Resuscitation

 

83 (2012) 27–

 

31

Contents

 

lists

 

available

 

at

 

ScienceDirect

Resuscitation

j o

 

u

 

r n

 

a l

 

h o m

 

e p a g e

 

:

 

w w w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n

Commentary

 

and

 

concepts

Guidance

 

for

 

ambulance

 

personnel

 

on

 

decisions

 

and

 

situations

 

related

 

to

out-of-hospital

 

CPR

夽

Anders

 

Ågård

a

,

∗

,

 

Johan

 

Herlitz

b

,

 

Maaret

 

Castrén

c

,

 

Lars

 

Jonsson

d

,

 

Lars

 

Sandman

e

a

Sahlgrenska

 

Academy,

 

Institute

 

of

 

Medicine,

 

Gothenburg,

 

Sweden

b

The

 

Center

 

for

 

Prehospital

 

Research

 

in

 

Western

 

Sweden,

 

University

 

College

 

of

 

Borås

 

and

 

Sahlgrenska

 

University

 

Hospital,

 

Gothenburg,

 

Sweden

c

Department

 

of

 

Clinical

 

Science

 

and

 

Education,

 

Karolinska

 

Institutet,

 

Södersjukhuset,

 

Stockholm,

 

Sweden

d

Stockholm

 

Prehospital

 

Centre,

 

Södersjukhuset,

 

Stockholm,

 

Sweden

e

School

 

of

 

Health

 

Science,

 

University

 

of

 

Borås,

 

Sweden

a

 

r

 

t

 

i

 

c

 

l

 

e

 

i

 

n

 

f

 

o

Article

 

history:

Received

 

15

 

March

 

2011

Received

 

in

 

revised

 

form

 

15

 

July

 

2011

Accepted

 

20

 

July

 

2011

Keywords:
Cardiopulmonary

 

resuscitation

Prehospital

 

emergency

 

care

Ethics
Practice

 

guideline

Ambulance

a

 

b

 

s

 

t

 

r

 

a

 

c

 

t

Ethical

 

guidelines

 

on

 

out-of-hospital

 

cardio-pulmonary

 

resuscitation

 

(CPR)

 

are

 

designed

 

to

 

provide

 

sub-

stantial

 

guidance

 

for

 

the

 

people

 

who

 

have

 

to

 

make

 

decisions

 

and

 

deal

 

with

 

situations

 

in

 

the

 

real

 

world.

The

 

crucial

 

question

 

is

 

whether

 

it

 

is

 

possible

 

to

 

formulate

 

practical

 

guidelines

 

that

 

will

 

make

 

things

 

some-

what

 

easier

 

for

 

ambulance

 

personnel.

 

The

 

aims

 

of

 

this

 

article

 

are

 

to

 

address

 

the

 

ethical

 

aspects

 

related

 

to

out-of-hospital

 

CPR,

 

primarily

 

to

 

decisions

 

on

 

not

 

starting

 

or

 

terminating

 

resuscitation

 

attempts,

 

using

the

 

views

 

and

 

experience

 

of

 

ambulance

 

personnel

 

as

 

a

 

starting

 

point,

 

and

 

to

 

summarise

 

the

 

key

 

points

in

 

a

 

practice

 

guideline

 

on

 

the

 

subject.

© 2011 Elsevier Ireland Ltd. All rights reserved.

1.

 

Introduction

The

 

rationale

 

for

 

guidelines

 

including

 

the

 

ethics

 

of

 

resuscitation

is

 

to

 

enable

 

professionals

 

to

 

make

 

more

 

appropriate

 

decisions

 

and

to

 

act

 

more

 

effectively

 

compared

 

with

 

what

 

might

 

happen

 

if

 

their

decisions

 

and

 

actions

 

were

 

only

 

based

 

on

 

individual

 

judgements

and

 

their

 

own

 

values.

1–3

The

 

challenge

 

is

 

to

 

provide

 

substantial

guidance

 

on

 

questions

 

or

 

problems

 

that

 

are

 

experienced

 

in

 

the

 

real

world.

4,5

Ambulance

 

personnel

 

are

 

confronted

 

by

 

a

 

number

 

of

 

ethical

considerations

 

when

 

they

 

are

 

on

 

their

 

way

 

to

 

treat

 

a

 

person

 

who

has

 

suffered

 

an

 

out-of-hospital

 

cardiac

 

arrest

 

(OHCA)

 

with

 

car-

diopulmonary

 

resuscitation

 

(CPR).

4–8

The

 

most

 

crucial

 

question

 

is

whether,

 

and

 

in

 

which

 

particular

 

circumstances,

 

they

 

can

 

be

 

given

a

 

mandate

 

to

 

decide

 

to

 

terminate

 

a

 

resuscitation

 

attempt

 

at

 

the

scene.

