Resuscitation 83 (2012) 27 31
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Resuscitation
jo u rn al hom epage : www.elsevier.com/locate/resuscitation
Commentary and concepts
Guidance for ambulance personnel on decisions and situations related to
out-of-hospital CPR
Anders Ågårda,", Johan Herlitzb, Maaret Castrénc, Lars Jonssond, Lars Sandmane
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 a b s t r a c t
Article history:
Ethical guidelines on out-of-hospital cardio-pulmonary resuscitation (CPR) are designed to provide sub-
Received 15 March 2011
stantial guidance for the people who have to make decisions and deal with situations in the real world.
Received in revised form 15 July 2011
The crucial question is whether it is possible to formulate practical guidelines that will make things some-
Accepted 20 July 2011
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
Keywords:
in a practice guideline on the subject.
Cardiopulmonary resuscitation
© 2011 Elsevier Ireland Ltd. All rights reserved.
Prehospital emergency care
Ethics
Practice guideline
Ambulance
1. Introduction of the views and experience of ambulance personnel, and to
summarise the key points in a practice guideline on the sub-
The rationale for guidelines including the ethics of resuscitation ject.
is to enable professionals to make more appropriate decisions and
to act more effectively compared with what might happen if their
2. The objective of CPR
decisions and actions were only based on individual judgements
and their own values.1 3 The challenge is to provide substantial
From the ambulance personnel s point of view, a reasonable way
guidance on questions or problems that are experienced in the real
to measure the effectiveness of a resuscitation attempt is whether
world.4,5
patients affected by an OHCA have spontaneous circulation when
Ambulance personnel are confronted by a number of ethical
they are delivered to the emergency room.4 However, this way of
considerations when they are on their way to treat a person who
defining what constitutes successful CPR hardly applies from the
has suffered an out-of-hospital cardiac arrest (OHCA) with car-
patient s viewpoint.
diopulmonary resuscitation (CPR).4 8 The most crucial question is
We argue that the objective of CPR is to restore life with quality
whether, and in which particular circumstances, they can be given
acceptable to the patient and in accordance with his or her will.
a mandate to decide to terminate a resuscitation attempt at the
To properly evaluate the effectiveness of their attempts, personnel
scene.
involved in out-of-hospital CPR must therefore be informed about
The aims of this article are to address and to clarify the ethi-
the outcome of the patients in a systematic quality improvement
cal aspects related to out-of-hospital CPR, based on our knowledge
system. In some ambulance systems, they are only aware of and are
only evaluated on the basis of prehospital results.

A Spanish translated version of the abstract of this article appears as Appendix
3. Choices to be made
in the final online version at doi:10.1016/j.resuscitation.2011.07.028.
"
Corresponding author at: Medicinmottagningen, Angereds Närsjukhus, Box 22,
When confronted by a person with cardiac arrest, the emer-
SE-424 65 Göteborg, Sweden. Tel.: [phone]; fax: [phone]; mobile
gency personnel can initiate and then continue CPR, or initiate and
[phone].
E-mail address: [e-mail] (A. Ågård). 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
Cardiac
arrest
Obvious evidence of
Yes
irreversible death
do-not-attempt-resuscitation
(DNAR)
No
If suspected:
Drowning
mortis, deco
Start CPR
Hypothermia
DNAR
Connect defibrillator
Intoxication
Obvious pregnancy
ECG analysis
Yes No
Defibrillate?
 Asystole
 Not witnessed
CPR according
 No bystander CPR
No/Unknown
to guidelines
 Alarm  arrival >15 min
(the decision takes account of the
patient s biological age)
Yes
Continued asystole during
Stop
Yes
> 20 min CPR
resuscitation
attempt
Continued effective CPR
Transport to hospital
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 on whom CPR was not initiated because of obvious death signs or
quality or a life with less than acceptable quality. If CPR is withheld, ethical reasons.
