Resuscitation Ethics - Resuscitation Emergency Management

Resuscitation Ethics

CPR Efficacy

·        Wide variation in outcome depending on clinical circumstances. Discharge rate is 15%. Biased by large number of „futile‟ resuscitations.

·        Poor outcomes (e.g. brain damage, organ failure) are inversely correlated with chances of survival.

·        Age per se is not an independent predictor of survival after CPR – but is correlated with illness

CPR and Consent

·        Family members are not able to give consent (either for treatment or withdrawal treatment) under common law in NZ, although H&DC Code has provision for taking into account “the views of other suitable persons who are interested in the welfare of the consumer…”

·        Doctor must make a „substituted professional judgement‟: immediate decision on available information (usually not much) of what is in the patient‟s best interests

·        Ethically wrong to undertake resuscitation in patients in whom it is possible to predict a very low rate of intact survival

·        Futile treatment diverts resources from other people. It is the principle of justice not the principle of autonomy that creates a right to treatment

·        Doctor‟s should not make decisions based on their assessment of the patient‟s quality of life. Only the patient can make this assessment. However, this information is not usually available in acute setting. Revise further resuscitation/treatment decisions when this becomes available (i.e. the decision to resuscitate or not is not static)

·        There is no ethical difference (may be other differences) between withholding and withdrawing treatment. Can revise decision to resuscitate as the probability of poor outcome grows or other information (e.g. patient‟s wishes) comes to light

DNR Orders

·        = Do not resuscitate, DNAR = Do not attempt resuscitation

·        Reasons for DNR orders:

o   Refusal by a competent and informed patient

o   Poor quality of life after CPR (patient‟s, not doctor‟s view)

o   Futility: a clinical decision – so should the patient be involved or not?

·        DNR orders should be discussed where:

o   Requested by a competent patient

o   Considered on grounds of poor quality of life

·        Circumstances where it is not necessary to discuss DNR orders:

o   Patient is incompetent

o   Competent patient but grounds of quantitative futility

o   Where discussion of CPR would be detrimental to patient‟s well being

o   Where patient indicates they do not wish to discuss CPR

·        Role of family/friends: get their input, but doctor makes the decision regarding CPR unless the patient has a welfare guardian or has an advance directive

·        Other points:

o   A DNR doesn‟t mean other treatment is withdrawn

o   DNRs must be clearly documented in notes, including discussion of decision making process 

o   DNRs should be reviewed regularly and may be withdrawn if warranted by change in clinical circumstances