Cardiopulmonary resuscitation and ethics

This article discusses the ethical dilemmas related to the need to make critical decisions in emergency or acute settings regarding cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) techniques.

Rev Bras Ter Intensiva. 2013;25(4):265-269
Cardiopulmonary resuscitation and ethics
SPECIAL ARTICLE
INTRODUCTION
The earliest documentation of cardiopulmonary resuscitation
dates to the Old Testament, which describes how the prophet
resuscitated an apparently dead child by blowing air into his m(1)
Modern CPR began in 1960 with the landmark study by Kouwenhove
Jude, and Knickerbocker,which reportedcombiningclosed chest
compression, mouth-to-mouth breathing, and external defibrillati(1)
Since that time, CPR and advanced cardiac life support (ACLS) techn
have saved many lives but have also raised several ethical dil
Consent for CPR procedures is universally presumed. However, there
times when patients' right to receive CPR contrasts with their caregi
impression that such treatment is not medically indicated. Con
some patients receive resuscitation that they would not have w
Decisionsregardingresuscitationand the duration of resuscitative
efforts often entail several crucial ethical issues. This article w
on the ethical dilemmas related to the need to make critical decision
emergency or acute settings.
Risks and benefits of resuscitative efforts
Since 1900, cardiovasculardiseasehas been the leadingcauseof
death.(2) Cardiopulmonary resuscitation is a labor-intensive, high-cost
undertaken over an estimated 800,000 times annually in the United(3)
Although reports on the survival from in-hospital and out-of-hospital
arrest vary widely,(4-6) several factors have been identified to be associate
outcome. The most important factor determining survival is the time
since arrest (down time).(3) Recent studies estimate that the mortality
increases 3% for each minute without CPR and 4% for each minute w
defibrillation.(7,8) This public healthproblemspawnedthe development
of out-of-hospital cardiac care in the 1960s and its continued
the present.(9,10) Risk-adjusted survival after in-hospital cardiac arres
significantly improved over the past decade.(7) Several epidemiological studies
have identified factors associated with lower rates of survival, includ
in defibrillation, off-hours or unwitnessed arrests. Furthermore,
variation in survival outcomes exists across hospitals, suggestin
facilities may be instituting better strategies for resuscitation care.(7,11)
Francesca Rubulotta1, Giorgia Rubulotta2
1. Imperial College NHS Trust London, UK
2. Siracusa General Hospital - Sicily, Italy
Conflicts of interest: None.
Submitted on November 26, 2013
Accepted on December 10, 2013
Corresponding author:
Francesca Rubulotta
Charing Cross Hospital
Fulham Road SW6 6LJ, London
00447540500674
E-mail: [e-mail]
Ressuscitação cardiopulmonar e ética
DOI: 10.5935/0103-507X.20130046

