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<HTML> <HEAD> <META NAME="GENERATOR" CONTENT="Adobe PageMill 2.0 Win"> <TITLE>ACLS Chapter 16</TITLE> </HEAD> <BODY TEXT="#bafddc" LINK="#ffcc66" VLINK="#5cf373" BGCOLOR="#006666" ALINK= "#fb1814"> <H1>Chapter 16</H1> <H1>Ethical Aspects of CPR and ECC<HR ALIGN=LEFT></H1> <H1><A NAME="anchor145056"></A>16.1 Introduction</H1> Cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) have the same goals as all other medical interventions — to preserve life, restore health, relieve suffering, and limit disability. An additional goal unique to CPR is the reversal of "clinical death." However, in providing CPR these goals are often not achieved. Moreover, the provision of resuscitation may conflict with a patient's own desires and requests or may not be in the patient's best interest.<A HREF= "http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0001" TARGET="Footnote #1">1</A> Like other medical therapies, CPR and ECC have specific indications and contraindications. In certain circumstances CPR can be predicted to be unsuccessful and may be considered futile. In certain instances CPR may not be a wise or just use of limited medical resources. However, concern about costs associated with prolonged intensive care should not preclude emergency resuscitative attempts. The purpose of this section is to guide ECC providers in making difficult decisions about starting and stopping CPR and ECC. These are guidelines only. Each decision must be individualized and made with compassion and reason. <A NAME="anchor1"></A> Competent and informed patients have a moral and legal right to consent to or refuse recommended medical interventions, including CPR.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0002" TARGET="Footnote #2">2-7</A> The right to refuse medical treatment does not depend on the presence or absence of terminal illness, the agreement of family members, or the approval of physicians or hospital administrators. Under ideal circumstances adult patients are presumed to be competent unless a court has declared them incompetent to make medical decisions.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0008" TARGET="Footnote #8">8</A> In practice, physicians often determine whether patients can make informed decisions about their medical care. To have this decision-making capacity, patients must be able to understand basic information about their condition and prognosis, the nature of the proposed intervention, the alternatives, the risks and benefits, and the consequences. In addition, the patient must be able to deliberate and choose among alternatives. In cases of doubt, the patient should be regarded as competent. When decision-making capacity is temporarily impaired by such factors as concurrent illness, medications, or depression, treatment of these conditions may restore that capacity. <A NAME="anchor2"></A> If the patient cannot make an informed decision about CPR, the attending physician should consider the patient's advance directives or decisions by appropriate surrogates, as well as the likely response to CPR.<HR ALIGN=LEFT> <A NAME="anchor3"></A> <H1><A NAME="anchor145590"></A>16.2 Ethical Principles and Guidelines</H1> <H2>16.2.1 Advance Directives and Surrogate Decision Making</H2> By using advance directives, competent patients indicate what interventions they would refuse or accept if they were to lose the capacity to make decisions about their care.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0009" TARGET= "Footnote #9">9</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0010" TARGET="Footnote #10">10</A> Following the advance directives of patients who have lost their decision-making capacity respects their autonomy, individuality, and self-determination as well as the law.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0001" TARGET="Footnote #1">1</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0003" TARGET="Footnote #3">3</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0004" TARGET="Footnote #4">4</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0007" TARGET="Footnote #7">7</A> <A NAME="anchor4"></A> Advance directives include conversations, written directives, living wills, and durable powers of attorney for health care. Conversations the patient had with relatives, friends, or physicians while still competent are the most common form of advance directives. However, the courts consider written advance directives more trustworthy. <A NAME="anchor5"></A> Living wills constitute clear and convincing evidence of a patient's wishes, and in most states living wills are legally enforceable. In living wills, patients direct their physicians in the provision of medical care if the patients become terminally ill and are incapable of making decisions. <A NAME="anchor6"></A> The durable power of attorney for health care allows a competent patient to designate a surrogate, typically a relative or close friend, to make medical decisions if the patient loses decision-making capacity.