ETHICS OF RESUSCITATION

ETHICS OF RESUSCITATION

0749-0704/96 $0.00 MEDICAL ETHICS + .20 ETHICS OF RESUSCITATION C. Christopher Hook, MD, and Kathryn A. Koch, MD, FCCP, FCCM Since their inception...

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0749-0704/96 $0.00

MEDICAL ETHICS

+ .20

ETHICS OF RESUSCITATION C. Christopher Hook, MD, and Kathryn A. Koch, MD, FCCP, FCCM

Since their inception in the 1960s, both cardiopulmonary resuscitation and advanced life support techniques have saved many lives, but also have generated an immense amount of ethical questions and dilemmas. If one’s vision is restricted simply to the four principles so commonly taught as the framework of medical ethics: autonomy, beneficence, nonmaleficence, and justice? resuscitation often has served as a locus for conflict. Autonomy includes, among other things, the concepts of informed consent, competence, and the right to refuse unwanted treatment. Yet resuscitation is a procedure for which consent is presumed universally, whether it is informed or not, and has been established as the standard of care and as an intervention exceptional to all others. Consequently, patients autonomously demanding their right to the standard of resuscitation sometimes are pitted against caregivers who may believe such treatment is not indicated medically. Sometimes patients have been the victims of default resuscitation that they did not desire. Beneficence requires interventions to contribute to the patient’s good, whereas nonmaleficence implores caregivers to avoid or to prevent harm. Resuscitation, however, results in a good outcome (life preservation) in only a minority of cases. In contrast, significant physical trauma (i. e., broken bones or organ laceration) may occur as a consequence of resuscitation efforts, and the outcome may be far from desirable (a persistent vegetative state or permanent neurologic impairment). Physicians faced with this reality and motivated by the principles previously described may be compelled to withhold resuscitation. Such motivation, although

From the Division of Hematology and Internal Medicine, Mayo Clinic and Mayo Foundation, and Mayo Medical School, Rochester, Minnesota (CCH); and the Division of Critical Care, Department of Medicine, University of Florida Health Science Center/ Jacksonville, Jacksonville, Florida (KAK)

CRITICAL CARE CLINICS VOLUME 12 * NUMBER 1 *JANUARY 1996

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well intentioned, will not guarantee the prevention of conflict with a patient or family demanding their ”right” to resuscitation. Current resuscitation practices challenge the concept of justice by mandating the expenditure of medical and personnel resources in situations that have only a slight chance of a favorable outcome. But justice also requires equal access to the ”standard of care” and condemns prejudicial exclusion from resuscitation on the basis of age or prior disability. A large body of literature exists that has examined these questions at length. This article does not reiterate much of the discussion here; instead, the authors refer the reader to other summaries.1,4, 14, 23, 43 The focus here is on three issues in the ethics of resuscitation: (1) inpatient resuscitation and the presumption of consent, (2) outpatient resuscitation and the right to refuse treatment, and (3) the ethical aspects of teaching resuscitation skills. INPATIENT RESUSCITATION AND THE PRESUMPTION OF CONSENT

Before 1960 the concept of resuscitation was limited to an occasional patient with respiratory arrest. Open chest massage, electrical cardioversion for ventricular fibrillation, and mouth-to-mouth resuscitation had been well described in the 1950s. In 1960, Kouwenhoven, Jude, and Knickerbocker= reported a technique of ”closed chest” compression that made the present technique of cardiopulmonary resuscitation (CPR) possible. The technique was intended for use in patients experiencing sudden cardiac death, particularly as it occurs in association with acute myocardial infarction. During the decades of the 1960s and 1970s the use of CPR, augmented by advanced life support (ALS) techniques, became the standard of care for all dying patients.22The age of the “code” was born. The necessity to intervene immediately and the potential for these techniques to resuscitate some individuals suffering from a life-threatening crisis have created a situation in which consent for resuscitation is assumed universally. There is no time to sort out questions of value to determine if the patient would wish resuscitation when he or she is unconscious and in the throes of a cardiac arrest. In 1983, The President’s Commission for the Study of Ethical Problems in Medicine issued its report, Deciding to Forego Life-Sustaining Treatment. The Commission reiterated what had become universal practice, that resuscitation must be performed unless there is a specific decision not to resuscitate. Furthermore, this decision not to resuscitate requires the consent of the patient or his or her surrogate. ”When a physician’s assessment conflicts with a competent patient’s decision....the physician must follow the patient’s decision or transfer responsibility for the patient to another phy~ician.”~~ The Hastings Center’s Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying similarly stated that ”any patient

