Chapter 27: Ethical Issues of Resuscitation

The study of ethics is an effort to understand and examine the moral life.¹ The Hippocratic Oath is revered as one of the oldest codes of medical ethics. More recently, the American Medical Association Code of Ethics (earliest version in 1847)^2,3 and the American College of Emergency Physicians Code of Ethics (1997 and 2008)^4,5 have provided guidance to emergency physicians in the application of ethical principles to clinical practice. Most ethical codes share common tenets such as beneficence (doing good); nonmaleficence (primum non nocere, or "do no harm"); respect for patient autonomy, confidentiality, and honesty; distributive justice; and respect for the law. Ethical dilemmas arise when there is a potential conflict between two principles or values. Physicians resolve these dilemmas by gathering additional information; conducting meetings with other healthcare professionals, patients, and families; and applying an informed judgment in individual situations. In some circumstances, physicians may seek the involvement of the institutional ethics committee or the judicial system.

There are approximately 300,000 sudden deaths in the United States annually.⁶ The outcome of resuscitative efforts for victims of cardiac arrest is uniformly poor but varies depending on a variety of factors, including time elapsed since arrest (down time), presenting rhythm, bystander CPR, and response to prehospital advanced cardiac life support protocols.

Physicians should consider the patient's potential outcome including quality of life when initiating a resuscitation effort. Patients who receive early advanced cardiac life support have improved outcomes.^7,8 Patients presenting with ventricular fibrillation or ventricular tachycardia have higher survival rates than patients with asystole or pulseless electrical activity.^9,10 Many studies of cardiac arrest victims have estimated survival to hospital discharge to be between 0% and 13%.^6,8–19 Advanced resuscitative techniques, such as therapeutic hypothermia and advanced cardiac life support protocols, have improved the survival rate for patients with cardiac arrest.⁹

Based on such data, several authors have proposed criteria for withholding resuscitative efforts for patients with a low likelihood of successful resuscitation. Several validated decision rules incorporate related factors predictive of dismal outcome^20–29 (Table 27-1).

When considering offering or withholding resuscitative efforts, the physician must take into account the risks and benefits of resuscitation. The primary goals of resuscitative efforts are to restore the patient's circulation and, ideally, normal function. Another less tangible benefit may be providing additional time for survivors to accept the distressing news of imminent death of their loved one.

Resuscitative measures are frequently undertaken in clinical situations where physiologic survival with meaningful neurologic function is very unlikely. Patients may be left with significant anoxic brain injury, persistent vegetative state, or dementia with poor quality of life.

Substantial resources are consumed in resuscitative efforts, and clinicians are taken away from other patients (a violation of distributive justice). Another benefit in limiting resuscitative efforts is the freeing of time and resources for family counseling and communication.

The term futility is subject to interpretation.³⁰ Healthcare professionals may determine futile interventions to be those that carry an absolute impossibility of successful outcome, a low likelihood of return to spontaneous circulation, a low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of meaningful quality of life. Futility can be defined as "any effort to achieve a result that is possible, but that reasoning or experience suggests is highly improbable and that cannot be systematically produced."³¹ There is no consensus among physicians about the meaning of the term. It is probably more accurate to use terminology such as nonbeneficial, ineffectual, or low likelihood of success when discussing resuscitation with patients or families.

Many ethicists agree that physicians are not required to provide treatments that they estimate will provide little or no benefit to the patient.^32,33 The American Medical Association Council on Ethical and Judicial Affairs stated that CPR may be withheld, even if requested by the patient, "when efforts to resuscitate a patient are judged by the treating physician to be futile."³⁴ Dilemmas regarding nonbeneficial interventions often arise due to inadequate or ineffective communication between the physician, patient, and family. This is of particular concern in emergency medicine, in which previous relationships with patients and family rarely exist and time is often inadequate to establish effective relationships. Thus, initial efforts should be directed to improve communication, education, and joint decision making.

The American College of Emergency Physicians states that "physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient" (Table 27-2). Emergency physicians' judgments should be unbiased, based on available scientific evidence, mindful of societal and professional standards, and sensitive to differences of opinion regarding the value of medical intervention in various situations.³⁵

Ultimately, the decision regarding CPR and its likelihood of benefit to the patient and decisions to provide, limit, or withhold resuscitative efforts are to be made by the emergency physician in the context of well-accepted research results, patient and family wishes, and professional judgment. Individual bias regarding quality of life or other related issues should be avoided. There are many situations in which dying can be accepted as a natural process, even in an emergency setting.

An advance directive is any proactive document stating the patient's wishes in various situations should the patient be unable to do so. The living will is a document suitable for terminally ill individuals, and the treating physician should accept the provisions. Many advance directives state that no life support should be applied in situations in which meaningful recovery is improbable. Durable power of attorney specifies a surrogate decision maker in the event that the patient no longer has the capacity to make medical decisions. The U.S. Federal Patient Self-Determination Act mandates that the opportunity to sign an advance directive is provided for all patients admitted to a hospital.

Despite widespread advocacy and legal mandates for the increased use of advance directives, only a minority of patients have completed an advance directive, and an even smaller minority arrive in the ED with the necessary documentation.³⁶ Advance directives and code status are especially important in emergency care medical decision making.^32,37,38

Family presence during resuscitation may serve to improve understanding and relieve family member guilt or disappointment and may be a helpful part of the grieving process.^{39, 40, 41, 42, 43, 44, 45} Physicians should be sensitive to the possibility that this option may be difficult for certain family members or staff.⁴⁶ If family members are invited to be present, provide a liaison to assist with communication and education about procedures and other medical issues.⁴²

The practices of teaching and performing procedures on recently deceased patients are controversial. The most important benefit of these practices is the opportunity for hands-on practice for students, house staff, and even experienced physicians.⁴⁷ However, some consider performing procedures without informed consent to be disrespectful, deceptive, or unethical.⁴⁸ Obtaining consent from families or surrogates is recommended before such practice.^49,50

Research on resuscitation techniques and pharmaceuticals has been problematic due to the frequent inability to obtain informed consent and the constraints of the decision-making process. Ordinarily, the informed consent procedure for human subject research is designed to ensure protection and autonomy of the subject. However, this process is time-consuming and requires decisional capacity in the subject. Because of these difficulties, the U.S. Food and Drug Administration issued guidelines under which resuscitation research may be performed, with a waiver of informed consent under certain conditions.⁵¹ When designing such research protocols, relevant factors include the patient's wishes (if known), expected safety of the study protocol, expected benefit of the therapeutic intervention, overall predicted benefit to society by improved knowledge regarding resuscitation, related animal data, feasibility of surrogate consent, local institutional review board opinion, and local general public opinion, if available. Waiver of consent is available through application with the Food and Drug Administration with local institutional review board approval.

Counseling should be available for families and friends of those patients who have died in the ED. See chapter 300, "Death Notification and Advance Directives": Delivering Effective Death Notifications in the Emergency Department, for detailed discussion on communication strategies. Table 27-3 provides a summary of practical advice for resuscitation scenarios.