The

 

aims

 

of

 

this

 

article

 

are

 

to

 

address

 

and

 

to

 

clarify

 

the

 

ethi-

cal

 

aspects

 

related

 

to

 

out-of-hospital

 

CPR,

 

based

 

on

 

our

 

knowledge

夽 A

 

Spanish

 

translated

 

version

 

of

 

the

 

abstract

 

of

 

this

 

article

 

appears

 

as

 

Appendix

in

 

the

 

final

 

online

 

version

 

at

 

doi:10.1016/j.resuscitation.2011.07.028

.

∗ Corresponding

 

author

 

at:

 

Medicinmottagningen,

 

Angereds

 

Närsjukhus,

 

Box

 

22,

SE-424

 

65

 

Göteborg,

 

Sweden.

 

Tel.:

 

+46

 

31

 

3326700;

 

fax:

 

+46

 

31

 

3320369;

 

mobile

+46

 

0

 

761

 

360364.

E-mail

 

address:

 

anders.s.agard@vgregion.se

 

(A.

 

Ågård).

of

 

the

 

views

 

and

 

experience

 

of

 

ambulance

 

personnel,

 

and

 

to

summarise

 

the

 

key

 

points

 

in

 

a

 

practice

 

guideline

 

on

 

the

 

sub-

ject.

2.

 

The

 

objective

 

of

 

CPR

From

 

the

 

ambulance

 

personnel’s

 

point

 

of

 

view,

 

a

 

reasonable

 

way

to

 

measure

 

the

 

effectiveness

 

of

 

a

 

resuscitation

 

attempt

 

is

 

whether

patients

 

affected

 

by

 

an

 

OHCA

 

have

 

spontaneous

 

circulation

 

when

they

 

are

 

delivered

 

to

 

the

 

emergency

 

room.

4

However,

 

this

 

way

 

of

defining

 

what

 

constitutes

 

successful

 

CPR

 

hardly

 

applies

 

from

 

the

patient’s

 

viewpoint.

We

 

argue

 

that

 

the

 

objective

 

of

 

CPR

 

is

 

to

 

restore

 

life

 

with

 

quality

acceptable

 

to

 

the

 

patient

 

and

 

in

 

accordance

 

with

 

his

 

or

 

her

 

will.

To

 

properly

 

evaluate

 

the

 

effectiveness

 

of

 

their

 

attempts,

 

personnel

involved

 

in

 

out-of-hospital

 

CPR

 

must

 

therefore

 

be

 

informed

 

about

the

 

outcome

 

of

 

the

 

patients

 

in

 

a

 

systematic

 

quality

 

improvement

system.

 

In

 

some

 

ambulance

 

systems,

 

they

 

are

 

only

 

aware

 

of

 

and

 

are

only

 

evaluated

 

on

 

the

 

basis

 

of

 

prehospital

 

results.

3.

 

Choices

 

to

 

be

 

made

When

 

confronted

 

by

 

a

 

person

 

with

 

cardiac

 

arrest,

 

the

 

emer-

gency

 

personnel

 

can

 

initiate

 

and

 

then

 

continue

 

CPR,

 

or

 

initiate

 

and

subsequently

 

stop

 

CPR

 

or

 

withhold

 

CPR

 

in

 

the

 

first

 

place.

 

If

 

CPR

 

is

0300-9572/$

 

–

 

see

 

front

 

matter ©

 

 2011 Elsevier Ireland Ltd. All rights reserved.

doi:

10.1016/j.resuscitation.2011.07.028

28

A.

 

Ågård

 

et

 

al.

 

/

 

Resuscitation

 

83 (2012) 27–

 

31

Algorithm for the treatment of an out-of-hospital cardiac arrest

Obvious evidence of

irreversible death

do-not-attempt-resuscitation

 (DNAR)   

mortis, deco

DNAR

Stop 

resuscitation 

attempt

No

Start CPR

Connect defibrillator

ECG analysis

Defibrillate?

No

Yes

Yes

No/Unknown

Yes

CPR according 

to guidelines

Yes

Cardiac 

arrest

Continued asystole during 
> 20 min

 

CPR

If suspected:
Drowning
Hypothermia
Intoxication  
Obvious

 

pregnancy

Continued effective CPR
Transport to hospital

–
–
–
–

Asystole
Not witnessed
No bystander CPR
Alarm –

 

arrival

 

>15 min

(the decision takes account of the 

patient’s biological age)

Fig.

 

1.

 

Algorithm

 

for

 

the

 

treatment

 

of

 

an

 

out-of-hospital

 

cardiac

 

arrest.

initiated,

 

the

 

patient

 

has

 

a

 

chance

 

to

 

be

 

saved

 

for

 

a

 

life

 

of

 

acceptable

quality

 

or

 

a

 

life

 

with

 

less

 

than

 

acceptable

 

quality.

 

If

 

CPR

 

is

 

withheld,

the

 

patient

 

will

 

definitely

 

die.