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- 4. Attempting to act in the patient s best interest
mation about the patient s medical condition before the cardiac
arrest is often insufficient. Second, the patient s preference regard- CPR is sometimes considered futile or unethical, even in cases
ing CPR is generally unknown. Third, it is difficult to make correct
where there is a small chance of saving lives. Among patients
prognoses about the chances of survival and quality of life following
affected by severe diseases, which substantially influence their
resuscitation attempts.
quality of life and expected remaining lifetime, doubts can be raised
However, there are reasonable exceptions to the general rule
about whether CPR is in the patient s best interest. Studies have
to initiate CPR, such as cases of obvious mortal injury or death.
actually shown that the ambulance personnel sometimes drive
Moreover, taking the available knowledge relating to factors that
more slowly than normal to the scene when the emergency call
influence the outcome, clinical prediction rules and algorithms for
relates to a very old, very ill patient with a cardiac arrest. They may
terminating resuscitative efforts in the field have been proposed.9 occasionally feel that prehospital resources are not used cost effec-
We suggest an alternative algorithm for the treatment of an OHCA
tively. Moreover, they may not try as hard as they normally do to
that includes criteria for stopping resuscitation attempts (Fig. 1).
optimise the CPR procedure in this category of patients. A com-
By looking retrospectively at the records from the Swedish Cardiac
mon argument for this behaviour is their wish not to take away
Arrest Registry, we calculate that CPR would be stopped after a
a peaceful, dignified death from the patient and family.4,7,8 How-
short period in approximately 2% of the cases if the algorithm were
ever, references to  dignity are problematic. In fact, the concept of a
implemented in our services. The registry does not include patients
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 patient s perspective, as the consequence is basically the same 
diseases may want CPR to be given the chance to live a little the patient will die.
longer.11 Hence, even though the prognosis is statistically poor and On the other hand, four  psychological reasons for continu-
the chronological age is high, patients may benefit from CPR and ing CPR deemed to be unsuccessful or futile have been identified.
regain an acceptable quality of life. As a result, it is generally beyond Firstly, emergency personnel may be inclined to prolong CPR to
the competence of the emergency personnel to assess whether or show, or convince, those around them that  everything that can
not a resuscitation attempt is in the patient s best interest, or to possibly be done is actually being done. It has been argued, when
determine the kind of death the patient would have preferred. referring to the potential benefit for family members, that this way
Being in the presence of a person with cardiac arrest, hav- of acting is ethically justified.14 Second, the personnel may want
ing first-hand information and being able to make an appropriate to confirm that bystanders did the right thing when they initiated
examination is a great advantage. We argue, based on our own and the treatment.4,7 Third, the personnel want to escape from taking
others experience, that emergency services staff members with care of grieving persons, who just have lost a loved one. By contin-
the appropriate training could be given a mandate to decide not uing CPR, it is possible to transport patients to hospital who have
to initiate or to stop a resuscitation attempt under well-defined not yet been pronounced dead. Moreover, some members of the
conditions.7 At the same time, the creation of an organisation in emergency team may not even feel that it is their job or profes-
which emergency personnel can easily consult physicians, emer- sional responsibility to provide emotional support at the scene.15
gency doctors, cardiologists or anaesthesiologists at the prehospital Fourthly, family members do not want the resuscitation attempt to
stage, to obtain support or advice, can be recommended. An organ- be terminated.
isation of this kind has, for example, been created in Helsinki and We argue that CPR could be continued for a short period of time,
Oslo.7 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-
5. Advance directives mendable. Perhaps this strategy could also ease the possible guilt of
not being successful in terms of restoring the function of the heart.
In principle, there are two ways to find out what a patient would The persons who are concerned should then be informed clearly
have wanted in the event of an OHCA. Firstly, if possible and appro- and tactfully about the reasons for terminating the resuscitation
priate, people who are close to the patient could be asked tactfully attempt.
what they think the patient would have wanted in terms of CPR.
However, this does not mean that decisions relating to out-of-
7. The presence of family members and bystanders
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
Despite the fact that life or death is at stake and that CPR may be
death, which can in turn give rise to future guilt and doubts, for
regarded as a somewhat violent procedure, most people want to be
example. When consulting family members, it should be remem-
near their loved ones during resuscitation efforts.1 However, some
bered that their will might differ from the will of the patient or that
members of the emergency team may feel that the presence of per-
they could have misinterpreted the patient s wishes. As a result, it
sons close to the patient and bystanders constitutes a problem. For
may be difficult to distinguish between what is in the patient s best
instance, there are concerns about how they will experience wit-
interest and the family s best interest.