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without a DNR (do not resuscitate) order should receive CPR in the event of a cardiac or pulmonary arrest.'"l, 28 To this extent, resuscitation has become an exceptional therapy compared to all other treatments. Consent must be given not to receive the treatment. In fact, patients often have had to go out of their way by preparing advance directives to be free from what they would consider to be an assault on their person. Having resuscitation universally considered the standard of care creates myriad ethical and practical dilemmas. The first is that it assumes that all patients wish to receive this treatment because it may reverse death, when in reality this is not the case. Over the 1970s and 1980s it became clear that many patients did not desire resuscitation in the event of death. The living will movement had as its major impetus the tragic case of Karen Ann Quinlan, who "benefited" from resuscitation only to spend over a decade in a persistent vegetative state/]= Now subsequent case law and general agreement among medical ethicists, the medical community, and society at large have confirmed that patients have the right to refuse resuscitation and other life-sustaining therapy. Unfortunately, many patients still receive invasive resuscitation attempts that they may not necessarily desire. Current mechanisms are inadequate for allowing the full expression of a patient's right to refuse resuscitation treatment. Advance directives may have been helpful but are still lacking; they are not a "no-CPR' order. The living will is a very limited document that may not convey the patient's true desires and concerns. The Patient Self Determination Act (PSDA), which was Congress's response to the Cruzan decision, has informed the public of its right to have advance directives, but has not ensured that the appropriate discussions between caregivers and patients have taken or will take place.20,4.1 Numerous studies have shown the reluctance of caregivers to raise the question of resuscitation with their patients, in part because they feel that to do so may communicate to the patient that they are giving up on them, or may imply to patients that they are worse off than they really are. Many physicians are simply uncomfortable talking about such life-and-death issues. Patients, on the other hand, are often hesitant to interrupt their physician's busy schedule to insist on a discussion of these important questions, believe it is the physician's responsibility to raise the issue, or are uncomfortable with the topic themselves.*0,21, 39 Another ethical dilemma created by resuscitation efforts is that this standard of care creates additional emotional burdens for the patient, family, and caregivers. The present system communicates to patients that resuscitation is a successful technique that will restore a life that would otherwise slip away. It obscures the reality that in general, the outcomes from resuscitation are quite dismal. It has been shown that most inpatients will not survive resuscitation to discharge, with only 3.8% to 16.5% of patients reported to survive to lo, 18, 19, 29, 40-42, 45, 46, 51 Patients with a critical illness, chronic di~missal.~-~,