There

 

are

 

strong

 

reasons

 

for

 

ambulance

 

personnel

 

to

 

initiate

 

CPR

routinely

 

on

 

persons

 

who

 

have

 

suffered

 

an

 

OCHA.

 

Firstly,

 

the

 

infor-

mation

 

about

 

the

 

patient’s

 

medical

 

condition

 

before

 

the

 

cardiac

arrest

 

is

 

often

 

insufficient.

 

Second,

 

the

 

patient’s

 

preference

 

regard-

ing

 

CPR

 

is

 

generally

 

unknown.

 

Third,

 

it

 

is

 

difficult

 

to

 

make

 

correct

prognoses

 

about

 

the

 

chances

 

of

 

survival

 

and

 

quality

 

of

 

life

 

following

resuscitation

 

attempts.

However,

 

there

 

are

 

reasonable

 

exceptions

 

to

 

the

 

general

 

rule

to

 

initiate

 

CPR,

 

such

 

as

 

cases

 

of

 

obvious

 

mortal

 

injury

 

or

 

death.

Moreover,

 

taking

 

the

 

available

 

knowledge

 

relating

 

to

 

factors

 

that

influence

 

the

 

outcome,

 

clinical

 

prediction

 

rules

 

and

 

algorithms

 

for

terminating

 

resuscitative

 

efforts

 

in

 

the

 

field

 

have

 

been

 

proposed.

9

We

 

suggest

 

an

 

alternative

 

algorithm

 

for

 

the

 

treatment

 

of

 

an

 

OHCA

that

 

includes

 

criteria

 

for

 

stopping

 

resuscitation

 

attempts

 

(

Fig.

 

1

).

By

 

looking

 

retrospectively

 

at

 

the

 

records

 

from

 

the

 

Swedish

 

Cardiac

Arrest

 

Registry,

 

we

 

calculate

 

that

 

CPR

 

would

 

be

 

stopped

 

after

 

a

short

 

period

 

in

 

approximately

 

2%

 

of

 

the

 

cases

 

if

 

the

 

algorithm

 

were

implemented

 

in

 

our

 

services.

 

The

 

registry

 

does

 

not

 

include

 

patients

on

 

whom

 

CPR

 

was

 

not

 

initiated

 

because

 

of

 

obvious

 

death

 

signs

 

or

ethical

 

reasons.

4.

 

Attempting

 

to

 

act

 

in

 

the

 

patient’s

 

best

 

interest

CPR

 

is

 

sometimes

 

considered

 

futile

 

or

 

unethical,

 

even

 

in

 

cases

where

 

there

 

is

 

a

 

small

 

chance

 

of

 

saving

 

lives.

 

Among

 

patients

affected

 

by

 

severe

 

diseases,

 

which

 

substantially

 

influence

 

their

quality

 

of

 

life

 

and

 

expected

 

remaining

 

lifetime,

 

doubts

 

can

 

be

 

raised

about

 

whether

 

CPR

 

is

 

in

 

the

 

patient’s

 

best

 

interest.

 

Studies

 

have

actually

 

shown

 

that

 

the

 

ambulance

 

personnel

 

sometimes

 

drive

more

 

slowly

 

than

 

normal

 

to

 

the

 

scene

 

when

 

the

 

emergency

 

call

relates

 

to

 

a

 

very

 

old,

 

very

 

ill

 

patient

 

with

 

a

 

cardiac

 

arrest.

 

They

 

may

occasionally

 

feel

 

that

 

prehospital

 

resources

 

are

 

not

 

used

 

cost

 

effec-

tively.

 

Moreover,

 

they

 

may

 

not

 

try

 

as

 

hard

 

as

 

they

 

normally

 

do

 

to

optimise

 

the

 

CPR

 

procedure

 

in

 

this

 

category

 

of

 

patients.

 

A

 

com-

mon

 

argument

 

for

 

this

 

behaviour

 

is

 

their

 

wish

 

not

 

to

 

take

 

away

a

 

peaceful,

 

dignified

 

death

 

from

 

the

 

patient

 

and

 

family.

4,7,8

How-

ever,

 

references

 

to

 

‘dignity’

 

are

 

problematic.

 

In

 

fact,

 

the

 

concept

 

of

 

a

dignified

 

death

 

can

 

be

 

interpreted

 

in

 

a

 

number

 

of

 

different

 

ways.

10

A.

 

Ågård

 

et

 

al.

 

/

 

Resuscitation

 

83 (2012) 27–

 

31

29

Studies

 

have

 

shown

 

that

 

patients

 

in

 

the

 

late

 

stages

 

of

 

chronic

diseases

 

may

 

want

 

CPR

 

to

 

be

 

given

 

the

 

chance

 

to

 

live

 

a

 

little

longer.

11

Hence,

 

even

 

though

 

the

 

prognosis

 

is

 

statistically

 

poor

 

and

the

 

chronological

 

age

 

is

 

high,

 

patients

 

may

 

benefit

 

from

 

CPR

 

and

regain

 

an

 

acceptable

 

quality

 

of

 

life.

