Resuscitation

83 (2012) 27–

31

Contents

lists

available

at

ScienceDirect

Resuscitation

j o

u

r n

a l

h o m

e p a g e

:

w w w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n

Commentary

and

concepts

Guidance

for

ambulance

personnel

on

decisions

and

situations

related

to

out-of-hospital

CPR

夽

Anders

Ågård

a

,

∗

,

Johan

Herlitz

b

,

Maaret

Castrén

c

,

Lars

Jonsson

d

,

Lars

Sandman

e

a

Sahlgrenska

Academy,

Institute

of

Medicine,

Gothenburg,

Sweden

b

The

Center

for

Prehospital

Research

in

Western

Sweden,

University

College

of

Borås

and

Sahlgrenska

University

Hospital,

Gothenburg,

Sweden

c

Department

of

Clinical

Science

and

Education,

Karolinska

Institutet,

Södersjukhuset,

Stockholm,

Sweden

d

Stockholm

Prehospital

Centre,

Södersjukhuset,

Stockholm,

Sweden

e

School

of

Health

Science,

University

of

Borås,

Sweden

a

r

t

i

c

l

e

i

n

f

o

Article

history:

Received

15

March

2011

Received

in

revised

form

15

July

2011

Accepted

20

July

2011

Keywords:
Cardiopulmonary

resuscitation

Prehospital

emergency

care

Ethics
Practice

guideline

Ambulance

a

b

s

t

r

a

c

t

Ethical

guidelines

on

out-of-hospital

cardio-pulmonary

resuscitation

(CPR)

are

designed

to

provide

sub-

stantial

guidance

for

the

people

who

have

to

make

decisions

and

deal

with

situations

in

the

real

world.

The

crucial

question

is

whether

it

is

possible

to

formulate

practical

guidelines

that

will

make

things

some-

what

easier

for

ambulance

personnel.

The

aims

of

this

article

are

to

address

the

ethical

aspects

related

to

out-of-hospital

CPR,

primarily

to

decisions

on

not

starting

or

terminating

resuscitation

attempts,

using

the

views

and

experience

of

ambulance

personnel

as

a

starting

point,

and

to

summarise

the

key

points

in

a

practice

guideline

on

the

subject.

© 2011 Elsevier Ireland Ltd. All rights reserved.

1.

Introduction

The

rationale

for

guidelines

including

the

ethics

of

resuscitation

is

to

enable

professionals

to

make

more

appropriate

decisions

and

to

act

more

effectively

compared

with

what

might

happen

if

their

decisions

and

actions

were

only

based

on

individual

judgements

and

their

own

values.

1–3

The

challenge

is

to

provide

substantial

guidance

on

questions

or

problems

that

are

experienced

in

the

real

world.

4,5

Ambulance

personnel

are

confronted

by

a

number

of

ethical

considerations

when

they

are

on

their

way

to

treat

a

person

who

has

suffered

an

out-of-hospital

cardiac

arrest

(OHCA)

with

car-

diopulmonary

resuscitation

(CPR).

4–8

The

most

crucial

question

is

whether,

and

in

which

particular

circumstances,

they

can

be

given

a

mandate

to

decide

to

terminate

a

resuscitation

attempt

at

the

scene.

The

aims

of

this

article

are

to

address

and

to

clarify

the

ethi-

cal

aspects

related

to

out-of-hospital

CPR,

based

on

our

knowledge

夽 A

Spanish

translated

version

of

the

abstract

of

this

article

appears

as

Appendix

in

the

final

online

version

at

doi:10.1016/j.resuscitation.2011.07.028

.

∗ Corresponding

author

at:

Medicinmottagningen,

Angereds

Närsjukhus,

Box

22,

SE-424

65

Göteborg,

Sweden.

Tel.:

+46

31

3326700;

fax:

+46

31

3320369;

mobile

+46

0

761

360364.

E-mail

address:

[e-mail]

(A.

Ågård).

of

the

views

and

experience

of

ambulance

personnel,

and

to

summarise

the

key

points

in

a

practice

guideline

on

the

sub-

ject.

2.

