Chapter 27: Ethical Issues of Resuscitation

GENERAL PRINCIPLES OF MEDICAL ETHICS

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.

CARDIAC RESUSCITATION AND OUTCOMES

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).

RISKS AND BENEFITS OF RESUSCITATIVE EFFORTS

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, ...