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Ethical considerations in resuscitation
Disease-a-Month 59 (2013) 217–220
Contents lists available at SciVerse ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
Ethical considerations in resuscitation Kyle Petty, BS, Noah DeGarmo, MD, Robert Aitchison, BA, Pamela Aitchison, BSN, RN, Ernest Wang, MD, FACEP, Morris Kharasch, MD, FACEP
Recorded human resuscitative practices predate biblical times. At least 350,000 people will suffer cardiac arrest each year in the United States, one every 90 sec.1 Many will be subject to cardiopulmonary resuscitation (CPR) by bystanders, emergency medical services, and inhospital healthcare providers. Even with advances in defibrillation and modern era resuscitative techniques, statistics show that gains with respect to survival after cardiac arrest and neurologic preservation have been modest at best. Ethical resuscitation has become increasingly more relevant with advances in modern medicine that may prolong the physical body without improving the quality of life. As such, medical providers must be increasingly mindful of ethical, legal, and cultural considerations while providing CPR. Resuscitative efforts must balance the goals of preserving life and restoring health with those of alleviating suffering and respecting individual autonomy.
1. Principle of respect for autonomy The principle of respect for autonomy is the idea based on society’s respect for the ability of the individual to make informed decisions about his or her own healthcare. Adults are presumed to have this decision-making ability as long as they are not incapacitated or declared incompetent by a court of law. Informed decisions have three distinct parts that require a strong healthcare provider–patient relationship. First, patients must receive and understand accurate information about their condition, prognosis, nature of proposed interventions, alternatives, risks, and benefits. Second, patients should be able to paraphrase the information, at which point the healthcare provider can assess the patients’ understanding and correct any misinformation. Finally, patients must deliberate and make a healthcare decision. 1.1. Advanced directives, living wills, and patient self-determination In 1991, the Patient Self-Determination Act mandated that healthcare institutions should facilitate the completion of advance directives—written form being most trustworthy according to courts.2 Living will documents dictate the care a patient receives. They give information to healthcare providers about the care an individual would wish to receive in the 0011-5029/$ - see front matter & 2013 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.disamonth.2013.03.008
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event that he or she is incapacitated. A durable power of attorney accounts for unforeseen circumstances by appointing a person to make healthcare decisions for someone when they are incapacitated. The appointed person should make healthcare decisions as he or she thinks would be most in line with the patient’s wishes. Comprehensive healthcare advanced directives combine both the living will and the durable power of attorney into a single legal document. This should be updated regularly and revised as patient’s desires for treatment and medical advances can change. Do not attempt resuscitation (DNR) orders must be given by a licensed physician, they explicitly describe the resuscitation interventions to be performed in case of an emergency. Patients should understand that a DNR order does not preclude all interventions, unless those measures are included in the order. This order must be completed in accordance with local regulations to be binding. In the event that a patient is incapacitated and there are no advanced directives, a close relative or friend can become a surrogate decision maker. Surrogate decision makers should base their decisions on the patient’s previously expressed preferences or, in the absence of that knowledge, to the decision maker’s best understanding of what is in the best interest of the patient. Generally, minors are considered incompetent to provide legally binding consent about their healthcare; therefore, parents or guardians are empowered to make decisions on their behalf. When medical providers believe a parent or guardian’s decisions place the child in serious harm compared to other options, the medical provider may seek the help of state agencies to allow treatment. Discussions and arrangements of advanced directives, living wills, and DNR orders should not occur in an emergency setting. Primary care physicians can help educate patients and their family members by discussing comprehensive healthcare advanced directives and encouraging their patients to share advanced directives with loved ones so that families can have a better understanding of their loved one’s wishes. Primary care physicians can incorporate the discussion and facilitation of advanced directives into their regular patient visits and ensure that their patients have up-to-date, written advanced directives that are easily accessible to the EMS personnel.
2. Principle of futility Families may request care that is highly unlikely to benefit the patient; however, the physician has the authority to withhold efforts when scientific and social evidences hold that treatment would be ineffective. This evidence is defined as any intervention that gives the patient a o1% chance of survival.3 Primary care physicians can help avoid conflicts surrounding futile care efforts by encouraging their patients to share advanced directives with loved ones so that families have a better understanding of their loved one’s wishes. Without objective signs of irreversible death and in the absence of known advanced directives against resuscitative efforts, full resuscitation should be offered.