The

objective

of

CPR

From

the

ambulance

personnel’s

point

of

view,

a

reasonable

way

to

measure

the

effectiveness

of

a

resuscitation

attempt

is

whether

patients

affected

by

an

OHCA

have

spontaneous

circulation

when

they

are

delivered

to

the

emergency

room.

4

However,

this

way

of

defining

what

constitutes

successful

CPR

hardly

applies

from

the

patient’s

viewpoint.

We

argue

that

the

objective

of

CPR

is

to

restore

life

with

quality

acceptable

to

the

patient

and

in

accordance

with

his

or

her

will.

To

properly

evaluate

the

effectiveness

of

their

attempts,

personnel

involved

in

out-of-hospital

CPR

must

therefore

be

informed

about

the

outcome

of

the

patients

in

a

systematic

quality

improvement

system.

In

some

ambulance

systems,

they

are

only

aware

of

and

are

only

evaluated

on

the

basis

of

prehospital

results.

3.

Choices

to

be

made

When

confronted

by

a

person

with

cardiac

arrest,

the

emer-

gency

personnel

can

initiate

and

then

continue

CPR,

or

initiate

and

subsequently

stop

CPR

or

withhold

CPR

in

the

first

place.

If

CPR

is

0300-9572/$

–

see

front

matter ©

2011 Elsevier Ireland Ltd. All rights reserved.

doi:

10.1016/j.resuscitation.2011.07.028

28

A.

Ågård

et

al.

/

Resuscitation

83 (2012) 27–

31

Algorithm for the treatment of an out-of-hospital cardiac arrest

Obvious evidence of

irreversible death

do-not-attempt-resuscitation

(DNAR)

mortis, deco

DNAR

Stop

resuscitation

attempt

No

Start CPR

Connect defibrillator

ECG analysis

Defibrillate?

No

Yes

Yes

No/Unknown

Yes

CPR according

to guidelines

Yes

Cardiac

arrest

Continued asystole during
> 20 min

CPR

If suspected:
Drowning
Hypothermia
Intoxication
Obvious

pregnancy

Continued effective CPR
Transport to hospital

–
–
–
–

Asystole
Not witnessed
No bystander CPR
Alarm –

arrival

>15 min

(the decision takes account of the

patient’s biological age)

Fig.

1.

Algorithm

for

the

treatment

of

an

out-of-hospital

cardiac

arrest.

initiated,

the

patient

has

a

chance

to

be

saved

for

a

life

of

acceptable

quality

or

a

life

with

less

than

acceptable

quality.

If

CPR

is

withheld,

the

patient

will

definitely

die.

There

are

strong

reasons

for

ambulance

personnel

to

initiate

CPR

routinely

on

persons

who

have

suffered

an

OCHA.

Firstly,

the

infor-

mation

about

the

patient’s

medical

condition

before

the

cardiac

arrest

is

often

insufficient.

Second,

the

patient’s

preference

regard-

ing

CPR

is

generally

unknown.

Third,

it

is

difficult

to

make

correct

prognoses

about

the

chances

of

survival

and

quality

of

life

following

resuscitation

attempts.

However,

there

are

reasonable

exceptions

to

the

general

rule

to

initiate

CPR,

such

as

cases

of

obvious

mortal

injury

or

death.

Moreover,

taking

the

available

knowledge

relating

to

factors

that

influence

the

outcome,

clinical

prediction

rules

and

algorithms

for

terminating

resuscitative

efforts

in

the

field

have

been

proposed.

9

We

suggest

an

alternative

algorithm

for

the

treatment

of

an

OHCA

that

includes

criteria

for

stopping

resuscitation

attempts

(

Fig.

1

).

By

looking

retrospectively

at

the

records

from

the

Swedish

Cardiac

Arrest

Registry,

we

calculate

that

CPR

would

be

stopped

after

a

short

period

in

approximately

2%

of

the

cases

if

the

algorithm

were

implemented

in

our

services.

The

registry

does

not

include

patients

on

whom

CPR

was

not

initiated

because

of

obvious

death

signs

or

ethical

reasons.

4.