 

As

 

a

 

result,

 

it

 

is

 

generally

 

beyond

the

 

competence

 

of

 

the

 

emergency

 

personnel

 

to

 

assess

 

whether

 

or

not

 

a

 

resuscitation

 

attempt

 

is

 

in

 

the

 

patient’s

 

best

 

interest,

 

or

 

to

determine

 

the

 

kind

 

of

 

death

 

the

 

patient

 

would

 

have

 

preferred.

Being

 

in

 

the

 

presence

 

of

 

a

 

person

 

with

 

cardiac

 

arrest,

 

hav-

ing

 

first-hand

 

information

 

and

 

being

 

able

 

to

 

make

 

an

 

appropriate

examination

 

is

 

a

 

great

 

advantage.

 

We

 

argue,

 

based

 

on

 

our

 

own

 

and

others’

 

experience,

 

that

 

emergency

 

services

 

staff

 

members

 

with

the

 

appropriate

 

training

 

could

 

be

 

given

 

a

 

mandate

 

to

 

decide

 

not

to

 

initiate

 

or

 

to

 

stop

 

a

 

resuscitation

 

attempt

 

under

 

well-defined

conditions.

7

At

 

the

 

same

 

time,

 

the

 

creation

 

of

 

an

 

organisation

 

in

which

 

emergency

 

personnel

 

can

 

easily

 

consult

 

physicians,

 

emer-

gency

 

doctors,

 

cardiologists

 

or

 

anaesthesiologists

 

at

 

the

 

prehospital

stage,

 

to

 

obtain

 

support

 

or

 

advice,

 

can

 

be

 

recommended.

 

An

 

organ-

isation

 

of

 

this

 

kind

 

has,

 

for

 

example,

 

been

 

created

 

in

 

Helsinki

 

and

Oslo.

7

5.

 

Advance

 

directives

In

 

principle,

 

there

 

are

 

two

 

ways

 

to

 

find

 

out

 

what

 

a

 

patient

 

would

have

 

wanted

 

in

 

the

 

event

 

of

 

an

 

OHCA.

 

Firstly,

 

if

 

possible

 

and

 

appro-

priate,

 

people

 

who

 

are

 

close

 

to

 

the

 

patient

 

could

 

be

 

asked

 

tactfully

what

 

they

 

think

 

the

 

patient

 

would

 

have

 

wanted

 

in

 

terms

 

of

 

CPR.

However,

 

this

 

does

 

not

 

mean

 

that

 

decisions

 

relating

 

to

 

out-of-

hospital

 

CPR

 

should

 

be

 

handed

 

over

 

to

 

them.

 

It

 

can

 

actually

 

be

 

a

burden

 

to

 

feel

 

responsible

 

for

 

making

 

a

 

decision

 

relating

 

to

 

life

 

and

death,

 

which

 

can

 

in

 

turn

 

give

 

rise

 

to

 

future

 

guilt

 

and

 

doubts,

 

for

example.

 

When

 

consulting

 

family

 

members,

 

it

 

should

 

be

 

remem-

bered

 

that

 

their

 

will

 

might

 

differ

 

from

 

the

 

will

 

of

 

the

 

patient

 

or

 

that

they

 

could

 

have

 

misinterpreted

 

the

 

patient’s

 

wishes.

 

As

 

a

 

result,

 

it

may

 

be

 

difficult

 

to

 

distinguish

 

between

 

what

 

is

 

in

 

the

 

patient’s

 

best

interest

 

and

 

the

 

family’s

 

best

 

interest.

Second,

 

this

 

is

 

possible

 

by

 

having

 

access

 

to

 

written

 

advance

directives.

 

The

 

whole

 

idea

 

of

 

documents

 

containing

 

advance

 

direc-

tives

 

is

 

to

 

give

 

people

 

a

 

chance

 

to

 

convey

 

their

 

wishes

 

or

 

exercise

their

 

autonomy,

 

in

 

situations

 

in

 

which

 

they

 

have

 

temporarily

 

or

permanently

 

lost

 

the

 

ability

 

to

 

do

 

this.

 

However,

 

there

 

are

 

ques-

tions

 

and

 

problems

 

related

 

to

 

the

 

legal

 

status

 

and

 

validity

 

of

 

these

documents.

 

For

 

instance,

 

even

 

if

 

the

 

advance

 

directives

 

state

 

that

a

 

person

 

does

 

not

 

want

 

CPR,

 

can

 

the

 

emergency

 

team

 

take

 

it

 

for

granted

 

that

 

the

 

document

 

belongs

 

to

 

the

 

person

 

with

 

a

 

cardiac

arrest

 

in

 

front

 

of

 

them,

 

that

 

the

 

patient

 

really

 

wanted

 

to

 

have

 

this

statement

 

written

 

down

 

and

 

that

 

the

 

person

 

has

 

not

 

changed

 

his

or

 

her

 

attitude

 

towards

 

CPR

 

since

 

then?