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disease, or advanced malignancies fare even worse with 0% to 10.5% of 24, 37, 53 those receiving resuscitation surviving to di~charge.’~, The present system does not communicate the potential for serious consequences if the patient survives. These consequences include physical injuries incurred during the resuscitation effort or severe neurologic injury. Reports of the incidence of some type of neurologic injury after CPR have ranged from 0% to 57’/0.~Patients frequently decline chemotherapy or other interventions when quoted realistic estimates of risk and outcome, yet such information for CPR commonly is not shared with the patient. Because CPR is different, physicians do not seem to believe that patients need to know the outcome data that they would otherwise feel obligated to share for any other proposed intervention. Murphy et al,39 however, demonstrated that patients understand outcome data and most would not wish to receive resuscitation once they understand the probability of survival. Under the current paradigm, patients or their surrogates must refuse resuscitation. The emotional connotation is that they are refusing their rightful chance to stay alive, adding to the guilt and grief associated with serious illness. This is an unnecessary additional burden. Or, they may believe that in consenting to DNR, they are forfeiting other treatments as well. Unfortunately, physicians often interpret DNR or no-CPR status in the same way as their patients. LaPuma et a135have reported that many physicians inappropriately see a DNR decision as implying more than just a refusal for CPR and ALS measures. They interpret the DNR status as meaning that they may or should also discontinue IV fluids, antibiotics, and other treatments that may be indicated and appropriate. The third dilemma caused by resuscitation is that because of the unrealistic expectations of positive outcomes from resuscitation efforts, patients and families have become increasingly at odds with caregivers about whether to assign DNR status to a patient. The issues surrounding CPR have been the primary stimulants for the discussion of ”medical futility.” By making CPR the standard of care, the issue of futility is made more difficult to resolve. In the current system, CPR is the patient’s right. To claim that outcomes data will help us to establish a new standard of care that would enable caregivers to deny CPR on the basis of futility is naive. As long as universal consent is assumed and CPR is the default treatment, it will remain the standard of care. Even if proposals to change DNR status to a futility-based process rather than a consent-based process (such as advanced by Tomlinson and B r ~ d y were ~ ~ ) accepted, the problem would still remain. It may be argued that ”If the process is useless, why do we have to go to such effort not to receive it? Why is it the default treatment?” Moreover, as BakeP has pointed out, if ”we fail to require consent for a DNR order in cases in which CPR is effective but of questionable value we [continue to] treat CPR as an exception.” It is unlikely that futility-based DNR policies will survive challenges from the legal system. Even if they did, the emotional burdens of

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"withholding" would remain. Worst of all, futility-based DNR policies would allow the unilateral discontinuation of care that potentially could do great violence to the most deeply held values of some patients. Clearly the status quo is fraught with problems. The assumption of universal consent to CPR creates unrealistic expectations among patients and their families and creates additional ethical dilemmas if the use of resuscitation is questioned. Two potential alternative approaches can be envisioned. The first changes the default status from resuscitate to DNR. The second attempts to eliminate a default system and replace it with a prospective requirement for appropriate consideration, discussion, and the issuing of an order either for or against resuscitation. Removing the Presumption of Consent for Inpatient Resuscitation

Changing the default status for inpatients by requiring a positive order for CPR in the event of arrest offers several advantages. First and foremost, it returns the status of CPR to that of all therapies. It requires that indications, outcome data, and potential complications be shared with patients to secure their informed consent. This would be particularly useful in those situations when CPR has been shown to be of less value. By depriving CPR of its select status, the emotional burden of deciding not to resuscitate hopefully would be lessened. This process requires more conscious consideration of when CPR is and is not indicated and forces this important issue to be confronted more honestly. Unfortunately, this approach inevitably allows some patients to die unnecessarily when they could have benefited from resuscitation efforts. As all human systems are fallible, not every case where CPR is indicated would be covered by an appropriate order. Some physicians might avoid confronting the issue by perfunctorily writing full-code orders on all of their patients whether appropriate or not. Preventing this would be difficult and most likely would require a written informed consent to CPR for inpatients, which may be perceived as burdensome. It is the potential for the unnecessary loss of even one life, however, that makes this paradigm shift undesirable. Determining the Level of Treatment at Admission

A compromise position might involve prospectively requiring that on admission, all patients receive information about resuscitation appropriate to their other medical concerns. A resuscitation order, either for resuscitation or refusing it, would be entered for every patient admitted to the institution. Resuscitation status would become a routine and required admission order just like the diet, frequency of vital signs, and medication orders. It seems somewhat silly that a patient cannot receive a glass of milk in a hospital without an order, but can receive, without