Attempting

to

act

in

the

patient’s

best

interest

CPR

is

sometimes

considered

futile

or

unethical,

even

in

cases

where

there

is

a

small

chance

of

saving

lives.

Among

patients

affected

by

severe

diseases,

which

substantially

influence

their

quality

of

life

and

expected

remaining

lifetime,

doubts

can

be

raised

about

whether

CPR

is

in

the

patient’s

best

interest.

Studies

have

actually

shown

that

the

ambulance

personnel

sometimes

drive

more

slowly

than

normal

to

the

scene

when

the

emergency

call

relates

to

a

very

old,

very

ill

patient

with

a

cardiac

arrest.

They

may

occasionally

feel

that

prehospital

resources

are

not

used

cost

effec-

tively.

Moreover,

they

may

not

try

as

hard

as

they

normally

do

to

optimise

the

CPR

procedure

in

this

category

of

patients.

A

com-

mon

argument

for

this

behaviour

is

their

wish

not

to

take

away

a

peaceful,

dignified

death

from

the

patient

and

family.

4,7,8

How-

ever,

references

to

‘dignity’

are

problematic.

In

fact,

the

concept

of

a

dignified

death

can

be

interpreted

in

a

number

of

different

ways.

10

A.

Ågård

et

al.

/

Resuscitation

83 (2012) 27–

31

29

Studies

have

shown

that

patients

in

the

late

stages

of

chronic

diseases

may

want

CPR

to

be

given

the

chance

to

live

a

little

longer.

11

Hence,

even

though

the

prognosis

is

statistically

poor

and

the

chronological

age

is

high,

patients

may

benefit

from

CPR

and

regain

an

acceptable

quality

of

life.

As

a

result,

it

is

generally

beyond

the

competence

of

the

emergency

personnel

to

assess

whether

or

not

a

resuscitation

attempt

is

in

the

patient’s

best

interest,

or

to

determine

the

kind

of

death

the

patient

would

have

preferred.

Being

in

the

presence

of

a

person

with

cardiac

arrest,

hav-

ing

first-hand

information

and

being

able

to

make

an

appropriate

examination

is

a

great

advantage.

We

argue,

based

on

our

own

and

others’

experience,

that

emergency

services

staff

members

with

the

appropriate

training

could

be

given

a

mandate

to

decide

not

to

initiate

or

to

stop

a

resuscitation

attempt

under

well-defined

conditions.

7

At

the

same

time,

the

creation

of

an

organisation

in

which

emergency

personnel

can

easily

consult

physicians,

emer-

gency

doctors,

cardiologists

or

anaesthesiologists

at

the

prehospital

stage,

to

obtain

support

or

advice,

can

be

recommended.

An

organ-

isation

of

this

kind

has,

for

example,

been

created

in

Helsinki

and

Oslo.

7

5.

Advance

directives

In

principle,

there

are

two

ways

to

find

out

what

a

patient

would

have

wanted

in

the

event

of

an

OHCA.

Firstly,

if

possible

and

appro-

priate,

people

who

are

close

to

the

patient

could

be

asked

tactfully

what

they

think

the

patient

would

have

wanted

in

terms

of

CPR.

However,

this

does

not

mean

that

decisions

relating

to

out-of-

hospital

CPR

should

be

handed

over

to

them.

It

can

actually

be

a

burden

to

feel

responsible

for

making

a

decision

relating

to

life

and

death,

which

can

in

turn

give

rise

to

future

guilt

and

doubts,

for

example.

When

consulting

family

members,

it

should

be

remem-

bered

that

their

will

might

differ

from

the

will

of

the

patient

or

that

they

could

have

misinterpreted

the

patient’s

wishes.

As

a

result,

it

may

be

difficult

to

distinguish

between

what

is

in

the

patient’s

best

interest

and

the

family’s

best

interest.

Second,

this

is

possible

by

having

access

to

written

advance

directives.

The

whole

idea

of

documents

containing

advance

direc-

tives

is

to

give

people

a

chance

to

convey

their

wishes

or

exercise

their

autonomy,

in

situations

in

which

they

have

temporarily

or

permanently

lost

the

ability

to

do

this.