3. Withholding CPR in out-of-hospital cardiac arrests (OHCA) Withholding CPR in OHCA might be appropriate in three situations: when performing CPR would put the rescuer at serious risk or harm, when there are signs of irreversible death (e.g., decapitation and decomposition), or when there is a valid DNR order. DNR orders in OHCA should be clearly written and provide information for everyone involved (family members and members of the healthcare team). Documentation can take many forms and the local emergency medical authority may have approved forms. The ideal DNR documentation is easily identifiable and can be carried on the person. Generally, emergency medical providers should initiate CPR whenever the existence or validity of DNR orders is in question. Primary care physicians can facilitate better hand-off and communication with resuscitation teams ensuring strong links in the ACLS ‘‘chain of survival’’ by having an update summary sheet including a list of medical problems, recent medications, and advanced directives for all of their patients.4
K. Petty et al. / Disease-a-Month 59 (2013) 217–220
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4. Withholding or withdrawing CPR for in-hospital cardiac arrests (IHCA) Due to the available resources and the shortened response times, there are several considerations that drive the decision to withhold or withdraw CPR inside the hospital. 4.1. For the neonatal patient When gestational age and congenital abnormalities are associated with almost certain early death, withholding resuscitation is acceptable. When survival is borderline and anticipated burden to the child is high, parental desires concerning resuscitation should be supported. There should be constant and clear communication between the parents, obstetric teams, and neonatal teams concerning these desires. Current guidelines suggest that it may be appropriate to terminate resuscitation if the heart rate is undetectable for 10 min.5 4.2. For the pediatric and adult patient There is uncertainty in predicting the futility of resuscitation in pediatric and adult patients. Unless there is a valid DNR order or signs of irreversible death, resuscitation should be initiated. In these populations, the responsible clinician should stop resuscitation if there is a high likelihood that the patient would not respond to further resuscitation efforts.
5. Providing emotional support to the family During resuscitation there are theoretical concerns that family members may interfere with efforts, syncopize or increase exposure to legal liability, but this has not been studied in the literature. Whether or not family presence leads to worse outcomes has not been studied; however some reports show that family members wish to be involved in resuscitation efforts feeling greater comfort and sense of meaning in the process.5 Family member reports suggest that family would like to be at the bedside and it’s helpful for them to cope with loss of their loved one.6 In light of this, it may be helpful for select family members to be present during resuscitative efforts (assuming the adult patient has not made prior objections). If the primary care physician is present for resuscitation, he or she can be the link between resuscitation and the family by encouraging them to be present, informing them of the actions being taken, and helping them to understand the process. 5.1. After termination A sudden, unexpected death leaves survivors unprepared for their loss. It is important to use non-medical language when preparing survivors for bad news. What survivors want most is a notifier who seems to care that their loved one has died. This should be done with the family’s culture, religious beliefs, and preconceptions of death in mind.
6. Limitation of care and withdrawal of life-sustaining therapies Decisions to limit or withdraw care are justifiable when a patient is brain dead, the physician and patient and/or surrogate agree that treatment goals cannot be met, or the burden of treatments outweigh any benefits. End-stage patients with terminal illnesses should receive care that ensures their autonomy, comfort, and dignity such as pain management, nursing, and comfort care. For such patients it is ethically acceptable to gradually increase the doses of narcotics and sedatives to relieve pain and suffering (just as an aside, giving pain medication or anti-anxiety medication in end of life does not shorten anyone’s life, it just makes it more
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comfortable). The prognosis of post-arrest patients has not been fully studied in the literature. It is recommended that clinical neurological signs, electrophysiological signs, biomarkers, and imaging be documented at three days post-arrest to guide the decision to withdraw lifesustaining therapy. References 1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220. 2. Koch KA. Patient Self-Determination Act. J Fla Med Assoc. 1992;79(4):240–243. 3. Marco CA, Schears RM. Societal opinions regarding CPR. Am J Emerg Med. 2002;20:207–211. 4. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729–S767. 5. Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675. 6. Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114(25):2839–2849.
Suggested reading Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675.
