ALS Ethical Issues

1. ALS Subcommittee 2010
ETHICAL ISSUES
in
Cardiopulmonary Resuscitation

2. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical issues
• CPR is a therapy
• KEY principles of ethics include:
- autonomy
- beneficence
- non maleficence
- justice
- dignity and honesty
• Withholding and withdrawal therapy

3. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles –
Patient Autonomy
• Recognized ethically and legally
• Right of patient to accept or refuse treatment
• Applied to those capable of making decision
• Decision based on understanding of disease,
patient condition, nature of treatment,
alternative therapy, risks and benefits

4. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles –
Beneficence
Benefit provided to patient while balancing risks
and benefits
Are we providing benefit to patient or are we
just delaying death and prolonging suffering?

5. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles –
Non-maleficence
Do no harm, or further harm
- CPR should not be initiated in futile cases

6. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles –
Justice
Duty to distribute limited health resources
equally within a society, and the decision of who
gets what treatment
If resuscitation is provided, it should be available
to all who will benefit from it within the available
resources

7. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles –
Dignity and Honesty
Patient’s right to be treated with dignity
Honesty in revealing information

8. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles
Advanced directives
• ‘Living will’, wishes or expression for end of life
care
• Based on conversational or written directives
• Periodic consideration needed as patient’s desire
and condition may change

9. ALS Subcommittee 2010ALS Subcommittee 2010
Ethical principles
Surrogate decision maker
• ‘Nominated’ decision maker when patient is
incapable of making one
• Spouse, adult child, parent, close relative
• ? friend

10. ALS Subcommittee 2010ALS Subcommittee 2010
MEDICAL FUTILITY
• When an intervention is highly unlikely to
benefit the patient
or
• When an intervention does not achieve
patient’s intended quality goals or physician’s
physiological goals
• Key determinants
- Length
- Quality of life

11. ALS Subcommittee 2010ALS Subcommittee 2010
PRINCIPLE OF FUTILITY
• Withholding resuscitation and discontinuation
of life-sustaining treatment during or after
resuscitation are ethically equivalent
• If the prognosis is uncertain, a trial of
treatment should be considered while further
information is gathered to help determine the
likelihood of survival and expected clinical
course

12. ALS Subcommittee 2010ALS Subcommittee 2010
When Not to Start CPR
• Advanced directives by patient or surrogate
decision maker
• Valid DNAR by attending physician
• Obvious signs of death e.g. Rigor mortis
• Algo mortis - steady lowering temperature
• Injuries incompatible with life

13. ALS Subcommittee 2010ALS Subcommittee 2010
When NOT to Stop
• Drug intoxication
• Hypothermia
• Ventricular fibrillation

14. ALS Subcommittee 2010ALS Subcommittee 2010
When to Stop CPR
• Return of spontaneous circulation (ROSC)
• Too exhausted to continue, or dangerous
• Obvious signs of death are apparent
• Decision to cease resuscitation effort are
often made on a case to case basis

15. ALS Subcommittee 2010ALS Subcommittee 2010
THANK YOU
NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
 Dr Tan Cheng Cheng
 Dr Luah Lean Wah
 Dr Ismail Tan
 Dr Wan Nasrudin
 Dr Chong Yoon Sin
 Dr Priya Gill
 Dr Ridzuan bin Dato’ Mohd Isa
 Dr Thohiroh Abdul Razak
 Dr Adi Osman