Cardiopulmonary resuscitation and ethics

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Added on 2023-06-15

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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.

Cardiopulmonary resuscitation and ethics

Added on 2023-06-15

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Rev Bras Ter Intensiva. 2013;25(4):265-269Cardiopulmonary resuscitation and ethics
SPECIAL ARTICLE
INTRODUCTION
The earliest documentation of cardiopulmonary resuscitation (CPR)
dates to the Old Testament, which describes how the prophet Elisha
resuscitated an apparently dead child by blowing air into his mouth.(1)
Modern CPR began in 1960 with the landmark study by Kouwenhoven,
Jude, and Knickerbocker, which reported combining closed chest
compression, mouth-to-mouth breathing, and external defibrillation.(1)
Since that time, CPR and advanced cardiac life support (ACLS) techniques
have saved many lives but have also raised several ethical dilemmas.
Consent for CPR procedures is universally presumed. However, there are
times when patients' right to receive CPR contrasts with their caregivers'
impression that such treatment is not medically indicated. Conversely,
some patients receive resuscitation that they would not have wanted.
Decisions regarding resuscitation and the duration of resuscitative
efforts often entail several crucial ethical issues. This article will focus
on the ethical dilemmas related to the need to make critical decisions in
emergency or acute settings.
Risks and benefits of resuscitative efforts
Since 1900, cardiovascular disease has been the leading cause of
death.(2) Cardiopulmonary resuscitation is a labor-intensive, high-cost endeavor,
undertaken over an estimated 800,000 times annually in the United States.(3)
Although reports on the survival from in-hospital and out-of-hospital cardiac
arrest vary widely,(4-6) several factors have been identified to be associated with
outcome. The most important factor determining survival is the time elapsed
since arrest (down time).(3) Recent studies estimate that the mortality rate
increases 3% for each minute without CPR and 4% for each minute without
defibrillation.(7,8) This public health problem spawned the development
of out-of-hospital cardiac care in the 1960s and its continued growth to
the present.(9,10) Risk-adjusted survival after in-hospital cardiac arrest has
significantly improved over the past decade.(7) Several epidemiological studies
have identified factors associated with lower rates of survival, including delays
in defibrillation, off-hours or unwitnessed arrests. Furthermore, substantial
variation in survival outcomes exists across hospitals, suggesting that some
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: frubulotta@hotmail.com
Ressuscitação cardiopulmonar e ética
DOI: 10.5935/0103-507X.20130046

Cardiopulmonary resuscitation and ethics_1

266Rubulotta F, Rubulotta G
Rev Bras Ter Intensiva. 2013;25(4):265-269
Early reports from emergency cardiac care systems
documented that the most common initial arrhythmias
encountered in cases of out-of-hospital cardiac arrest were
ventricular fibrillation (VF) or ventricular tachycardia
(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
fibrillation and 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
clinical settings with a low likelihood of successful
resuscitation (i.e., apneic, pulseless >10 minutes
before EMS arrival, no response to ACLS, asystole
or pulseless electrical activity, absence of 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
Cardiopulmonary resuscitation was developed for
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 health
care budgets is spent on CPR and ACLS, particularly
when the results are viewed in light of the aging of our
population and the high percentage of deaths that occur
in intensive care units. Additionally, several authors
have shown that physicians are unable to predict patient
preferences regarding treatment decisions.(27-29) Because
of the inherent difficulties in knowing the treatment
preferences of an individual patient, resuscitative measures
are undertaken for most patients with cardiac arrest,
unless a documented advance directive exists.(28,29) The
concern that CPR should be given more appropriately
to a selected number of patients who would certainly
benefit from it is a key problem in daily emergency
physician practice. There is a widespread belief that
people with reduced quality of life due to chronic diseases
do not want aggressive, life-sustaining treatments, even
in an emergency scenario.(30-33) By definition, the act of
restoring life is a decision that must be made rapidly by
emergency physicians, and unfortunately it is often based
on suboptimal amounts of available information. In some
countries, competent patients have the right to refuse
CPR in-hospital by using a code and outside the hospital
by wearing specific signs, such as a bracelet.
The capacity to provide life-sustaining treatments,
including CPR, has been accompanied by several
issues about how to make decisions regarding their use
and how to handle their cost.(31-34) The behaviors of
emergency physicians are frequently linked to their fear
of litigation or criticism.(34,35) Several authors assume that
physicians have no obligation to provide, and patients
and families have no right to demand, medical treatments
that are of no demonstrable benefit.(36-38) Respect for
patient autonomy does not require that the physician
must initiate procedures that are medically futile or
not appropriate.(37) Until formal policies are developed
by governing organizations in emergency medicine,
emergency physicians must make the choices they judge
to be most appropriate in the specific critical situation
encountered. Moreover, there is worldwide agreement
over the need to perform more selected and appropriate
resuscitations because of the substantial resources that
are invested during and after CPR.(38,39) The European
Commission has ruled that the patient has the right of
self-determination, including the right to refuse unwanted
therapies. However, it does not specify the need to use
advance directives or a proxy to achieve this goal in
non-competent patients. If physicians in Europe are going

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