Contents lists available at SciVerse ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
Ethical considerations in resuscitation Kyle Petty, BS, Noah DeGarmo, MD, Robert Aitchison, BA, Pamela Aitchison, BSN, RN, Ernest Wang, MD, FACEP, Morris Kharasch, MD, FACEP
Recorded human resuscitative practices predate biblical times. At least 350,000 people will suffer cardiac arrest each year in the United States, one every 90 sec.1 Many will be subject to cardiopulmonary resuscitation (CPR) by bystanders, emergency medical services, and inhospital healthcare providers. Even with advances in defibrillation and modern era resuscitative techniques, statistics show that gains with respect to survival after cardiac arrest and neurologic preservation have been modest at best. Ethical resuscitation has become increasingly more relevant with advances in modern medicine that may prolong the physical body without improving the quality of life. As such, medical providers must be increasingly mindful of ethical, legal, and cultural considerations while providing CPR. Resuscitative efforts must balance the goals of preserving life and restoring health with those of alleviating suffering and respecting individual autonomy.
1. Principle of respect for autonomy The principle of respect for autonomy is the idea based on society’s respect for the ability of the individual to make informed decisions about his or her own healthcare. Adults are presumed to have this decision-making ability as long as they are not incapacitated or declared incompetent by a court of law. Informed decisions have three distinct parts that require a strong healthcare provider–patient relationship. First, patients must receive and understand accurate information about their condition, prognosis, nature of proposed interventions, alternatives, risks, and benefits. Second, patients should be able to paraphrase the information, at which point the healthcare provider can assess the patients’ understanding and correct any misinformation. Finally, patients must deliberate and make a healthcare decision. 1.1. Advanced directives, living wills, and patient self-determination In 1991, the Patient Self-Determination Act mandated that healthcare institutions should facilitate the completion of advance directives—written form being most trustworthy according to courts.2 Living will documents dictate the care a patient receives. They give information to healthcare providers about the care an individual would wish to receive in the 0011-5029/$ - see front matter & 2013 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.disamonth.2013.03.008
218
K. Petty et al. / Disease-a-Month 59 (2013) 217–220
event that he or she is incapacitated. A durable power of attorney accounts for unforeseen circumstances by appointing a person to make healthcare decisions for someone when they are incapacitated. The appointed person should make healthcare decisions as he or she thinks would be most in line with the patient’s wishes. Comprehensive healthcare advanced directives combine both the living will and the durable power of attorney into a single legal document. This should be updated regularly and revised as patient’s desires for treatment and medical advances can change. Do not attempt resuscitation (DNR) orders must be given by a licensed physician, they explicitly describe the resuscitation interventions to be performed in case of an emergency. Patients should understand that a DNR order does not preclude all interventions, unless those measures are included in the order. This order must be completed in accordance with local regulations to be binding. In the event that a patient is incapacitated and there are no advanced directives, a close relative or friend can become a surrogate decision maker. Surrogate decision makers should base their decisions on the patient’s previously expressed preferences or, in the absence of that knowledge, to the decision maker’s best understanding of what is in the best interest of the patient. Generally, minors are considered incompetent to provide legally binding consent about their healthcare; therefore, parents or guardians are empowered to make decisions on their behalf. When medical providers believe a parent or guardian’s decisions place the child in serious harm compared to other options, the medical provider may seek the help of state agencies to allow treatment. Discussions and arrangements of advanced directives, living wills, and DNR orders should not occur in an emergency setting. Primary care physicians can help educate patients and their family members by discussing comprehensive healthcare advanced directives and encouraging their patients to share advanced directives with loved ones so that families can have a better understanding of their loved one’s wishes. Primary care physicians can incorporate the discussion and facilitation of advanced directives into their regular patient visits and ensure that their patients have up-to-date, written advanced directives that are easily accessible to the EMS personnel.
2. Principle of futility Families may request care that is highly unlikely to benefit the patient; however, the physician has the authority to withhold efforts when scientific and social evidences hold that treatment would be ineffective. This evidence is defined as any intervention that gives the patient a o1% chance of survival.3 Primary care physicians can help avoid conflicts surrounding futile care efforts by encouraging their patients to share advanced directives with loved ones so that families have a better understanding of their loved one’s wishes. Without objective signs of irreversible death and in the absence of known advanced directives against resuscitative efforts, full resuscitation should be offered.