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an order, potentially traumatic and invasive resuscitation therapy that may not be indicated or desired. Before finalizing the admission process, the presumption for resuscitation would remain in effect just as it would for outpatients, to protect against the unnecessary or inappropriate loss of life. This would return more authority to physicians to execute appropriate clinical judgment and recommend a reasonable course. The physician would always have to share with the patient or his or her surrogate the order written, just as is appropriate for any test or treatment ordered. It should be recognized and acknowledged clearly that no system will remove the potential for conflict over the issue of resuscitation. Patients possessing a vitalistic world-view always will be at odds with caregivers who do not share their values. These patients may create “living” wills that mandate that under all circumstances they should be resuscitated. No system should be seen as empowering the medical community to disrespect and to override the most deeply held intrinsic values of patients. Caregivers should be willing to provide resuscitation if preserving life, regardless of quality, is a fundamental aspect of the patient’s beliefs. A change from the current standard, however, may reduce the number of conflicts that currently exist. A procedure that prospectively requires all patients to receive an order for or against CPR would maintain the advantages of lessening the select status of CPR. It would remove the aura of wonder and faith in this intervention from public perception. It would make consideration of each case second nature, as it should be. It would mandate that a discussion take place. The safety net of presumed resuscitation would still be there until the admission order was considered and written. There is no question that such a process requires more effort and time from caregivers. At the beginning it most likely will be perceived as burdensome and intrusive, but in time it will become integrated into the routine aspects of care like securing an allergy history, reviewing medications, and so forth. As patients learn that such discussions always will take place on admission, emotional concerns will be reduced. Such an approach would have the ”teeth” that the PSDA lacks.

OUT-OF-HOSPITAL RESUSCITATION

Two issues are of concern with respect to out-of-hospital CPR. The first issue revolves around the criteria for initiation of resuscitation out-of-hospital by emergency medical technicians (EMTs), high-speed transportation of patients who have not responded to field resuscitation, and the duration of the continuation of efforts on arrival in the emergency department (ED). The second issue relates to appropriufe resuscitation, that is the degree of medical intervention appropriate to the patient’s underlying medical condition and the patient’s desire for such interventions. This question concerns patient autonomy and advance

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directives (e.g., living wills) under emergent life-threatening conditions and prehospital DNR orders.

Criteria for Out-of-Hospital Resuscitation: Medical The American Heart Association states that ”pre-hospital care providers have an obligation to initiate CPR when medically indicated unless a valid medical or legal reason exists to withhold it.”3 A valid medical reason includes evidence of irreversible death or sufficiently advanced underlying medical illness in which survival from cardiac arrest would be unprecedented. Data on the latter do not exist for out-of-hospital resuscitation. It is inappropriate to expand the responsibilities of EMTs to include a medical judgment as to the indications for CPR in a patient with a severe underlying illness-additional convincing reasons must be present. This is particularly true when debate still exists regarding rules for EMTs to determine ”irreversible” death.31 An obvious and irrefutable rule to withhold CPR clearly includes decapitation and decomposition. It has been argued, however, that criteria for ”irreversible” death might not include rigor mortis or extreme dependent lividity, as these have been shown to be unreliable signs of the time of death.15,50 Medical professionals, in fact, have not demonstrated 100% accuracy at determining death, as demonstrated by anecdotes such as the recent headline, “Woman Found Alive in Morgue.” To avoid events that Poe would fictionalize, therefore, there is a presumption for treatment for at least a period of time sufficient to confirm the diagnosis of death.

Criteria for Out-of-Hospital Resuscitation: Legal Informed refusal of resuscitation rather than informed consent for resuscitation is currently the national standard of care. A valid legal reason to withhold CPR and ALS measures includes a clearly written advance directive that would state specifically the wish of the patient or the determination of the primary physician that resuscitation is neither desired nor appropriate. Some states have instituted outpatient DNR orders to deal with this issue. The usual requirement for implementation of a living will is that the patient’s condition is terminal, which is beyond the expertise of an EMT in the field. Even if the living will clearly stated that the patient would not wish resuscitation, the request would not be honored unless the criteria for a terminal condition were satisfied. This point may be a source of frustration for the family (and potentially the patient) when the patient receives unwanted CPR despite the presence of a living will.

