Ethics and practicalities of resuscitation

Remscitation, 24 (1992) 239-244 Elsevier Scientific Publishers Ireland Ltd.

239

Ethics and practicalities of resuscitation A Statement for the Advanced Life Support Working Party of the European Resuscitation Council Stig Holmberg and Lars Ekstriim Department of Cardiology. Medical Clinic I, Sahlgren Hospital, 423 45 Goteberg, Sweden Key worak: ethics; resuscitation; patient autonomy; No CPR order; practicalities

INTRODUCTION

It is long since been proven that persons suffering a cardiac arrest could be successfully resuscitated. This raises two major ethical questions. Is it ethical to start resuscitation? Is it ethical to withhold resuscitation? Is it ethical to start resuscitation? During the history of mankind the fact that a heart stops beating has been considered the definite sign of death. Even long after it was demonstrated that the heart could be restarted it was questioned whether it was ethical to do so. The arguments against sometimes had a religious dimension and even within the medical profession there has until recently been doubts about the efftcacy of resuscitation procedures and about the ethics of resuscitation. It is easy to understand that with increasing age persons become more afraid of severe handicapping disease and of a protracted process of dying. In contrast a sudden death from a painless cardiac arrest could seem like a blessing. With increasing knowledge, however, it has become evident that cardiac arrest, especially when caused by ventricular fibrillation, is a complication that in most cases could be easily and successfully treated. Gradually it has become common knowledge that a cardiac arrest is not equal to inevitable death. The view that cardiac arrest in many cases is an easily treated complication has far reaching ethical implications. It raises the important ethical question: should persons who suffer cardiac arrest be given the chance of survival through resuscitation procedures as they are given medical help in other emergencies, or should they be left to die? It is obviously an ethical issue that relates not only to the person that starts resuscitation but also to organizers of medical care and to the whole society. The only reasonable stand to take by society and medical care organizations such as hospitals, is to offer CPR to every person suffering cardiac arrest with exception Correspondence to: Stig Holmberg, Department of Cardiology, Medical Clinic I, Sahlgren Hospital, 423 45 Goteberg, Sweden. 0300-9572/92!$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

240

only for those where there are specific contraindications to resuscitation. This view has implications for resource allocation both concerning organization, equipment and training of personnel. Each medical care organization has to define its own goals for the resuscitation organization and then allocate resources to reach them. The goals could be described separately for each link in ‘the chain of survival’. Whether the organization is a hospital, a city or county the organization must then be adjusted to this series of defined goals. For a hospital it could for example be defined that every in-hospital patient suffering a cardiac arrest should be given immediate CPR and be defibrillated within a defined time interval be it 2 min or 5 min. The consequence in this example would be that every employee has to be trained in CPR and that defibrillators have to be distributed accordingly within the hospital. In spite of the long known fact that a large proportion of persons suffering a cardiac arrest could be resuscitated and live a long and meaningful life, neither the society nor the medical community have fully accepted the consequences and organized effective resuscitation with the different aspects described as links in the chain of survival. Is it ethical to withhold resuscitation? The obligation to offer resuscitation to cardiac arrest victims raises new questions. Resuscitation is employed to achieve the same goals as all medical interventions to preserve life and restore health. However, among cardiac arrest victims a large proportion will not survive their cardiac arrest regardless of the intensity of resuscitation. These persons and their relatives are unnecessarily exposed to an often dramatic and undignified procedure wanted by no one. Everyone agrees that these persons should be left to die in dignity. The optimal solution to this ethical dilemma would be to start resuscitation only in those that will eventually survive. Unfortunately, in the majority of cases there is no way to determine in advance or early during the resuscitation procedure which cardiac arrest victims are going to survive. However, every one involved in planning or performing resuscitation has the obligation to decide in advance in the best possible way when there is no chance of survival - when the resuscitation procedure is futile and where resuscitation should be withheld or discontinued. The complexity of this problem is further increased by the previously often neglected need to respect the patient autonomy - the patient’s right to decide whether to accept treatment or not. FUTILITY

There are some strictly defined situations where efforts to resuscitate are futile: 1 Patients whose vital functions are deteriorating despite maximal therapy and who will derive no benefit from BLS or ACLS (for example CPR would not restore circulation if a patient suffered a cardiac arrest from progressive cardiogenic shock despite optimal treatment).

