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Received 15 March 2011; received in revised form 15 July 2011; accepted 20 July 2011. published online 12 August 2011. http://www.resuscitationjournal.com/article/S0300-9572(11)00466-7/fulltext
Article Outline
Abstract
Ethical guidelines on out-of-hospital cardio-pulmonary resuscitation (CPR) are designed to provide substantial 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 somewhat 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.
Keywords: Cardiopulmonary resuscitation, Prehospital emergency care, Ethics, Practice guideline, Ambulance
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, 2, 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 cardiopulmonary resuscitation (CPR).4, 5, 6, 7, 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 ethical aspects related to out-of-hospital CPR, based on our knowledge of the views and experience of ambulance personnel, and to summarise the key points in a practice guideline on the subject.
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.4However, 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 emergency personnel can initiate and then continue CPR, or initiate and subsequently stop CPR or withhold CPR in the first place. If CPR is 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 information about the patient's medical condition before the cardiac arrest is often insufficient. Second, the patient's preference regarding 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.
Fig. 1.
Algorithm for the treatment of an out-of-hospital cardiac arrest.
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 effectively. Moreover, they may not try as hard as they normally do to optimise the CPR procedure in this category of patients. A common argument for this behaviour is their wish not to take away a peaceful, dignified death from the patient and family.4, 7, 8 However, references to `dignity' are problematic. In fact, the concept of a dignified death can be interpreted in a number of different ways.10
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, having 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, emergency doctors, cardiologists or anaesthesiologists at the prehospital stage, to obtain support or advice, can be recommended. An organisation 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 appropriate, 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 remembered 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 directives 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 questions 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 directives, 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 initiating 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 continuing 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 continuing 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 professional 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 commendable. 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 persons close to the patient and bystanders constitutes a problem. For instance, there are concerns about how they will experience witnessing 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 generally 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 initial 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 support. 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. Moreover, terminating CPR and caring for the patient's survivors at home appear to have a positive impact on the grieving process.17, 18,19
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 personnel 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 attempts will be subsequently considered unethical or unjustified, 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 discharged 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 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. As a result, the views of the members 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 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 possibly 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 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.
Appendix A. Supplementary data
References
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