However,

there

are

ques-

tions

and

problems

related

to

the

legal

status

and

validity

of

these

documents.

For

instance,

even

if

the

advance

directives

state

that

a

person

does

not

want

CPR,

can

the

emergency

team

take

it

for

granted

that

the

document

belongs

to

the

person

with

a

cardiac

arrest

in

front

of

them,

that

the

patient

really

wanted

to

have

this

statement

written

down

and

that

the

person

has

not

changed

his

or

her

attitude

towards

CPR

since

then?

As

a

result,

emergency

personnel

should

be

recommended

to

deal

with

advance

direc-

tives,

such

as

do-not-resuscitate

orders,

critically

and

with

sound

judgement.

12

However,

these

directives

should

generally

be

seen

as

a

valuable

help

when

attempting

to

make

a

decision

that

is

in

the

patient’s

best

interest.

6.

Withholding

or

withdrawing

CPR

Health

professionals

often

find

it

psychologically

more

difficult

to

withdraw

CPR

rather

than

not

starting

it

in

the

first

place.

13

As

a

result,

there

might

be

occasions

on

which

members

of

emergency

teams

are

unwilling

to

start

CPR

to

avoid

finding

themselves

in

a

situation

in

which

they

have

to

make

a

decision

to

terminate

the

treatment,

especially

in

the

presence

of

other

people.

In

our

opinion,

there

is

no

relevant

ethical

difference

between

not

initi-

ating

and

initiating

and

subsequently

withdrawing

CPR

from

the

patient’s

perspective,

as

the

consequence

is

basically

the

same

–

the

patient

will

die.

On

the

other

hand,

four

‘psychological’

reasons

for

continu-

ing

CPR

deemed

to

be

unsuccessful

or

futile

have

been

identified.

Firstly,

emergency

personnel

may

be

inclined

to

prolong

CPR

to

show,

or

convince,

those

around

them

that

“everything

that

can

possibly

be

done

is

actually

being

done.”

It

has

been

argued,

when

referring

to

the

potential

benefit

for

family

members,

that

this

way

of

acting

is

ethically

justified.

14

Second,

the

personnel

may

want

to

confirm

that

bystanders

did

the

right

thing

when

they

initiated

the

treatment.

4,7

Third,

the

personnel

want

to

escape

from

taking

care

of

grieving

persons,

who

just

have

lost

a

loved

one.

By

contin-

uing

CPR,

it

is

possible

to

transport

patients

to

hospital

who

have

not

yet

been

pronounced

dead.

Moreover,

some

members

of

the

emergency

team

may

not

even

feel

that

it

is

their

job

or

profes-

sional

responsibility

to

provide

emotional

support

at

the

scene.

15

Fourthly,

family

members

do

not

want

the

resuscitation

attempt

to

be

terminated.

We

argue

that

CPR

could

be

continued

for

a

short

period

of

time,

if

there

are

no

clear

signs

of

death,

even

though

it

may

be

deemed

not

to

be

successful,

to

assure

close

relatives

and

bystanders

that

everything

possible

has

been

done

and

that

their

efforts

were

com-

mendable.

Perhaps

this

strategy

could

also

ease

the

possible

guilt

of

not

being

successful

in

terms

of

restoring

the

function

of

the

heart.

The

persons

who

are

concerned

should

then

be

informed

clearly

and

tactfully

about

the

reasons

for

terminating

the

resuscitation

attempt.

7.

The

presence

of

family

members

and

bystanders

Despite

the

fact

that

life

or

death

is

at

stake

and

that

CPR

may

be

regarded

as

a

somewhat

violent

procedure,

most

people

want

to

be

near

their

loved

ones

during

resuscitation

efforts.

1

However,

some

members

of

the

emergency

team

may

feel

that

the

presence

of

per-

sons

close

to

the

patient

and

bystanders

constitutes

a

problem.

For

instance,

there

are

concerns

about

how

they

will

experience

wit-

nessing

a

resuscitation

attempt.

Emergency

personnel

may

also

feel

that

their

ability

to

provide

adequate

CPR

is

negatively

influenced

by

family

members

who

interfere

with

the

treatment.