241

2 Patients where appropriate BLS or ACLS have been attempted for adequate times without restoration of circulation or breathing. 3 Patients in certain conditions where well designed studies have shown resuscitation efforts to be ineffective (for example where CPR is attempted in patients with metastatic cancer or a sepsis, certain studies have demonstrated that almost no patients survive to hospital discharge) ‘. For patients where it is proven beyond doubt that resuscitation would be futile it is justified with unilateral decisions by physicians to withhold or terminate resuscitation. These patients should have the right to die with dignity. The term ‘futility’ has unfortunately been used in contexts which do not justify unilateral decisions by physicians to withhold resuscitation efforts. For patients where the chances of survival are low but not zero it has been claimed that resuscitation is futile. It is important to use the term ‘futility’ in a strict sense in decisions to withhold resuscitation. PATIENT AUTONOMY

The question of when to start and when to withhold or discontinue resuscitation is not only based on medical judgement. The patient autonomy - the patient’s right to make his own decisions concerning his treatment - has to be respected. In many cardiac arrest situations it is not in the patient’s best interest that resuscitation is started. Especially patients with severe disease or patients of high age often prefer the quick and painless death of cardiac arrest to a perceived protracted and painful process of dying. This right to accept or reject medical care also continues after the patient has lost decision making capacity. At this time medical care could be directed by decisions taken in advance, living wills, substituted judgement or other surrogate decision maker. Physicians have an obligation to provide sufficient information for informed decision making and patient decisions must be made without undue pressure. Physicians have an obligation to serve as the patient’s advocate attempting to do what is in the patient’s best interest and to avoid undue harm. The physician should communicate with the patient and attempt to provide a range of acceptable alternatives to the patient or surrogate based on the patient’s medical and personal needs. THE NO CPR ORDER

Based on the view that the patient has the right to treatment when he suffers a cardiac arrest there is no need for a physician’s order to start resuscitation. On the contrary a physician’s order is required to withhold CPR. The commonly used term to withhold CPR the DNR or Do Not Resuscitate order is confusing. It could be interpreted to imply that one could resuscitate a patient if one wishes which is often not the case. The term Do Not Attempt Resuscitation (DHAR) is better because it could not be misinterpreted in the same way. The term No CPR may be even more effective to communicate the intended meaning: ‘In the event of an acute cardiopulmonary arrest no resuscitation will be instituted or continued’.

242

A No CPR order issued by the patient-responsible physician could be based on the patient’s own decision either conveyed verbally or based on a living will. It could also be based on physician’s judgement of futility. A No CPR order should be written as a formal order in the medical record documenting in the medical record both the rationale for the order and the patient’s role and possible informed consent. Physicians responsible for writing the orders should make sure they conform to current standards of care regarding informed consent, are medically indicated and are reviewed periodically. Physicians should invite patients to describe their own view on their present and future life and also encourage them to discuss their own treatment preference in the case of cardiac arrest. It is important to ensure that patients do not misinterpret an order of No CPR as an abandonment. Patients may fear pain more than death and physicians need to emphasize plans to control pain, provide comfort measures and to see the patient regularly. PRACTICALITIES OF RESUSCITATION