 

As

 

a

 

result,

 

emergency

personnel

 

should

 

be

 

recommended

 

to

 

deal

 

with

 

advance

 

direc-

tives,

 

such

 

as

 

do-not-resuscitate

 

orders,

 

critically

 

and

 

with

 

sound

judgement.

12

However,

 

these

 

directives

 

should

 

generally

 

be

 

seen

as

 

a

 

valuable

 

help

 

when

 

attempting

 

to

 

make

 

a

 

decision

 

that

 

is

 

in

the

 

patient’s

 

best

 

interest.

6.

 

Withholding

 

or

 

withdrawing

 

CPR

Health

 

professionals

 

often

 

find

 

it

 

psychologically

 

more

 

difficult

to

 

withdraw

 

CPR

 

rather

 

than

 

not

 

starting

 

it

 

in

 

the

 

first

 

place.

13

As

 

a

result,

 

there

 

might

 

be

 

occasions

 

on

 

which

 

members

 

of

 

emergency

teams

 

are

 

unwilling

 

to

 

start

 

CPR

 

to

 

avoid

 

finding

 

themselves

 

in

a

 

situation

 

in

 

which

 

they

 

have

 

to

 

make

 

a

 

decision

 

to

 

terminate

the

 

treatment,

 

especially

 

in

 

the

 

presence

 

of

 

other

 

people.

 

In

 

our

opinion,

 

there

 

is

 

no

 

relevant

 

ethical

 

difference

 

between

 

not

 

initi-

ating

 

and

 

initiating

 

and

 

subsequently

 

withdrawing

 

CPR

 

from

 

the

patient’s

 

perspective,

 

as

 

the

 

consequence

 

is

 

basically

 

the

 

same

 

–

the

 

patient

 

will

 

die.

On

 

the

 

other

 

hand,

 

four

 

‘psychological’

 

reasons

 

for

 

continu-

ing

 

CPR

 

deemed

 

to

 

be

 

unsuccessful

 

or

 

futile

 

have

 

been

 

identified.

Firstly,

 

emergency

 

personnel

 

may

 

be

 

inclined

 

to

 

prolong

 

CPR

 

to

show,

 

or

 

convince,

 

those

 

around

 

them

 

that

 

“everything

 

that

 

can

possibly

 

be

 

done

 

is

 

actually

 

being

 

done.”

 

It

 

has

 

been

 

argued,

 

when

referring

 

to

 

the

 

potential

 

benefit

 

for

 

family

 

members,

 

that

 

this

 

way

of

 

acting

 

is

 

ethically

 

justified.

14

Second,

 

the

 

personnel

 

may

 

want

to

 

confirm

 

that

 

bystanders

 

did

 

the

 

right

 

thing

 

when

 

they

 

initiated

the

 

treatment.

4,7

Third,

 

the

 

personnel

 

want

 

to

 

escape

 

from

 

taking

care

 

of

 

grieving

 

persons,

 

who

 

just

 

have

 

lost

 

a

 

loved

 

one.

 

By

 

contin-

uing

 

CPR,

 

it

 

is

 

possible

 

to

 

transport

 

patients

 

to

 

hospital

 

who

 

have

not

 

yet

 

been

 

pronounced

 

dead.

 

Moreover,

 

some

 

members

 

of

 

the

emergency

 

team

 

may

 

not

 

even

 

feel

 

that

 

it

 

is

 

their

 

job

 

or

 

profes-

sional

 

responsibility

 

to

 

provide

 

emotional

 

support

 

at

 

the

 

scene.

15

Fourthly,

 

family

 

members

 

do

 

not

 

want

 

the

 

resuscitation

 

attempt

 

to

be

 

terminated.

We

 

argue

 

that

 

CPR

 

could

 

be

 

continued

 

for

 

a

 

short

 

period

 

of

 

time,

if

 

there

 

are

 

no

 

clear

 

signs

 

of

 

death,

 

even

 

though

 

it

 

may

 

be

 

deemed

not

 

to

 

be

 

successful,

 

to

 

assure

 

close

 

relatives

 

and

 

bystanders

 

that

everything

 

possible

 

has

 

been

 

done

 

and

 

that

 

their

 

efforts

 

were

 

com-

mendable.

 

Perhaps

 

this

 

strategy

 

could

 

also

 

ease

 

the

 

possible

 

guilt

 

of

not

 

being

 

successful

 

in

 

terms

 

of

 

restoring

 

the

 

function

 

of

 

the

 

heart.

The

 

persons

 

who

 

are

 

concerned

 

should

 

then

 

be

 

informed

 

clearly

and

 

tactfully

 

about

 

the

 

reasons

 

for

 

terminating

 

the

 

resuscitation

attempt.