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0011" TARGET="Footnote #11">11</A> The surrogate (also referred to as the healthcare agent or proxy) should base decisions on the previously expressed preferences of the patient if they are known or in the patient's best interest if the patient's values are not known. Unlike the living will, the durable power of attorney for health care applies to all situations in which the patient is incapable of making medical decisions, not only terminal illness. Appointing a surrogate, together with providing a statement of preferences regarding life-sustaining treatment, is the preferred way for a patient to provide written advance directives. <A NAME="anchor7"></A> Physicians should encourage patients to provide advance directives and should make forms readily available.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0012" TARGET="Footnote #12">12</A> Physicians need to know the requirements in their states, for example, about witnesses or notarization. In discussions with patients, physicians can ensure that advance directives are informed, specific, and up-to-date.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0012" TARGET="Footnote #12">12</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0013" TARGET="Footnote #13">13</A> <A NAME="anchor8"></A> When patients lack the capacity to make informed decisions, a surrogate, informed and advised by the attending physician, should be identified to make medical decisions for the patient. In some instances, the patient while still competent will have selected a surrogate by executing a durable power of attorney for health care. When the patient has not selected a proxy, state law may dictate the order in which relatives should be asked to serve as surrogates.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0007" TARGET= "Footnote #7">7</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0014" TARGET="Footnote #14">14</A> Physicians can ask the courts to appoint surrogates for patients lacking decision-making capacity. However, legal proceedings may result in long delays or superficial review of the case, even when expedited procedures are used. In practice, the physician and the family often select the appropriate surrogate. The person chosen for that role should be someone who knows the patient's value system and respects its values and will act in the patient's best interest. Generally the appropriate surrogate is a relative or close friend, or the parents if the patient is a child. <A NAME="anchor9"></A> In pediatric patients, respect for the principles of autonomy and self-determination requires that children be included in decision making consistent with their neurological status and level of maturity. There is legal precedent for participation by mature adolescents in personal decisions concerning CPR.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0015" TARGET="Footnote #15">15</A> <A NAME="anchor10"></A> Some patients with impaired decision-making capacity have no family members or close friends who can make decisions on their behalf. Decisions for such patients may present serious ethical dilemmas. In clinical practice, decisions for such patients are commonly made without resorting to the courts. It is desirable but not always possible for the attending physician to ask someone who is not directly involved in the patient's care to consult on the case. Such consultation helps to ensure that hidden assumptions and value judgments are made explicit, that the personal values of the caregivers are not projected onto the patient, that all points of view and alternatives are considered, and that the decision is made thoughtfully. Review by the hospital ethics committee, an ethics consultant, or another physician can be useful. <A NAME="anchor11"></A> <H2>16.2.2 Futility</H2> Physicians should not be obligated to provide futile therapy when asked to do so by patients or surrogates.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0002" TARGET="Footnote #2">2</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0016" TARGET="Footnote #16">16-18</A> While this general rule seems obvious, it may be difficult to define futility in a particular case. People often use the term futile in very different ways, and unilateral decisions by physicians to withhold or terminate resuscitation are justified only when it is futile in a strict sense.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0016" TARGET="Footnote #16">16</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0019" TARGET="Footnote #19">19</A> Medical futility justifies unilateral decisions by physicians to withhold or terminate resuscitation under the following circumstances: <A NAME="anchor12"></A> <BLOCKQUOTE> 1. Appropriate basic life support (BLS) and advanced life support (ALS) have already been attempted without restoration of circulation and breathing. <A NAME="anchor13"></A> 2. No physiological benefit from BLS and ALS can be expected because a patient's vital functions are deteriorating despite maximum therapy. For example, CPR would not restore circulation in a patient who suffered a cardiac arrest despite optimal treatment for progressive septic or cardiogenic shock. <A NAME="anchor14"></A> 3. No survivors after CPR have been reported under the given circumstances in well-designed studies. For example, when CPR has been attempted in patients with metastatic cancer, several large series have reported that no patients survived to hospital discharge.