266 Rubulotta F, Rubulotta G
Rev Bras Ter Intensiva. 2013;25(4):265-269
Earlyreportsfrom emergencycardiaccaresystems
documented that the most common initial arrhythmias
encountered in cases of out-of-hospital cardiac arrest were
ventricularfibrillation(VF) or ventriculartachycardia
(VT).(11,12)
Survival rates from out-of-hospital cardiac arrest
range from 2% to 26%, with the wide range ascribed
to variations in the population reported.(13) Ventricular
fibrillationand VT are "treatable"arrhythmias,and
restoration of spontaneous circulation is not unexpected;
this is in contrast to the results of resuscitative efforts
when non-ventricular arrhythmias are encountered. The
poor outcome of out-of-hospital cardiac arrest caused by
non-ventricular arrhythmias has led to both renewed interest
into the causes of such arrhythmias and in a reevaluation
of therapeutic interventions.(14,15) The historically dismal
outcome of these patients has led to suggestions that
resuscitative interventions be withheld from patients with
out-of-hospital cardiac arrest who do not have rhythms
that are responsive to electrical cardioversion or counter
shock.(16) However, patients who experience a witnessed
out-of-hospital arrest and who are found to be in asystole
do not have a uniformly fatal outcome.(17,18) In 1998,
Stratton supported the practice of initiating resuscitative
efforts in patients found to be in asystole, particularly if the
collapse was witnessed.(19) Improved outcomes have been
demonstrated for witnessed arrests in which early CPR and
ACLS protocols were instituted.(20,21)
The location is also an
important factor, largely owing to the more rapid institution
of CPR for witnessed arrests outside of the home.(20)
The underlying medical condition of the patient is
another important factor affecting outcome.(22,23)
Based on these data, several authors have suggested
withholding resuscitative efforts for patients in certain
clinicalsettingswith a low likelihoodof successful
resuscitation(i.e., apneic, pulseless>10 minutes
beforeEMS arrival,no responseto ACLS, asystole
or pulselesselectricalactivity,absenceof pupillary
reactions, preexisting terminal disease). Knowledge of
data regarding resuscitation outcomes in various clinical
settings is crucial when one is making evidence-based
decisions regarding the risks and benefits of attempting
CPR and ACLS.(22-26)
Ethics and cardiopulmonary resuscitation
Cardiopulmonaryresuscitationwas developedfor
acute illnesses, such as trauma or myocardial infarctions.
Actually, CPR is universal in application, regardless of the
underlying cause of the cardio-respiratory arrest. There is
growing concern that a disproportionate amount of h
care budgets is spent on CPR and ACLS, particu
when the results are viewed in light of the aging of o
population and the high percentage of deaths that o
in intensivecareunits. Additionally,severalauthors
have shown that physicians are unable to predict pa
preferences regarding treatment decisions.(27-29) Because
of the inherent difficulties in knowing the treatm
preferences of an individual patient, resuscitative m
are undertaken for most patients with cardiac a
unless a documented advance directive exists.(28,29) The
concern that CPR should be given more appropr
to a selected number of patients who would ce
benefit from it is a key problem in daily emerg
physicianpractice.Thereis a widespreadbeliefthat
people with reduced quality of life due to chronic dis
do not want aggressive, life-sustaining treatment
in an emergency scenario.(30-33) By definition, the act of
restoring life is a decision that must be made rapidly
emergency physicians, and unfortunately it is often
on suboptimal amounts of available information. In s
countries, competent patients have the right to
CPR in-hospital by using a code and outside the hosp
by wearing specific signs, such as a bracelet.
The capacityto providelife-sustainingtreatments,
includingCPR, has been accompaniedby several
issues about how to make decisions regarding t
and how to handle their cost.(31-34) The behaviors of
emergency physicians are frequently linked to their
of litigation or criticism.(34,35)
Several authors assume that
physicians have no obligation to provide, and pa
and families have no right to demand, medical treat
that are of no demonstrable benefit.(36-38) Respect for
patient autonomy does not require that the phy
mustinitiateproceduresthat are medicallyfutile or
not appropriate.(37) Until formal policies are develope
by governingorganizationsin emergencymedicine,
emergency physicians must make the choices they
to be most appropriate in the specific critical si
encountered. Moreover, there is worldwide agree
over the need to perform more selected and approp
resuscitations because of the substantial resourc
are invested during and after CPR.(38,39) The European
Commission has ruled that the patient has the
self-determination, including the right to refuse unw
therapies. However, it does not specify the need
advance directives or a proxy to achieve this g
non-competent patients. If physicians in Europe are