7.

 

The

 

presence

 

of

 

family

 

members

 

and

 

bystanders

Despite

 

the

 

fact

 

that

 

life

 

or

 

death

 

is

 

at

 

stake

 

and

 

that

 

CPR

 

may

 

be

regarded

 

as

 

a

 

somewhat

 

violent

 

procedure,

 

most

 

people

 

want

 

to

 

be

near

 

their

 

loved

 

ones

 

during

 

resuscitation

 

efforts.

1

However,

 

some

members

 

of

 

the

 

emergency

 

team

 

may

 

feel

 

that

 

the

 

presence

 

of

 

per-

sons

 

close

 

to

 

the

 

patient

 

and

 

bystanders

 

constitutes

 

a

 

problem.

 

For

instance,

 

there

 

are

 

concerns

 

about

 

how

 

they

 

will

 

experience

 

wit-

nessing

 

a

 

resuscitation

 

attempt.

 

Emergency

 

personnel

 

may

 

also

 

feel

that

 

their

 

ability

 

to

 

provide

 

adequate

 

CPR

 

is

 

negatively

 

influenced

by

 

family

 

members

 

who

 

interfere

 

with

 

the

 

treatment.

 

In

 

particular,

a

 

conflict

 

between

 

staff

 

and

 

family

 

members

 

may

 

arise

 

when

 

they

have

 

a

 

different

 

opinion

 

about

 

what

 

is

 

the

 

right

 

thing

 

to

 

do,

 

to

 

keep

resuscitating

 

or

 

to

 

discontinue

 

it.

16

Family

 

members

 

should

 

gener-

ally

 

be

 

offered

 

the

 

chance

 

to

 

be

 

present

 

during

 

CPR.

 

The

 

importance

of

 

informing

 

them

 

about

 

what

 

is

 

happening

 

and

 

caring

 

for

 

them

during

 

the

 

procedure

 

is

 

emphasised.

 

In

 

our

 

opinion,

 

the

 

emergency

team

 

members

 

have

 

a

 

professional

 

responsibility

 

to

 

provide

 

ini-

tial

 

emotional

 

support

 

for

 

the

 

people

 

who

 

have

 

lost

 

someone

 

close

to

 

them

 

before

 

leaving

 

the

 

scene.

 

They

 

should

 

also

 

help

 

them

 

to

contact

 

other

 

persons

 

or

 

organisations

 

that

 

can

 

offer

 

further

 

sup-

port.

 

Family

 

members

 

are

 

generally

 

satisfied

 

with

 

the

 

overall

 

care

provided

 

by

 

the

 

emergency

 

personnel

 

at

 

the

 

scene.

 

In

 

fact,

 

family

members

 

often

 

prefer

 

or

 

accept

 

that

 

CPR

 

is

 

terminated

 

at

 

home

 

so

that

 

their

 

dead

 

loved

 

ones

 

are

 

not

 

transported

 

to

 

hospital.

 

More-

over,

 

terminating

 

CPR

 

and

 

caring

 

for

 

the

 

patient’s

 

survivors

 

at

 

home

appear

 

to

 

have

 

a

 

positive

 

impact

 

on

 

the

 

grieving

 

process.

17–19

8.

 

The

 

formulation

 

of

 

guidelines

 

that

 

deal

 

with

 

ethical

problems

 

related

 

to

 

out-of-hospital

 

CPR

Guidelines

 

cannot

 

possibly

 

cover

 

all

 

the

 

circumstances

 

that

surround

 

a

 

particular

 

situation.

 

As

 

a

 

result,

 

the

 

ambulance

 

per-

sonnel

 

always

 

have

 

to

 

use

 

their

 

knowledge,

 

skills,

 

experience

 

and

values

 

when

 

dealing

 

with

 

decisions

 

and

 

situations

 

related

 

to

 

out-of-

hospital

 

CPR.

 

Moreover,

 

there

 

are

 

two

 

important

 

things

 

that

 

must

be

 

accepted.

 

Firstly,

 

it

 

is

 

an

 

inevitable

 

fact

 

that

 

some

 

resuscitation

30

A.

 

Ågård

 

et

 

al.

 

/

 

Resuscitation

 

83 (2012) 27–

 

31

attempts

 

will

 

be

 

subsequently

 

considered

 

unethical

 

or

 

unjusti-

fied,

 

when

 

further

 

information

 

about

 

the

 

medical

 

condition

 

of

 

a

patient

 

prior

 

to

 

the

 

cardiac

 

arrest

 

is

 

obtained,

 

for

 

example.

 

Second,

guidelines

 

may

 

help

 

to

 

define

 

some

 

situations

 

in

 

which

 

it

 

might

be

 

justified

 

to

 

withhold

 

or

 

withdraw

 

CPR.