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Criteria for Out-of-Hospital Resuscitation: Ethical

In educating the patient and family regarding practical ramifications of outpatient DNR orders, caregivers must ensure that they accept the possibility of the terminal event happening out of the hospital and are willing to deal with that situation should it occur. Families may panic because of a lack of preparation when the patient enters the terminal event and call 911 for assistance when what they desire is reassurance and support. An intercurrent illness, in fact, may be eminently treatable and the patient might desire such treatment. This could make the patient reluctant to place any formal limitation on treatment until he or she can be examined fully by his or her physician. This is certainly a concern with AIDS patients, who might wish to receive emergent care for a motor vehicle accident or supportive care for a pneumonia. A strong relationship with a primary medical professional who is comfortable with death is required to achieve the necessary balance. This is a difficult problem in patient education, acceptance or denial of death, and the relationship with the primary caregiver. The practitioner’s own education and awareness of the available options for dying patients is critical. Commitment and sensitivity are required for the caregiver to educate the patient and family effectively. Complex issues of patient autonomy are involved. The critical care practitioner has a significant contribution to make here, as too often this decision is not faced until the patient develops a critical illness. As discharge planning proceeds while the patient is still in the intensive care unit (ICU) setting, outpatient DNR and advance directives should be addressed while the realities of resuscitation are evident to the patient. Between 4% and 5% of patients who have DNR status in the ICU will be discharged from the hospital alive, with the critical care practitioner having been in the closest position to address these conc e r n ~Not . ~ ~only do we fail to address these issues with patients who survive to hospital discharge following critical illness and an in-hospital DNR decision, we also fail to address the issue when non-DNR patients survive the ICU experience. At no time will the realities of CPR be illustrated so clearly to the patient as when he or she has survived the ICU. Even patients who are not ”terminal” should be offered the option of refusing CPR in and out of the hospital. Whenever the patient is generating a living will, discussion among practitioner, patient, and family should occur regarding out-of-hospital emergent care. Even when this dialogue happens, decisions and correlated written documentation may not develop. It has been demonstrated that even under circumstances of careful patient education and in the presence of a terminal illness, most patients have not accepted formal mechanisms to limit treatment, such as the living will.27,44 There is also a significant minority of patients who would want medical measures continued in a persistent vegetative statez1or in terminal illness with poor chance of survival.26,47, 48 Finally, there are cultural and religious

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biases, lack of enfranchisement of minorities, and suspicions about the 33 medical profession that inhibit adequate discussion of these issues.12* (Koch KA, DeHaven JM, Kellogg-Robinson M: Impediments to obtaining living wills: After the patient self-determination act. Unpublished.)

Criteria for Out-of-Hospital Resuscitation: Summary

Even if a document that is legal in a given state exists and furthermore is provided to the EMT when he or she is called to a dying patient, there are concerns about the variable implementation of such documents. This certainly has been demonstrated within the hospital setting.35,36 There presently are few criteria that can limit the initiation of resuscitation by EMT services clearly and crisply. These are restricted to irrefutable evidence of irreversible death and written documentation that is accepted legally in a specific state, such as the outpatient DNR order.

DURATION OF RESUSCITATION

The American College of Emergency Physicians has stated that any overtreatment initiated by EMTs ”can be withdrawn at a later time when the proper medical, legal, and ethical considerations can be evaluated more thoroughly.”2 The absence of a satisfactory outcome after prolonged efforts in the field has been proposed as a criterion to limit resuscitation efforts and avoid the high-risk, dangerous, high-speed race to the hospital.31Similar conclusions could be derived from research regarding high-dose epinephrine resuscitation in the ED or in-hospital setting; even if cardiac response to resuscitation is achieved, functional survival of the patient is n ~ t . ~ , ~ ~ Prolonged ED resuscitation consumes resources and human effort that could be expended more properly on patients who are potentially more viable. This is a matter of distributive justice or economics of personnel and resources, and is true regardless of the in-hospital location whether it be the ED, hospital ward, or ICU. It is also a balancing act among autonomy, beneficence, and nonmaleficence, particularly in the teaching setting. Patients with serious underlying illnesses should not be subjected to the ”every-intervention-in-the-book” approach to resuscitation. The chances of a successful outcome rapidly deteriorate with the increasing duration of ongoing resuscitation. The problem faced, particularly in the ED, is the lack of knowledge of the providers regarding the patient’s condition and wishes, when time is of the essence. There is liability both in failure to treat (i.e., negligence) and in treatment against the patient’s will (i.e., assault and battery). The instruction of ED staff in liability

