Resuscitation

                ETHICAL
                DILEMMAS             K.S. Chew
                    School of Medica...
Emergency Procedures Without Written Consent - The
Doctrine of Necessity


Three Groups of Incompetent
                   ...
Principle #1 AutonomyDoes my action
                                                                 Four Basic
 impinge o...
Ethical Issues In
Cardiopulmonary
   Resuscitation
Biomedical Ethics
 in Resuscitation

                           A whole of gamut of
                          complicated ...
Case Scenario 1


You are rushing to catch your flight in another 30 minutes. As
you are heading to your departing gate, y...
Case Scenario 2

A building has collapsed. You are called in to
help out with the disaster. At the disaster site,
a man ha...
Case Scenario 3
A 80-year old man with history of frequent exacerbation of
COPD is diagnosed with acute pulmonary edema,
c...
Case Scenario 4


A 50-year old, previously healthy and active sportsman, is
admitted for sudden onset of chest pain. He c...
Case Scenario 5

A 40-year old, previously healthy, army is involved in a
serious car accident. On arrival to the emergenc...
Cardiopulmonary
 Resuscitation: Ethical Issues
                               Resuscitation Decisions
Resuscitation Decisi...
GENERAL PRINCIPLES GOVERNING
   RESUSCITATION DECISION


 Is governed by two important principles:

 A. The Principle of P...
GENERAL PRINCIPLES GOVERNING
   RESUSCITATION DECISION


 B. The Principle of Futility

 Definition: If the purpose of a m...
“Physicians are NOT obliged to
   provide care when there is
scientific and social consensus
      that the treatment is
 ...
“Whereas patients have a
right to refuse treatment, they
do not have automatic right to
   demand treatment; they
        ...
“It is wise for a doctor to
   seek a second opinion in
        making a momentous
         decision to with-hold
resuscit...
Doctor’s Personal Factors
Influencing Resuscitation Decision



“Most doctors will err on the side of
intervention in chil...
DO NOT ATTEMPT RESUSCITATION
        (DNAR) ORDER


 DNAR order means just that - in the event of
 cardiopulmonary arrest,...
Criteria For NOT to Start
                 CPR for In-Hospital Setting
    # 3 No
  physiologic
   al benefit
   expected
...
“If something is worth
                  doing, it is worth doing it
                                       well”
       “...
Criteria To STOP CPR
                   For In-Hospital Setting
         #1
      Patients
     with DNAR
        Order


...
Criteria For NOT Starting CPR
  In Out-of-Hospital Setting

  Paramedics are trained to start CPR at the very
  first inst...
Criteria To STOP CPR In Out-
      of-Hospital Setting

  1. Restoration of effective, spontaneous
  circulation and venti...
Withdrawing Life Support

1. Not usually done in A&E department
2. Often in intensive care units for clinical
brain death ...
If you or your team have made
 the decision to withdraw a life
 support system in emergency
  department, you should also
...
SURROGATE DECISION MAKERS
   (IN ORDER OF PRIORITY)


1. Spouse
2. Adult child
3. Parent
4. Any relative
5. Person nominat...
Conclusion

Decision making in cardiopulmonary resuscitation
can be very complex due to the diversity of the
cases
It may ...
Ethics in Resuscitation
Ethics in Resuscitation
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Ethics in Resuscitation