Cardiopulmonary resuscitation and ethics 267
Rev Bras Ter Intensiva. 2013;25(4):265-269
to use patient outcomes or quality of life in the decision
making process about whether or not to provide CPR, it
is important to have an appropriate understanding of the
terminology. Quality of life is, according to the WHO,
a part of the definition of the word "health". According
to Curtis, it is "a holistic, self-determined evaluation of
satisfaction with issues important to the individual". All
researchers confirm that it is influenced by many factors,
and, consequently, many authors use the more restrictive
meaning of "health-related quality of life". Patients with
a lower current quality of life want fewer life-sustaining
therapies. Moreover, all patients receiving CPR, even
if their previous quality of life was not compromised,
embrace the risk that if circulation is restored, significant
anoxic brain injury could result.
Appropriate care
The concept of medical futility became popular
with the growth of high technology in medical science,
which createdconcernthat this technologywould
simply delay death for short periods rather than restore
patients to health. Before 1987, the concept of futility
was unrecognized. In 1995, 134 articles on the topic
were published, and in 1999, 31 new items were found
in MedLine by searching for the keyword "futility".
(39,40)The term futility is fraught with difficulties in its
definition and interpretation. There is no consensus
among physicians about the definition of futility.(41)
In fact, there are a variety of definitions, including
physiologic futility (failure to produce a physiologic
response),quantitativefutility (the likelihood of
benefit to the patient falls below a minimal threshold),
and patient-centered futility (failure to produce effects
that the patient can appreciate).(42) Non-beneficial or
having a low likelihood of success are the concepts
most used in futility discussions. Appropriate care is
what ethicist are looking for, and it has been identified
by experts looking at the care provided in the ICU.
(43) A treatment that does not improve the patient's
prognosis,comfort,well-being,or generalstateof
health should be considered futile, or even better, not
appropriate.Healthcarepractitionersmay interpret
inappropriateinterventionsas thosethat carry an
absolute impossibility of a successful outcome, a low
likelihood of success or survival, or a low probability of
restoration of a meaningful quality of life. Schneiderman
defined futility as "an effort to achieve a result that
is possible but that reasoning or experience suggests
is highly improbableand cannotbe systematically
produced".(44) The issues surrounding CPR have bee
the primary stimulants for the discussion of med
appropriateness.Among a group of Europeanand
Israeli ICU clinicians, perceptions of inappropriate ca
were frequently reported and were inversely associa
with factors indicating good teamwork.(43) Physicians
have no ethical obligations to offer disproportion
or non-appropriateinterventionsto their patients
because they can exercise their professional jud
in assessing if a treatment request is appropriat
reach a therapeutic goal. If requests are not reasona
the physicianshould not feel obligedto provide
them;(45) furthermore, givenlimitedresources,it is
ethically justifiable to limit access to treatments
are expensive and offer minimal benefit.(46) Decisions
about appropriateness involve moral judgments abo
right or good care.(47)
The lack of knowledge of ethics and laws is
to exert a cautionary influence and create exag
concernsaboutethicaland legalliability.In 1996,
physiciansworkingin CaliforniaofferedCPR to all
patients,regardlessof acquiredbenefitsand despite
a hospitalpolicy that allowedthem to not offer
cardiopulmonary resuscitation to everyone. Most
69 intensivists interviewed believed that CPR should
offered to all patients. However, ethicists have a
that CPR should not to be given to patients wh
unlikely to benefit.(43) Physicians experience considerable
uncertainty about what is and is not ethically and le
permissible.(43-47)A valid legal reason to withhold CPR an
ACLS measures is a clearly written advanced directi
states the wishes of the patient or the determin
the primary physician that resuscitation is neither d
nor appropriate. Unfortunately, this is not a stan
of practice in Europe, especially in Southern Eur
countries.
CONCLUSION
Decisions regarding resuscitation and the dura
resuscitativeeffortsare commonlyencounteredaspects
of emergency medicine and often entail several
ethical issues. Positive and negative consequenc
be carefullyconsideredwhenmakingsuchdecisions.
More research is needed on the effects and ben
cardiopulmonaryresuscitation.Cost containmentis
needed, and the appropriate use of medical resourc
goal of emergency medicine. Particular attention sh
paid to the well-being of the survivors.

268 Rubulotta F, Rubulotta G
Rev Bras Ter Intensiva. 2013;25(4):265-269
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