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0020" TARGET="Footnote #20">20</A> <A NAME="anchor15"></A> </BLOCKQUOTE> In these strictly defined situations, the decision to stop or withhold resuscitation is appropriately a medical judgment.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0018" TARGET="Footnote #18">18</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0021" TARGET="Footnote #21">21</A> Patients (or surrogates of incompetent patients) should be informed of the no-CPR order but not offered the choice of CPR. <A NAME="anchor16"></A> The term futility, however, is also used in less strict and less objective ways that do not justify unilateral decisions by physicians to withhold CPR.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0016" TARGET="Footnote #16">16</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0019" TARGET="Footnote #19">19</A> Some physicians regard CPR as "futile" when important goals of care cannot be achieved, although other significant goals might be. For example, for a young patient in a persistent vegetative state, CPR in the case of cardiopulmonary arrest would not restore cerebral function, although it might restore circulation and allow long-term survival. Another looser meaning of futility is that the reported survival rate after CPR is low but not 0%. In calling CPR futile in these circumstances, physicians make value judgments about which goals of treatment and what probability of success are worthwhile. Physicians need to appreciate that in these situations their role is to initiate discussions with patients or their surrogates and to provide information and advice but not to be the sole decision makers. <A NAME="anchor17"></A> <H2>16.2.3 Allocation of Resources</H2> Recent ethical deliberations have arisen out of concern for overtreatment of patients with a poor prognosis; however, a major consideration should be the lack of consistent access to and quality of ECC and other medical services. Efforts should continue to be devoted to decreasing response times and improving CPR performance through all links in the chain of survival. Justice dictates that a certain level of emergency care should be provided to all citizens and that resources should be justly allocated to ensure some degree of equitable distribution of medical resources to all citizens. Physicians must play a major role in determining how to derive maximum benefit from available medical resources. However, when making individual treatment decisions for a patient, the physician should maintain a position of advocacy for that patient's best interest. When resources are inadequate to meet immediate patient care needs, rationing (ie, triage) of medical services occurs. Rationing, the distribution of a scarce resource, should be based on ethically oriented criteria. <A NAME="anchor18"></A> <H2>16.2.4 No-CPR Orders</H2> Most patients want to discuss the no-CPR or do-not-resuscitate (DNR) decision with their physicians. Physicians, however, often hesitate to initiate the discussions, fearing that such discussions would harm some patients by provoking severe anxiety or undermining hope, even though there is little evidence to support this. On a practical level, busy physicians may think they do not have time to discuss CPR in a meaningful way with patients. <A NAME="anchor19"></A> Often physicians discuss CPR only with patients whom they consider at risk for cardiopulmonary arrest.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0022" TARGET="Footnote #22">22</A> Typically the possibility of cardiopulmonary arrest becomes clear as a patient's condition worsens. At that point the patient often is no longer capable of making decisions,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0019" TARGET="Footnote #19">19</A> although often the patient was capable of doing so on admission to the hospital.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0022" TARGET="Footnote #22">22</A> Targeting sicker patients reinforces the belief that discussion of no-CPR or DNR orders signifies a bleak prognosis. Selective discussions may also be inequitable. Physicians discuss no-CPR orders more frequently with patients who have acquired immunodeficiency syndrome (AIDS) or cancer than with patients who have coronary artery disease, cirrhosis, and other diseases with a similarly poor prognosis.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0023" TARGET= "Footnote #23">23</A> For these reasons, physicians must consider taking the initiative in discussing CPR with all adults admitted for medical and surgical care or with their surrogates. <A NAME="anchor20"></A> To allow patients or surrogates to make informed decisions, physicians need to disclose pertinent information about the patient's condition and prognosis, the nature of CPR, the likely outcome, the risk, and the alternative of certain death. Patients need to understand that CPR is often unsuccessful. About 15% of hospitalized patients on general medical or surgical floors in whom CPR is attempted survive.