Ethical guidance on resuscitation - has your organisation given this some thought?
First Response Australia delivers training to various organisations that are remote from the “urban” Emergency Medical Services (EMS). In many instances Emergency Response personnel have found themselves in the situation of having to apply resuscitation to work colleagues or visitors in their workplace with no support from arriving emergency services as one would have in an urban environment. This has lead to them being in the unenviable situation of having to commence and / or continue resuscitation in some instances for what may seem as hopeless and futile situations.
A recent article in the journal Resuscitation (Jan. 2012) discusses “Guidance for ambulance personnel on decisions and situations to out-of-hospital CPR”. Although this article was aimed at Ambulance personnel, the guiding principles suggested in this article can be adapted to or adopted by organisations that find themselves in situations where the EMS cannot simply “take over” a resuscitation situation. Any policy formation should include all stakeholders such as the local EMS, Emergency Response personnel, management, company medical adviser etc.
Listed below is a summary of the conclusions from that article:
General ethical aspects:
The overall objective is to restore the patient to a life of (from the viewpoint of the patient) acceptable quality, if this is what the patient wants.
A successful CPR attempt means that the patient can be discharged from hospital with acceptable quality of life and in accordance with his or her will.
Decisions to hold or withdraw CPR must always be based on sufficient information. As a result, it is important to accept that some resuscitation attempts will be subsequently regarded as unethical or unjustified, when further information about the medical condition of a patient prior to the cardiac arrest is obtained.
It is generally beyond the competence of the emergency personnel to assess wether or not a resuscitation attempt is in the patient’s best interest, or to determine the kind of death the patient would have preferred. As a result, the views of the members of the emergency team regarding what constitutes a peaceful and dignified death should be used cautiously when guiding the action that should be taken.
There is no relevant ethical difference between not initiating, initiating then subsequently withdrawing CPR from the patient’s perspective, as the consequence is basically the same - the patient will die.
The decision making process:
The general rule is to initiate CPR when confronted by a person with an out-of-hospital cardiac arrest. As a result, when there is the slightest doubt about what is the right thing to do, the active treatment strategy should always be chosen.
An experienced ambulance or emergency services staff member with the appropriate training could be given a mandate to decide not to initiate or to stop a resuscitation attempt in well-defined conditions.
The creation of an organistaion in which emergency personnel could easily consult physicians with a particular area of expertise in emergency medicine at the prehospital stage, to obtain support, advice or a second opinion, is recommended.
Family members could be asked if they know, or what they think the patient would have wanted, when it comes to CPR. However, it should be made clear to them that they are not responsible for the final decision.aspects in the concrete situation. The potential risk of severe cerebral damage for the survivor, as well as the patient’s biological age, should be taken into account. However, biological age per se should not be used as a single discriminatory factor for treatment decisions related to CPR.
The emergency personnel involved in a resuscitation attempt outside hospital should obtain information about whether or not the patient survived to be discharged from hospital and about his/her mental and physical condition on discharge.
Withholding or withdrawing out-of-hospital CPR:
A decision to withhold or withdraw CPR should be made after weighing the relevant medical facts and ethical Treatment with CPR for an out-of-hospital cardiac arrest can be withheld or withdrawn in an out-of-hospital setting in obvious cases of mortal injury or death (e.g. decapitation, rigor mortis, and decomposition), or when the following criteria are met: the arrest was not witnessed; no bystander CPR was administered; the time between the alarm and the arrival of ambulance exceeded 15 minutes; and the type of arrhythmia recorded by the rescue team is asystole.
Moreover, in cases in which emergency personnel has access to definite and reliable information that the patient with a cardiac arrest is suffering from the end stage of an irreversible medical condition (life expectancy < 6-12 months) and there is a clear written statement (an advance directive) saying that he or she does not want CPR and/or a valid do not resuscitate (DNR) order, treatment with CPR could be withheld or withdrawn in an out-of-hospital setting.
Caring for those who are close to the patient and/or bystanders:
Family members should generally be offered the chance to be present during CPR. If they wish to be present, it is important that the personnel provide information about what is happening and take care of them during the procedure.
It could be regarded as ethically defensible for the personnel to continue CPR for a short period time, even though they expect it to be unsuccessful, to show bystanders/family members that they did something good when they initiated CPR and to make them feel that everything that can possible be done to save the patient's life is actually being done.
Before leaving the scene, emergency team members have a professional responsibility to provide emotional support for the people who have lost someone close to them.
Stay Safe Charles Makray