nessing a resuscitation attempt. Emergency personnel may also feel
Second, this is possible by having access to written advance
that their ability to provide adequate CPR is negatively influenced
directives. The whole idea of documents containing advance direc-
by family members who interfere with the treatment. In particular,
tives is to give people a chance to convey their wishes or exercise
a conflict between staff and family members may arise when they
their autonomy, in situations in which they have temporarily or
have a different opinion about what is the right thing to do, to keep
permanently lost the ability to do this. However, there are ques-
resuscitating or to discontinue it.16 Family members should gener-
tions and problems related to the legal status and validity of these
ally be offered the chance to be present during CPR. The importance
documents. For instance, even if the advance directives state that
of informing them about what is happening and caring for them
a person does not want CPR, can the emergency team take it for
during the procedure is emphasised. In our opinion, the emergency
granted that the document belongs to the person with a cardiac
team members have a professional responsibility to provide ini-
arrest in front of them, that the patient really wanted to have this
tial emotional support for the people who have lost someone close
statement written down and that the person has not changed his
to them before leaving the scene. They should also help them to
or her attitude towards CPR since then? As a result, emergency
contact other persons or organisations that can offer further sup-
personnel should be recommended to deal with advance direc-
port. Family members are generally satisfied with the overall care
tives, such as do-not-resuscitate orders, critically and with sound
provided by the emergency personnel at the scene. In fact, family
judgement.12 However, these directives should generally be seen
members often prefer or accept that CPR is terminated at home so
as a valuable help when attempting to make a decision that is in
that their dead loved ones are not transported to hospital. More-
the patient s best interest.
over, terminating CPR and caring for the patient s survivors at home
appear to have a positive impact on the grieving process.17 19
6. Withholding or withdrawing CPR
8. The formulation of guidelines that deal with ethical
Health professionals often find it psychologically more difficult problems related to out-of-hospital CPR
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 Guidelines cannot possibly cover all the circumstances that
teams are unwilling to start CPR to avoid finding themselves in surround a particular situation. As a result, the ambulance per-
a situation in which they have to make a decision to terminate sonnel always have to use their knowledge, skills, experience and
the treatment, especially in the presence of other people. In our values when dealing with decisions and situations related to out-of-
opinion, there is no relevant ethical difference between not initi- hospital CPR. Moreover, there are two important things that must
ating and initiating and subsequently withdrawing CPR from the 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- for the survivor, as well as the patient s biological age, should be
fied, when further information about the medical condition of a taken into account. However, chronological age per se should not
patient prior to the cardiac arrest is obtained, for example. Second, be used as a single discriminatory factor for treatment decisions
guidelines may help to define some situations in which it might related to CPR.
"
be justified to withhold or withdraw CPR. However, when there is Treatment with CPR for an out-of-hospital cardiac arrest can be
the slightest doubt about what is the right thing to do, the active withheld or withdrawn in an out-of-hospital setting in obvious
treatment strategy should be chosen. 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
9. Conclusion
was administered; the time between the alarm and the arrival
of the ambulance exceeded 15 min; and the type of arrhythmia
Our views can be summarised thus:
recorded by the rescue team is asystole (Figure).
General ethical aspects
" Moreover, in cases in which the emergency personnel have access
to definite and reliable information that the patient with a cardiac
" The overall objective of CPR is to restore the patient to a life of
arrest is suffering from the end stage of an irreversible medi-
(from the viewpoint of the patient) acceptable quality, if this is
cal condition (life expectancy < 6 12 months) and there is a clear
what the patient wants.
written statement (an advance directive) saying that he or she
" A successful CPR attempt means that the patient can be dis-
does not want CPR and/or a valid do not resuscitate (DNR) order,
charged from hospital with acceptable quality of life and in
treatment with CPR could be withheld or withdrawn in an out-
accordance with his or her will.
of-hospital setting.
" Decisions to withhold or withdraw CPR must always be based
on sufficient information. As a result, it is important to accept
Caring for those who are close to the patient and/or bystanders
that some resuscitation attempts will be subsequently regarded
as unethical or unjustified, when further information about the
" Family members should generally be offered the chance to be
medical condition of a patient prior to the cardiac arrest is
present during CPR. If they wish to be present, it is important
obtained.
that the personnel provide information about what is happening
" It is generally beyond the competence of the emergency per-
and take care of them during the procedure.
sonnel to assess whether or not a resuscitation attempt is in
" It could be regarded as ethically defensible for the personnel to
the patient s best interest, or to determine the kind of death the
continue CPR for a short period time, even though they expect
patient would have preferred. As a result, the views of the mem-
it to be unsuccessful, to show bystanders/family members that
bers of the emergency team regarding what constitutes a peaceful
they did something good when they initiated CPR and to make
and dignified death should be used very cautiously when guiding
them feel that everything that can possibly be done to save the
the action that should be taken.
patient s life is actually being done.
" There is no relevant ethical difference between not initiating and
" Before leaving the scene, emergency team members have a pro-
initiating and subsequently withdrawing CPR from the patient s
fessional responsibility to provide initial emotional support for
perspective, as the consequence is basically the same  the patient
the people who have lost someone close to them.
will die.