Out-of-hospital

cardiac arrest

As a rule very little or nothing is known about the previous medical condition of a person in cardiac arrest when a resuscitation team arrives at the scene. However, it could be assumed that the person was in a fairly good medical condition before the event merely by the fact he did not require hospital treatment before the cardiac arrest. The basic rule must be to start resuscitation in persons suffering cardiac arrest outside hospital with exception only for those with specific contraindications. Withholding resuscitation. Obviously persons with reliable criteria for determination of death i.e. rigor mortis, lividity or tissue decomposition, trauma such as decapitation or hemisection should not be treated. Another important exception is patients who are in the process of dying or have known malignant diseases with an expected short life where resuscitation would be futile. Yet another category of patients are those who have decided that they do not want a resuscitation procedure. Based on the view that patient autonomy must be respected it is important that this view of the patient is documented in advance in a living will or corresponding document. Both for patients with conditions that make resuscitation procedure futile and for patients who for other reasons do not want such a procedure, resuscitation could be withheld in different ways. The patient’s relatives could abstain from calling the EMS system for a time long enough to ensure the patient’s death with dignity. If the relatives, which often will be the case, choose to alert the EMS service, withholding of CPR will still be a possibility. The responsible physician could in advance have written a No CPR order based either on his own judgement of futility of resuscitation or based on the patient’s own will. A No-CPR order written for out-of-hospital patients will in many situations create problems for the ambulance service. It will work only in a medical community where there is an agreement between responsible physicians and the ambulance service that they will honour such No CPR orders.

243

Discontinuing resuscitation. For basic life support the rules for discontinuing of CPR are simple: (1) effective spontaneous circulation and ventilation have been restored; (2) care is transferred to a better trained and certified individual who takes over the responsibility; (3) the rescuers are unable to continue resuscitation for reasons of exhaustion or if environmental hazards endanger the rescuer, or if continued resuscitation would jeopardize the lives of others. In remote areas special rules for EMS personnel might be required giving advise on duration of resuscitation efforts. Discontinuing advanced cardiac life support is basically a decision to be made by a doctor. The decision could be taken in the field by a doctor present or by on-line tele communication. If it is legally accepted the right to discontinue advanced cardiac life support could also be transferred by standing orders to other categories of health personnel i.e. paramedics or nurses. In the majority of cases patients suffering a cardiac arrest outside hospital are brought to hospital with ongoing resuscitation and the final decision to discontinue is made in the emergency room by a physician.

In-hospital cardiac arrests

Also in hospital all patients in cardiac arrest with the exception only for those where there are specific contraindications should be offered resuscitation. As a rule in hospital the patient’s medical condition and will is well defined before the event of cardiac arrest. The contraindications could therefore be identified and documented. Withholding resuscitation. There are two types of contraindications to resuscitation. The first is medical conditions that make resuscitation futile. In today’s society a large proportion of patients die in hospital-many in conditions where it could be predicted that death is inevitable. For all these patients it is important to protect them from unnecessary and undignified procedures such as full scale resuscitation procedures. It must be the attending physician’s responsibility to make the best possible judgement for every patient. For each patient where it is obvious that resuscitation would be futile this must be stated in a document. It is also important to protect the medical personnel from the stress of taking part in futile resuscitation procedures. It is a highly demoralizing experience to repeatedly take part in such procedures. The second contraindication concerns patients who do not want resuscitation, because patient autonomy must be respected. It is the duty of the responsible physician to take patients’ wishes seriously and therefore discuss the issue. If the patient is mentally healthy it must be accepted that he has the right to accept or reject medical care and his decision must therefore be honoured. The result of such a discussion and decision should be documented. The decision to withhold resuscitation should be documented in a No CPR order. Discontinuing resuscitation. Resuscitation procedures will be started on patients who eventually will not benefit. One group consists of patients where a No CPR order should have been issued because of underlying medical disease. Another group consists of patients where appropriate BLS and ACLS have been attempted for adequate time without restored respiration or circulation. When to discontinue

244

resuscitation in these cases is often difficult and requires knowledge and experience in resuscitation. For all hospitals it would be of value to have a resuscitation board who issues guidelines both for withholding and for discontinuing resuscitation. REFERENCE 1 Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation. J Am Med Assoc 1988; 260: 2069-2072.