3. Withholding CPR in out-of-hospital cardiac arrests (OHCA) Withholding CPR in OHCA might be appropriate in three situations: when performing CPR would put the rescuer at serious risk or harm, when there are signs of irreversible death (e.g., decapitation and decomposition), or when there is a valid DNR order. DNR orders in OHCA should be clearly written and provide information for everyone involved (family members and members of the healthcare team). Documentation can take many forms and the local emergency medical authority may have approved forms. The ideal DNR documentation is easily identifiable and can be carried on the person. Generally, emergency medical providers should initiate CPR whenever the existence or validity of DNR orders is in question. Primary care physicians can facilitate better hand-off and communication with resuscitation teams ensuring strong links in the ACLS ‘‘chain of survival’’ by having an update summary sheet including a list of medical problems, recent medications, and advanced directives for all of their patients.4
K. Petty et al. / Disease-a-Month 59 (2013) 217–220
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4. Withholding or withdrawing CPR for in-hospital cardiac arrests (IHCA) Due to the available resources and the shortened response times, there are several considerations that drive the decision to withhold or withdraw CPR inside the hospital. 4.1. For the neonatal patient When gestational age and congenital abnormalities are associated with almost certain early death, withholding resuscitation is acceptable. When survival is borderline and anticipated burden to the child is high, parental desires concerning resuscitation should be supported. There should be constant and clear communication between the parents, obstetric teams, and neonatal teams concerning these desires. Current guidelines suggest that it may be appropriate to terminate resuscitation if the heart rate is undetectable for 10 min.5 4.2. For the pediatric and adult patient There is uncertainty in predicting the futility of resuscitation in pediatric and adult patients. Unless there is a valid DNR order or signs of irreversible death, resuscitation should be initiated. In these populations, the responsible clinician should stop resuscitation if there is a high likelihood that the patient would not respond to further resuscitation efforts.
5. Providing emotional support to the family During resuscitation there are theoretical concerns that family members may interfere with efforts, syncopize or increase exposure to legal liability, but this has not been studied in the literature. Whether or not family presence leads to worse outcomes has not been studied; however some reports show that family members wish to be involved in resuscitation efforts feeling greater comfort and sense of meaning in the process.5 Family member reports suggest that family would like to be at the bedside and it’s helpful for them to cope with loss of their loved one.6 In light of this, it may be helpful for select family members to be present during resuscitative efforts (assuming the adult patient has not made prior objections). If the primary care physician is present for resuscitation, he or she can be the link between resuscitation and the family by encouraging them to be present, informing them of the actions being taken, and helping them to understand the process. 5.1. After termination A sudden, unexpected death leaves survivors unprepared for their loss. It is important to use non-medical language when preparing survivors for bad news. What survivors want most is a notifier who seems to care that their loved one has died. This should be done with the family’s culture, religious beliefs, and preconceptions of death in mind.
6. Limitation of care and withdrawal of life-sustaining therapies Decisions to limit or withdraw care are justifiable when a patient is brain dead, the physician and patient and/or surrogate agree that treatment goals cannot be met, or the burden of treatments outweigh any benefits. End-stage patients with terminal illnesses should receive care that ensures their autonomy, comfort, and dignity such as pain management, nursing, and comfort care. For such patients it is ethically acceptable to gradually increase the doses of narcotics and sedatives to relieve pain and suffering (just as an aside, giving pain medication or anti-anxiety medication in end of life does not shorten anyone’s life, it just makes it more
220
K. Petty et al. / Disease-a-Month 59 (2013) 217–220
comfortable). The prognosis of post-arrest patients has not been fully studied in the literature. It is recommended that clinical neurological signs, electrophysiological signs, biomarkers, and imaging be documented at three days post-arrest to guide the decision to withdraw lifesustaining therapy. References 1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220. 2. Koch KA. Patient Self-Determination Act. J Fla Med Assoc. 1992;79(4):240–243. 3. Marco CA, Schears RM. Societal opinions regarding CPR. Am J Emerg Med. 2002;20:207–211. 4. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729–S767. 5. Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675. 6. Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114(25):2839–2849.
Suggested reading Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675.