Conflict of interest statement
The decision-making process
None of the authors has a conflict of interest.
" 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
References
the slightest doubt about what is the right thing to do, the active
treatment strategy should always be chosen.
1. Lippert FK, Raffay V, Georgiou M, Steen PA, Bossaert L. European Resuscitation
" An experienced ambulance or emergency services staff member Council guidelines for resuscitation 2010. Section 10. The ethics of resuscitation
and end-of-life decisions. Resuscitation 2010;81:1444 51.
with the appropriate training could be given a mandate to decide
2. Morrison LJ, Kierzek G, Diekema DS, Sayre MR, Silvers SM, Mancini ME. Part
not to initiate or to stop a resuscitation attempt in well-defined
3. Ethics: 2010 American Heart Association guidelines for cardiopulmonary
conditions. resuscitation and emergency cardiovascular care. Circulation 2010;122(Suppl.
3):S665 75.
" The creation of an organisation in which emergency personnel
3. Decisions relating to cardiopulmonary resuscitation. A joint statement from the
can easily consult physicians with a particular area of expertise in
British Medical Association, the Resuscitation Council (UK) and the Royal College
emergency medicine at the prehospital stage, to obtain support,
of Nursing, 2007.
4. Sandman L, Nordmark A. Ethical conflicts in prehospital emergency care. Nurs
advice or a second opinion, is recommended.
Ethics 2006;13:592 607.
" Family members could be asked if they know, or what they think
5. Marco CA, Schears RM. Prehospital resuscitation practices: a survey of prehos-
the patient would have wanted, when it comes to CPR. However,
pital providers. J Emerg Med 2003;24:101 6.
6. Mohr M, Kettler D. Ethical aspects of prehospital CPR. Ann Emerg Med
it should be made clear to them that they are not responsible for
1997;17:298 300.
the final decision.
7. Naess A-C, Steen E, Steen PA. Ethics in treatment decisions during out-of-
" The emergency personnel involved in a resuscitation attempt
hospital resuscitation. Resuscitation 1997;33:245 56.
8. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation in the prehospital
outside hospital should obtain information about whether or not
setting for adult patients suffering nontraumatic cardiac arrest. National Asso-
the patient survived to be discharged from hospital and about
ciation of EMS Physicians Standards and Clinical Practice Committee. Prehosp
his/her mental and physical condition at discharge.
Emerg Care 2000;4:190 5.
9. Morrison LJ, Verbeek PR, Vermeulen MJ, et al. Derivation and evaluation of a
termination clinical prediction rule for advanced life support providers. Resus-
Withholding or withdrawing out-of-hospital CPR
citation 2007;74:266 75.
10. Macklin R. Dignity is a useless concept. BMJ 2003;327:1419 20.
11. Lo B. End-of-life care after termination of SUPPORT. Hastings Cent Rep
" A decision to withhold or withdraw CPR should be made after
1995;25:S6 8.
weighing the relevant medical facts and ethical aspects in the
12. Iserson KV. Foregoing prehospital care: should ambulance staff always resusci-
concrete situation. The potential risk of severe cerebral damage tate. J Med Ethics 1991;17:19 24.
A. Ågård et al. / Resuscitation 83 (2012) 27 31 31
13. Melltorp G, Nilstun T. The difference between withholding and withdrawing 17. Delbridge TR, Fosnocht DE, Garrison HG, Auble TE. Field termination of
life-sustaining treatment. Intensive Care Med 1997;23:1264 7. unsuccessful out-of-hospital cardiac arrest resuscitation: acceptance by family
14. Bishai D, Siegel A. Moral obligation to families when there is a sudden death. J members. Ann Emerg Med 1996;27:649 54.
Clin Ethics 2001;12:382 7. 18. Schmidt TA, Harrahill MA. Family response to out-of-hospital death. Acad Emerg
15. Jaslow D, Barbara JA, Johnson E, Moore W. Termination of nontraumatic car- Med 1995;2:513 8.
diac arrest resuscitative efforts in the field: a national survey. Acad Emerg Med 19. Edwardsen EA, Chiumento S, Davis E. Family perspective of medical
1997;4:904 7. care and grief support after field termination by emergency medical
16. Compton S, Madgy A, Goldstein M, Sandhu, Dunne R, Swor R. Emergency medi- services personnel: a preliminary report. Prehosp Emerg Care 2002;6:
cal service providers experience with family presence during cardiopulmonary 440 4.
resuscitation. Resuscitation 2006;70:223 8.