  1. 1. Resuscitation ETHICAL DILEMMAS K.S. Chew School of Medical Sciences Universiti Sains Malaysia
  2. 2. Emergency Procedures Without Written Consent - The Doctrine of Necessity Three Groups of Incompetent Five Things To Be Explained To the Patients to Give Informed Patient in an Informed Consent Consent Four Basic Five Essential Biomedical Elements of a Valid Bolam Test Informed Consent Principles Bolitho Test Proving Medical General Concepts of Negligence Biomedical Ethics
  3. 3. Principle #1 AutonomyDoes my action Four Basic impinge on an individual's personal 1 autonomy?Do all relevant parties consent to Principles my action?Do I acknowledge and respect that others may choose differently? Of Ethics Principle #2 BeneficenceWho benefits from 2 my action and in what way? 4 Principle #3: Non-maleficene Principle #4: Justice Which parties may be harmed by my action? What steps can I take to minimise this harm? Is my Have I communicated risks involved in a truthful proposed and open manner? 3 action equitable? How can I Beauchamp TL, Childress JF. Principles of biomedical Ethics. make it more 4th ed. Oxford: Oxford University Press, 1994. equitable?
  4. 4. Ethical Issues In Cardiopulmonary Resuscitation
  5. 5. Biomedical Ethics in Resuscitation A whole of gamut of complicated dilemma Successful v Unsuccessful (70 - 95%) Prolonging Suffering Persistent Vegetative State Patient’s right to die in dignity Decisions in matter of seconds!
  6. 6. Case Scenario 1 You are rushing to catch your flight in another 30 minutes. As you are heading to your departing gate, you witness a crowd of people, and one of them actually recognizes you as a doctor and says that a man has just collapsed and they need your help in the resuscitation. However, two things are going on in your mind - you have not been performing CPR for a long time since your ACLS course 5 years ago and you have a plane to catch. What would you do? If you do not help out in the resuscitation process, would you be liable for medical negligence in the future?
  7. 7. Case Scenario 2 A building has collapsed. You are called in to help out with the disaster. At the disaster site, a man has stopped breathing at a distance not far from where you are standing. The relatives over there are shouting for you to come over and help. However, you realize that some rocks are still falling from where the man is trapped. Would be liable to be sued if you do not?
  8. 8. Case Scenario 3 A 80-year old man with history of frequent exacerbation of COPD is diagnosed with acute pulmonary edema, currently complicated with respiratory failure Type 2. All other treatment modalities fail to prevent his deterioration. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort. 1. Would you have intubated him? 2. If the relatives insist on you to actively resuscitate him but you do not, would you be liable to be sued?
  9. 9. Case Scenario 4 A 50-year old, previously healthy and active sportsman, is admitted for sudden onset of chest pain. He collapses while being treated in the emergency department. You start CPR and defibrillation promptly. Realizing what you are doing, the wife intervenes and insists that you stop the resuscitation process. She says that he has verbally stated his wish that he does not want to be actively resuscitated and a prolonged suffering the moment he dies. What would you do?
  10. 10. Case Scenario 5 A 40-year old, previously healthy, army is involved in a serious car accident. On arrival to the emergency department, his GCS is 7/15. He is mechanically ventilated. His vital signs are good. A CT scan brain is done - showing a massive intraparenchymal bleeding over the right hemisphere with midline shift and generalized cerebral edema. Clinical re-assessment 30 minutes later shows that the patient is manifesting signs of increased ICP and transtentorial herniation. In view that his prognosis may not be good and that the ward resources are limited, the managing team decides to withdraw his support system in A&E. What do you think?
  11. 11. Cardiopulmonary Resuscitation: Ethical Issues Resuscitation Decisions Resuscitation Decisions for out-of- hospital for in-hospital settings settings 1. to initiate resuscitation 1. to initiate 2. NOT to initiate resuscitation resuscitation 2. NOT to initiate 3. to terminate resuscitation resuscitation 3. to terminate 4. to withdraw life resuscitation support system (rarely)
  12. 12. GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION Is governed by two important principles: A. The Principle of Patient Autonomy Advanced directives (DNAR) If patient preferences uncertain, emergency conditions should be treated until those preferences are known
  13. 13. GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION B. The Principle of Futility Definition: If the purpose of a medical treatment cannot be achieved, the treatment is considered futile. The key determinants - duration remaining in cardiac arrest, length and quality of life expected
  14. 14. “Physicians are NOT obliged to provide care when there is scientific and social consensus that the treatment is ineffective.” - American Heart Association
  15. 15. “Whereas patients have a right to refuse treatment, they do not have automatic right to demand treatment; they cannot insist that resuscitation must be attempted in any circumstances” - European Resuscitation Council
  16. 16. “It is wise for a doctor to seek a second opinion in making a momentous decision to with-hold resuscitation for fear of the doctor’s own personal values, or the questions of available resources might influence his/her decision.” - European Resuscitation Council
  17. 17. Doctor’s Personal Factors Influencing Resuscitation Decision “Most doctors will err on the side of intervention in children for emotional reasons, even though the overall prognosis is often worse in children than in adults.” - European Resuscitation Council
  18. 18. DO NOT ATTEMPT RESUSCITATION (DNAR) ORDER DNAR order means just that - in the event of cardiopulmonary arrest, CPR should not be attempted at all. Other treatment should be continued; e.g. pain relief, sedation on required basis in terminal illnesses.
  19. 19. Criteria For NOT to Start CPR for In-Hospital Setting # 3 No physiologic al benefit expected (futility) #2 Patient with signs of irreversible death (rigor #1 Patient mortis, decapitation, decomposition, dependent with DNAR order lividity)
  20. 20. “If something is worth doing, it is worth doing it well” “If the resuscitation process is worth doing, it is worth doing it well” Treat the resuscitation process seriously. Respect the solemn moment for the patient and relatives Do not laugh or joke when resuscitation is going on “not merely about drawing the curtain.....”
  21. 21. Criteria To STOP CPR For In-Hospital Setting #1 Patients with DNAR Order In general, resuscitation should be continued as long as VF persists. And resuscitation should be terminated when ongoing asystole for #2 On more than 20 minutes in the absence of a reversible cause, and with all Grounds of measures of BLS and ACLS in place Extra panel futility*
  22. 22. Criteria For NOT Starting CPR In Out-of-Hospital Setting Paramedics are trained to start CPR at the very first instance upon a victim in cardiac arrest with the exception of: 1. A person with obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, decomposition) 2. A person with clear DNAR order 3. Attempts to perform CPR would place the rescuer at risk of danger/physical injuries
  23. 23. Criteria To STOP CPR In Out- of-Hospital Setting 1. Restoration of effective, spontaneous circulation and ventilation 2. Care is transferred to a more senior-level emergency medical professional 3. The rescuer is unable to continue because of exhaustion 4. Reliable criteria indicating irreversible death 5. A valid DNAR order is presented
  24. 24. Withdrawing Life Support 1. Not usually done in A&E department 2. Often in intensive care units for clinical brain death patients 3. Patient in deep coma for >24 hrs, after ruling out potentially reversible causes 4. Done by two specialists (usually anesthesiologists, neurologists, neurosurgeons) on two assessments (6hrs apart) 5. Detailed criteria can be found in MMC Brain death Guidelines
  25. 25. If you or your team have made the decision to withdraw a life support system in emergency department, you should also be responsible to document and sign your decisions and to answer any doubts from the family. Do not push the job to another team.
  26. 26. SURROGATE DECISION MAKERS (IN ORDER OF PRIORITY) 1. Spouse 2. Adult child 3. Parent 4. Any relative 5. Person nominated as the person caring for the incapacitated patient 6. Specialized care professionals Must act in best interest of patient
  27. 27. Conclusion Decision making in cardiopulmonary resuscitation can be very complex due to the diversity of the cases It may have to be made in matters of seconds! If in doubt, always err on for the patient’s benefit Always treat the patient with dignity and respect If you do not want this to be done to your own family member, you do not want it to be done on your patient
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