 

However,

 

when

 

there

 

is

the

 

slightest

 

doubt

 

about

 

what

 

is

 

the

 

right

 

thing

 

to

 

do,

 

the

 

active

treatment

 

strategy

 

should

 

be

 

chosen.

9.

 

Conclusion

Our

 

views

 

can

 

be

 

summarised

 

thus:

General

 

ethical

 

aspects

• The

 

overall

 

objective

 

of

 

CPR

 

is

 

to

 

restore

 

the

 

patient

 

to

 

a

 

life

 

of

(from

 

the

 

viewpoint

 

of

 

the

 

patient)

 

acceptable

 

quality,

 

if

 

this

 

is

what

 

the

 

patient

 

wants.

• A

 

successful

 

CPR

 

attempt

 

means

 

that

 

the

 

patient

 

can

 

be

 

dis-

charged

 

from

 

hospital

 

with

 

acceptable

 

quality

 

of

 

life

 

and

 

in

accordance

 

with

 

his

 

or

 

her

 

will.

• Decisions

 

to

 

withhold

 

or

 

withdraw

 

CPR

 

must

 

always

 

be

 

based

on

 

sufficient

 

information.

 

As

 

a

 

result,

 

it

 

is

 

important

 

to

 

accept

that

 

some

 

resuscitation

 

attempts

 

will

 

be

 

subsequently

 

regarded

as

 

unethical

 

or

 

unjustified,

 

when

 

further

 

information

 

about

 

the

medical

 

condition

 

of

 

a

 

patient

 

prior

 

to

 

the

 

cardiac

 

arrest

 

is

obtained.

• It

 

is

 

generally

 

beyond

 

the

 

competence

 

of

 

the

 

emergency

 

per-

sonnel

 

to

 

assess

 

whether

 

or

 

not

 

a

 

resuscitation

 

attempt

 

is

 

in

the

 

patient’s

 

best

 

interest,

 

or

 

to

 

determine

 

the

 

kind

 

of

 

death

 

the

patient

 

would

 

have

 

preferred.

 

As

 

a

 

result,

 

the

 

views

 

of

 

the

 

mem-

bers

 

of

 

the

 

emergency

 

team

 

regarding

 

what

 

constitutes

 

a

 

peaceful

and

 

dignified

 

death

 

should

 

be

 

used

 

very

 

cautiously

 

when

 

guiding

the

 

action

 

that

 

should

 

be

 

taken.

• There

 

is

 

no

 

relevant

 

ethical

 

difference

 

between

 

not

 

initiating

 

and

initiating

 

and

 

subsequently

 

withdrawing

 

CPR

 

from

 

the

 

patient’s

perspective,

 

as

 

the

 

consequence

 

is

 

basically

 

the

 

same

 

–

 

the

 

patient

will

 

die.

The

 

decision-making

 

process

• The

 

general

 

rule

 

is

 

to

 

initiate

 

CPR

 

when

 

confronted

 

by

 

a

 

person

with

 

an

 

out-of-hospital

 

cardiac

 

arrest.

 

As

 

a

 

result,

 

when

 

there

 

is

the

 

slightest

 

doubt

 

about

 

what

 

is

 

the

 

right

 

thing

 

to

 

do,

 

the

 

active

treatment

 

strategy

 

should

 

always

 

be

 

chosen.

• An

 

experienced

 

ambulance

 

or

 

emergency

 

services

 

staff

 

member

with

 

the

 

appropriate

 

training

 

could

 

be

 

given

 

a

 

mandate

 

to

 

decide

not

 

to

 

initiate

 

or

 

to

 

stop

 

a

 

resuscitation

 

attempt

 

in

 

well-defined

conditions.

• The

 

creation

 

of

 

an

 

organisation

 

in

 

which

 

emergency

 

personnel

can

 

easily

 

consult

 

physicians

 

with

 

a

 

particular

 

area

 

of

 

expertise

 

in

emergency

 

medicine

 

at

 

the

 

prehospital

 

stage,

 

to

 

obtain

 

support,

advice

 

or

 

a

 

second

 

opinion,

 

is

 

recommended.

• Family

 

members

 

could

 

be

 

asked

 

if

 

they

 

know,

 

or

 

what

 

they

 

think

the

 

patient

 

would

 

have

 

wanted,

 

when

 

it

 

comes

 

to

 

CPR.

 

However,

it

 

should

 

be

 

made

 

clear

 

to

 

them

 

that

 

they

 

are

 

not

 

responsible

 

for

the

 

final

 

decision.

• The

 

emergency

 

personnel

 

involved

 

in

 

a

 

resuscitation

 

attempt

outside

 

hospital

 

should

 

obtain

 

information

 

about

 

whether

 

or

 

not

the

 

patient

 

survived

 

to

 

be

 

discharged

 

from

 

hospital

 

and

 

about

his/her

 

mental

 

and

 

physical

 

condition

 

at

 

discharge.

