly when intervention is futile. Without clear
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indicators, physicians may inappropriately jeopardize patient welfare by relying on unsubstantiated or poorly defined notions of futility, is Emergency physicians must therefore continue to work to develop an operational determination of futility. The indications, usefulness, and outcome of CPR and advanced life support must be better defined. 16,17 The need is most pressing in the prehospital setting, where clear guidelines for "dead on arrival" determinations and decisions to terminate resuscitation are needed. 18 FAMILY
Emergency physicians must realize that they have an ohhgation to the family of the patient, whether resuscitation is attempted or withheld. The emergency physician must provide clear and honest communication, medical information, sensitivity, and concern. 19 Information provided by family members may be important in establishing the patient's wishes regarding resuscitation, especially when there is sufficient time to investigate this issue. Conflict may arise when families request to limit resuscitation when no advance directive exists and when they have not been legally named as proxy decision makers. The ethical responsibility of the physician is to ensure that the best interests of the patient are served. This responsibility may sometimes require the physician to attempt resuscitation over the family's objection if that objection does not reflect the previously expressed wishes or the obvious best interests of the patient. Resuscitation must never be delayed due to discussions of whether to resuscitate. Families also may request resuscitation for a patient with a clear directive to withhold resuscitative effort. Overruling a valid advance directive is morally perilous. A physician should not carry out resuscitation when the patient refuses, as expressed through the clear and valid advance directive. Unless the family can demonstrate that the patient's preference has changed since the document was constructed or that the document is not apphcable in the current crisis, an advance directive is presumed to reflect the patient's wishes and should be honored. If there is any doubt regarding the apphcability or validity of the document, resuscitation would be carried out based on medical indications.
REFERENCES 1. Annas 6J: The health care proxy and the living will. JAMA 1991;324:1210-1213. 2. Ayers RJ: Current controversies in prehospital resuscitation of the terminally ill patient. Prehosp Disas Med 1990;5:49-58. 3. Siner OA: Advance directives in emergency medicine: Medical, legal and ethical implications. Ann Emerg Med 1989;18:1364-1369. 4. Strange 6R, Flynn RJ, Whitehall J: Ethical considerations in emergency department management of terminally il[ patients. Ann Emerg Med 1989;18:1085-1088. 5. Crimmins TJ: The need for a prehospital DNR system. Prehosp Oisas Mefli 1990;5:47-48. 6. Iserson KV: Commentary: Prehospital DNR orders. Hastings CenterReport1989;17-19. 7. North Carolina's new prehospital ONR order gets state attorney general's endersement. ACEPNewsJune 1991;10:12. 8. ACEP: Guidelines for "do not resuscitate" orders in the prehospital setting. Ann Emerg Med 1988;17:1106-1108. 9. Miles SH: Advanced directives to limit treatment: The need for pertability. JAGS 1987;35:74-76. 10. Miles SH, Crimmins TJ: Orders to limit emergency treatment for an ambulance service in a large metropolitan area. JAMA 1985;254:525-527. 11. Ramos T, Reagan JE: 'No' when the family says 'go': Resisting families" requests for futile OPR.Ann Emerg Med1989;18:898-899. 12. Hackler JC, Hiller FC: Family consent to orders not to resuscitate. JAMA 1990;264:1281-1283. 13. Murphy DJ, Matchar OB: Life sustaining therapy: A model for appropriate use, JAMA 1990;16:2103-2110. 14. Tomlinson T, Brody H: Futility and the ethics of resuscitation. JAMA 264;1990:1276-1280. 15. Younger SJ: Who defines futility? JAMA 1988;260:2094-2095. 16. Bonin M J, Swor RJ: Outcomes in unsuccessful field resuscitation attempts. Ann Emerg Med 1989;18:507-512. 17. Tresch DO, Thakur RK, Hoffman R6, et al: Should the elderly be resuscitated fallowing out-of-hospital cardiac arrest? Am J Med1989;86:145-150. 18. Frank M: Should we terminate futile resuscitations in the field? Can we afford not to? Ann Emerg Med 1989;18:594-596. 19. Schrnidt TA, Tolle SW: Emergency physicians' responses to families following patient death. Ann Emerg Med 1990;19:125-128. Addressforreprints: American College of Emergency Physicians PO Box 619911 Dallas, Texas 75261-9911
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