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issues must balance these facts. It is the duty of physicians in the ED to determine, in good faith, the patient’s prior condition and wishes. Unfortunately, the medical facts regarding the patient’s underlying condition may not be immediately available, or may be available from a potentially unreliable source. At the same time, uncertainty may exist as to the patient’s potential for response to treatment for what may be an intercurrent illness. These concerns argue in favor of continuing intervention until the lack of response to treatment makes it clear that resuscitation should not be continued, or until the facts can be verified. Medical standards demand independent observation and conclusion. On the one hand, lack of knowledge of the patient’s prior medical condition does not preclude data gathering; data can be gleaned from concomitant physical examination during the resuscitation, from the patient’s family or clinician, or from the medical record or hospital computer. A clinician should be freed whenever possible from the urgency of the actual resuscitation to obtain a database while emergent intervention proceeds. Accumulating facts may argue in favor of discontinuing ongoing resuscitation as the picture of the underlying medical condition is developed. There may be evidence of the patient’s wishes, such as patient statements or a prehospital DNR order, advance directive, statement of the patient’s physician or family, or a previous medical record. This brings up the matter of an evidentiary standard. There may be a lack of credibility of patient statements. Verbal statements of friends or family may be questioned. There may be concern as to the credibility or durability of prior written documents and questions about their relevance in the acute situation. The accuracy of the primary physician’s memory as to the patient’s wishes may be questioned. The presence of a terminal illness by itself does not justify withholding intervention on medical grounds, nor does the presence of extreme age or an illness with prejudicial connotations (e.g., AIDS). These concerns taken individually argue in favor of continuing intervention. On the other hand, statements by apparently reliable witnesses determined in good faith and any evidence of internal consistency of statements or documentation offered by the primary physician in the context of an ongoing therapeutic relationship support the discontinuation of ongoing intervention. The argument can be made that in a teaching institution, extensive intervention or resuscitation is warranted in the interest of the staff‘s education, regardless of its predicted benefit to the patient. This is a ”greater-good-for-the-greater-number” argument. Technical skills learned during such practice could save future lives. Leadership and team skills necessary for resuscitation need practice for optimal efficiency. Again, aggressive intervention is both personnel and resource intensive. There is a secondary reduction in the care and observation of other patients in the ED. This argues against focusing efforts on one individual who either will not benefit or would not want the intervention. Finally,

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here is an equal obligation of the teaching institution to instruct its staff in “when to quit,” making the decision to stop intervention as valid in its educational effect as the skills of the actual intervention itself. Once the decision has been made to discontinue CPR, the question then arises of whether or not the deceased could or should be used to train students in necessary skills. The argument has been made that permission to practice necessary skills on the recently dead should be obtained from the grieving family.” This approach makes a great deal of sense if the intent is to practice skills that would entail additional disfigurement of the patient’s body. The supervised instruction of endotracheal intubation, however, should not create additional disfigurement. It is an essential skill that is critical to the functional survival of many patients who would avoid full cardiac arrest if they were intubated in a timely fashion. The practice of endotracheal intubation on newly dead patients under supervision of more experienced personnel should be allowed without requiring consent from the family. As long as respect for the body is demonstrated, the grieving family is not prevented from being with their deceased, and the nursing staff are informed respectfully of the student’s need for instruction by the supervising physician. The practice of this skill, which is so critical, should be permitted. This is particularly relevant because the standard of medical care in this country is to assume consent for resuscitation. That argument can be extended to assuming consent for the necessary practice of nondisfiguring procedures to prepare the student for future near-resuscitation or resuscitation episodes. When any policy is instituted to obtain consent for resuscitation rather than assume consent, then the informed consent process for that decision could include discussion of the practice of necessary skills if the patient does not survive. It should be noted, however, that informed consent for the practice of intubation on living patients by inexperienced personnel is not discussed specifically even during the preoperative consent process. In the situation when practice intubation is permitted on living patients without their knowledge or consent, we are demonstrating less respect for the living than for the deceased. It is desirable to achieve consistency; the same consent mechanism should apply to both living and dead patients. SUMMARY