Withholding

 

or

 

withdrawing

 

out-of-hospital

 

CPR

• A

 

decision

 

to

 

withhold

 

or

 

withdraw

 

CPR

 

should

 

be

 

made

 

after

weighing

 

the

 

relevant

 

medical

 

facts

 

and

 

ethical

 

aspects

 

in

 

the

concrete

 

situation.

 

The

 

potential

 

risk

 

of

 

severe

 

cerebral

 

damage

for

 

the

 

survivor,

 

as

 

well

 

as

 

the

 

patient’s

 

biological

 

age,

 

should

 

be

taken

 

into

 

account.

 

However,

 

chronological

 

age

 

per

 

se

 

should

 

not

be

 

used

 

as

 

a

 

single

 

discriminatory

 

factor

 

for

 

treatment

 

decisions

related

 

to

 

CPR.

• Treatment

 

with

 

CPR

 

for

 

an

 

out-of-hospital

 

cardiac

 

arrest

 

can

 

be

withheld

 

or

 

withdrawn

 

in

 

an

 

out-of-hospital

 

setting

 

in

 

obvious

cases

 

of

 

mortal

 

injury

 

or

 

death

 

(e.g.,

 

decapitation,

 

rigor

 

mortis

 

and

decomposition),

 

or

 

when

 

the

 

following

 

criteria

 

are

 

met:

 

the

 

arrest

was

 

not

 

witnessed;

 

no

 

bystander

 

cardiopulmonary

 

resuscitation

was

 

administered;

 

the

 

time

 

between

 

the

 

alarm

 

and

 

the

 

arrival

of

 

the

 

ambulance

 

exceeded

 

15

 

min;

 

and

 

the

 

type

 

of

 

arrhythmia

recorded

 

by

 

the

 

rescue

 

team

 

is

 

asystole

 

(Figure).

• Moreover,

 

in

 

cases

 

in

 

which

 

the

 

emergency

 

personnel

 

have

 

access

to

 

definite

 

and

 

reliable

 

information

 

that

 

the

 

patient

 

with

 

a

 

cardiac

arrest

 

is

 

suffering

 

from

 

the

 

end

 

stage

 

of

 

an

 

irreversible

 

medi-

cal

 

condition

 

(life

 

expectancy

 

<

 

6–12

 

months)

 

and

 

there

 

is

 

a

 

clear

written

 

statement

 

(an

 

advance

 

directive)

 

saying

 

that

 

he

 

or

 

she

does

 

not

 

want

 

CPR

 

and/or

 

a

 

valid

 

do

 

not

 

resuscitate

 

(DNR)

 

order,

treatment

 

with

 

CPR

 

could

 

be

 

withheld

 

or

 

withdrawn

 

in

 

an

 

out-

of-hospital

 

setting.

Caring

 

for

 

those

 

who

 

are

 

close

 

to

 

the

 

patient

 

and/or

 

bystanders

• Family

 

members

 

should

 

generally

 

be

 

offered

 

the

 

chance

 

to

 

be

present

 

during

 

CPR.

 

If

 

they

 

wish

 

to

 

be

 

present,

 

it

 

is

 

important

that

 

the

 

personnel

 

provide

 

information

 

about

 

what

 

is

 

happening

and

 

take

 

care

 

of

 

them

 

during

 

the

 

procedure.

• It

 

could

 

be

 

regarded

 

as

 

ethically

 

defensible

 

for

 

the

 

personnel

 

to

continue

 

CPR

 

for

 

a

 

short

 

period

 

time,

 

even

 

though

 

they

 

expect

it

 

to

 

be

 

unsuccessful,

 

to

 

show

 

bystanders/family

 

members

 

that

they

 

did

 

something

 

good

 

when

 

they

 

initiated

 

CPR

 

and

 

to

 

make

them

 

feel

 

that

 

everything

 

that

 

can

 

possibly

 

be

 

done

 

to

 

save

 

the

patient’s

 

life

 

is

 

actually

 

being

 

done.

• Before

 

leaving

 

the

 

scene,

 

emergency

 

team

 

members

 

have

 

a

 

pro-

fessional

 

responsibility

 

to

 

provide

 

initial

 

emotional

 

support

 

for

the

 

people

 

who

 

have

 

lost

 

someone

 

close

 

to

 

them.

Conflict

 

of

 

interest

 

statement

None

 

of

 

the

 

authors

 

has

 

a

 

conflict

 

of

 

interest.

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Lippert

 

FK,

 

Raffay

 

V,

 

Georgiou

 

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European

 

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Mohr

 

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Ethical

 

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Bailey

 

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Wydro

 

GC,

 

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the

 

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adult

 

patients

 

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nontraumatic

 

cardiac

 

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Morrison

 

LJ,

 

Verbeek

 

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Vermeulen

 

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BMJ

 

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31

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Jaslow

 

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car-

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16. Compton

 

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medical

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grief

 

support

 

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medical

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personnel:

 

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