In

particular,

a

conflict

between

staff

and

family

members

may

arise

when

they

have

a

different

opinion

about

what

is

the

right

thing

to

do,

to

keep

resuscitating

or

to

discontinue

it.

16

Family

members

should

gener-

ally

be

offered

the

chance

to

be

present

during

CPR.

The

importance

of

informing

them

about

what

is

happening

and

caring

for

them

during

the

procedure

is

emphasised.

In

our

opinion,

the

emergency

team

members

have

a

professional

responsibility

to

provide

ini-

tial

emotional

support

for

the

people

who

have

lost

someone

close

to

them

before

leaving

the

scene.

They

should

also

help

them

to

contact

other

persons

or

organisations

that

can

offer

further

sup-

port.

Family

members

are

generally

satisfied

with

the

overall

care

provided

by

the

emergency

personnel

at

the

scene.

In

fact,

family

members

often

prefer

or

accept

that

CPR

is

terminated

at

home

so

that

their

dead

loved

ones

are

not

transported

to

hospital.

More-

over,

terminating

CPR

and

caring

for

the

patient’s

survivors

at

home

appear

to

have

a

positive

impact

on

the

grieving

process.

17–19

8.

The

formulation

of

guidelines

that

deal

with

ethical

problems

related

to

out-of-hospital

CPR

Guidelines

cannot

possibly

cover

all

the

circumstances

that

surround

a

particular

situation.

As

a

result,

the

ambulance

per-

sonnel

always

have

to

use

their

knowledge,

skills,

experience

and

values

when

dealing

with

decisions

and

situations

related

to

out-of-

hospital

CPR.

Moreover,

there

are

two

important

things

that

must

be

accepted.

Firstly,

it

is

an

inevitable

fact

that

some

resuscitation

30

A.

Ågård

et

al.

/

Resuscitation

83 (2012) 27–

31

attempts

will

be

subsequently

considered

unethical

or

unjusti-

fied,

when

further

information

about

the

medical

condition

of

a

patient

prior

to

the

cardiac

arrest

is

obtained,

for

example.

Second,

guidelines

may

help

to

define

some

situations

in

which

it

might

be

justified

to

withhold

or

withdraw

CPR.

However,

when

there

is

the

slightest

doubt

about

what

is

the

right

thing

to

do,

the

active

treatment

strategy

should

be

chosen.

9.

Conclusion

Our

views

can

be

summarised

thus:

General

ethical

aspects

• The

overall

objective

of

CPR

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

dis-

charged

from

hospital

with

acceptable

quality

of

life

and

in

accordance

with

his

or

her

will.

• Decisions

to

withhold

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

per-

sonnel

to

assess

whether

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

mem-

bers

of

the

emergency

team

regarding

what

constitutes

a

peaceful

and

dignified

death

should

be

used

very

cautiously

when

guiding

the

action

that

should

be

taken.

• There

is

no

relevant

ethical

difference

between

not

initiating

and

initiating

and

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

organisation

in

which

emergency

personnel

can

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.

• 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

at

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

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,

chronological

age

per

se

should

not

be

used

as

a

single

discriminatory

factor

for

treatment

decisions

related

to

CPR.

• 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

cardiopulmonary

resuscitation

was

administered;

the

time

between

the

alarm

and

the

arrival

of

the

ambulance

exceeded

15

min;

and

the

type

of

arrhythmia

recorded

by

the

rescue

team

is

asystole

(Figure).

• Moreover,

in

cases

in

which

the

emergency

personnel

have

access

to

definite

and

reliable

information

that

the

patient

with

a

cardiac

arrest

is

suffering

from

the

end

stage

of

an

irreversible

medi-

cal

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

possibly

be

done

to

save

the

patient’s

life

is

actually

being

done.

• Before

leaving

the

scene,

emergency

team

members

have

a

pro-

fessional

responsibility

to

provide

initial

emotional

support

for

the

people

who

have

lost

someone

close

to

them.

Conflict

of

interest

statement

None

of

the

authors

has

a

conflict

of

interest.

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