We have proposed that the presumption for consent to resuscitate should be questioned. We offer an approach to identifying consent or refusal of resuscitation that takes the PSDA one step further. An assumption that always favors intervention can be seriously invalid, and should be defaulted to only when adequate decision making cannot occur. Serious effort on the part of medical professionals to inform and to support the patient’s right to refuse resuscitation requires a paradigm

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shift from assuming consent. In the event that the default position must be held, an appropriate balance in the management of resuscitation efforts requires medical judgment regarding an appropriate end point. These issues all reflect the principles of distributive justice, autonomy, beneficence, and nonmaleficence, and the value of truth-telling in the face of medical uncertainty. It is the goal of the medical profession to return patients to functional life, and if not to cure or heal, at least to comfort. When the patient is “overmastered” by illness, the decision should be to turn to comfort measures. As caregivers, we must support our patients throughout the course of their illness. We must honor those who trust us, by enabling them to share their values, doubts, and fears. They must know that they have been heard and respected. Their confidence in us depends on our competence and our admission of our own limitations. Ethically based medical decision making demands that we open a more reality-based dialogue about resuscitation with our patients and with the community at large.

References 1. Adams JG, Derse AR, Gotthold WE, et al: Ethical aspects of resuscitation. AM Emerg Med 21:1273-1276, 1992 2. American College of Emergency Physicians: Guidelines for ”Do Not Resuscitate” orders in the prehospital setting [position paper). Ann Emerg Med l:llOf%1108, 1988 3. American Heart Association (AHA): Textbook of Advanced Cardiac Life Support, ed 2. Dallas, American Heart Association, National Center, 1987, p 27 4. Baker R The ethics of medical futility. Crit Care Clin :575-584, 1993 5. Ballew KA, Philbrick JT, Caven GE, et al: Predictors of survival following in-hospital cardiopulmonary resuscitation: A moving target. Arch Intern Med 154:242&2432, 1994 6. Bedell SA, Delbanco TL, Cook F, et al: Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 30:569-576, 1983 7. Berger R, Kelley M: Survival after in-hospital cardiopulmonary arrest of noncritically ill patients: A prospective study. Chest 106:872-879, 1994 8. Beauchamp TL, Childress JF: Principles of Biomedical Ethics, ed 3. New York, Oxford University Press, 1989 9. Brown CG, Martin DR, Pepe PE, et al: A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. N Engl J Med 3271051-1055, 1992 10. Brunetti LL, Carperos SD, Westlund RE: Physicians’ attitudes toward living wills and cardiopulmonary resuscitation. J Gen Intern Med 6:323-329, 1991 11. Burns JP, Reardon FE, Truog R D Using newly deceased patients to teach resuscitation procedures. N Engl J Med 331:1652-1655, 1994 12. Caralis PV, Davis B, Wright K, et al: The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics 4:155-165, 1993 13. Crawford SW, Schwartz DA, Finn B, et a1 Mechanical ventilation after marrow transplantation: Risk factors and clinical outcome. Am Rev Respir Dis 137682-687, 1988 14. Crimmins TJ: Ethical issues in adult resuscitation. Ann Emerg Med 22:495-501, 1993 15. Curran WJ, McGary AL, Petty C S Modern Legal Medicine, Psychiatry, and Forensic Science. Philadelphia, FA Davis, 1980, pp 151-154 16. Dans PE, Nevin KL, Seidmen CE, et al: In-hospital CPR 25 years later: Why has survival decreased? So Med J 78:1174-1178, 1985

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