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0022" TARGET="Footnote #22">22-26</A> Terminally ill patients may fear abandonment and pain more than death. In discussions with such patients, physicians need to emphasize their plans to control pain, provide comfort, and see the patient regularly, even if resuscitation is withheld. <A NAME="anchor21"></A> All medical decision making, including choices about CPR, begins with the physician's recommendation based on medical judgment, which is then communicated to patients or their surrogates or parents when they are asked to give their informed consent. Patients and their surrogates have a right to choose from among medically appropriate options based on their assessment of the relative benefits and burdens of the proposed intervention. This right to choose does not imply the right to demand care beyond appropriate options based on medical judgment and accepted standards of care, nor are physicians required to provide care in ways that in their personal judgment violate the principles of medical ethics. Physicians may choose to transfer care in such cases to other providers. There may be circumstances when conflicts of interest may lead parents to decisions not in the best interest of the infant or child. If patients or their surrogates or parents and physicians cannot agree on a course of action, steps should be taken to resolve the differences of opinion by involving consultants, ethics committees, or — as a last resort in pediatric cases — state child protection agencies. <A NAME="anchor22"></A> A growing number of children with chronic and potentially life-threatening conditions live in foster care environments under state jurisdiction. Existing ambiguities about the scope of decision-making authority vested in custodial guardians, especially decisions about CPR and prolonged life support, need to be clarified. <A NAME="anchor23"></A> Decisions to limit resuscitative efforts should be communicated to all professionals involved in the care of the adult or child in the context of an overall plan for patient care. Such interactions provide a wider information base, ensure that the staff is fully informed, and offer an opportunity for conflicts to be aired. <A NAME="anchor24"></A> Unlike other medical interventions, CPR is initiated without a physician's order, under the theory of implied consent for emergency treatment. However, a physician's order is required to withhold CPR.<A HREF= "http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0025" TARGET="Footnote #25">25</A> <A NAME="anchor25"></A> DNR or no-CPR orders represent one aspect of a patient treatment plan, ie, not to attempt CPR, and carry no inherent implications for limitations of other forms of treatment. Other aspects of the treatment plan should be separately documented and communicated. Admission to an intensive care unit for necessary care best provided in that facility is not necessarily inconsistent with a decision not to attempt CPR in the event of an arrest.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0027" TARGET="Footnote #27">27</A> <A NAME="anchor26"></A> The commonly used term do not resuscitate may be misleading. It suggests that healthcare workers could resuscitate a patient if they tried to do so, but this often is not the case. The term do not attempt resuscitation (DNAR) may more clearly connote that success at resuscitation is often not achieved. The scope of a DNR order may also be ambiguous. Even though CPR will be withheld, it may be appropriate to provide interventions such as fluids, nutrition, oxygen, antiarrhythmic agents, or vasopressors. The order no CPR may more effectively communicate the intended meaning that "in the event of an acute cardiac arrest, no CPR measures will be instituted or continued." Each of these terms — DNR, DNAR, and no CPR — is currently in use, and local custom will determine the preferred term. The term no CPR will be used throughout the remainder of this chapter. <A NAME="anchor27"></A> No-CPR orders should be reviewed before surgery to determine their applicability in the operating room and postoperative recovery room.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0028" TARGET="Footnote #28">28-30</A> They should be reviewed by the anesthesia care provider, attending physician, and patient or surrogate to determine how they should apply to events that may occur during the intraoperative or immediate postoperative period. The result of that review may be a suspension or continuance of the no-CPR order through the perioperative period.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0029" TARGET="Footnote #29">29</A><HR ALIGN=LEFT> <A NAME="anchor28"></A> <H1><A NAME="anchor146404"></A>16.3 Initiating and Discontinuing Resuscitation in the Prehospital Setting</H1> <H2>16.3.1 Basic Considerations</H2> When a person has suffered a cardiac or respiratory arrest, there is a strong presumption for initiation of CPR in the prehospital, hospital, and delivery room settings. Except in narrowly defined circumstances, citizen first responders are urged and professional first responders are expected always to attempt BLS and ACLS. Exceptions to this rule in the prehospital setting are the presence of obvious clinical signs of death, cases where attempts would place the rescuer at significant risk of physical injury, or cases where there is documentation or another reliable reason to believe that CPR is not indicated, wanted, or in the patient's best interest. Unwitnessed deaths in the presence of known serious, chronic, debilitating disease or in the terminal state of a fatal illness may be a reliable criterion in some settings to believe that CPR is not indicated. CPR is not indicated for traumatic arrests with extended response or transport times after a patent airway is ensured. In the past, debate has centered on the question of whether to initiate CPR when "irreversible brain damage" or "brain death" is suspected. Neither of these conditions can be reliably assessed in the prehospital setting. Thus, anticipated neurological status should not be used as a criterion to withhold CPR. <A NAME="anchor29"></A> Emergency medical services (EMS) protocols should have provisions to identify adults and children who have no-CPR orders.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0031" TARGET="Footnote #31">31</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0032" TARGET="Footnote #32">32</A> This could be done with a formal order sheet, identification cards, bracelets, or some other mechanism. <A NAME="anchor30"></A> In certain cases it may be difficult to determine if resuscitation should be started. For example, despite the presence of a no-CPR order, family members, surrogates, or the patient's physician may request that CPR be initiated. If there is reasonable doubt or substantive reason to believe the no-CPR order is invalid, CPR should be initiated. If evidence later indicates that no resuscitation is the patient's clearly expressed wish, CPR or other life support can be discontinued. <A NAME="anchor31"></A> No-CPR orders should not be confused with advance directives or living wills, which are requests by individuals to direct their medical care should they lose decision-making capacity. Advance directives and living wills require interpretation by a physician and need to be formulated into a treatment plan, including specific orders (no CPR), consistent with the patient's wishes. The existence of a living will does not necessarily indicate that a patient is foregoing aggressive medical care or CPR. <A NAME="anchor32"></A> Interpreting living wills and identifying proxies in the prehospital setting are fraught with difficulty, requiring the rescuer to interpret a legal document at the time of a medical emergency. A number of EMS systems are developing methods to ensure that no-CPR orders can be honored in the prehospital setting. This practice should be encouraged. Unless there are such policies in place authorizing the withholding of emergency treatment, first responders, emergency medical technicians, and paramedics should treat patients according to standard protocols and provide any advance directives to the physician responsible for subsequent treatment. Family members may be concerned that emergency medical personnel are not honoring the advance directives. However, EMS responders must sensitively and emphatically convey their responsibility to initiate treatment and await physician direction regarding advance directives or requests in a living will. Treatments initiated by EMS personnel should be discontinued in the emergency department or hospital if there is evidence that they are not wanted by the patient, not in the patient's best interest, or not medically indicated. <A NAME="anchor33"></A> Rescuers who initiate BLS should continue until one of the following occurs: <A NAME="anchor34"></A> <BLOCKQUOTE> 1. Effective spontaneous circulation and ventilation have been restored. <A NAME="anchor35"></A> 2. Care is transferred to emergency medical responders or another trained person who continues BLS. <A NAME="anchor36"></A> 3. Care is transferred to ALS emergency medical personnel. <A NAME="anchor37"></A> 4. Care is transferred to a physician who determines that resuscitation should be discontinued. <A NAME="anchor38"></A> 5. Reliable criteria for the determination of death are recognized. <A NAME="anchor39"></A> 6. The rescuer is too exhausted to continue resuscitation, environmental hazards endanger the rescuer, or continued resuscitation would jeopardize the lives of others. <A NAME="anchor40"></A> 7. A valid no-CPR order is presented to the rescuers. Ethically and legally there is no distinction between discontinuing CPR and not starting it in the first place. <A NAME="anchor41"></A> </BLOCKQUOTE> There is ongoing debate about the efficacy of BLS beyond 30 minutes. Rescuers in a remote environment and some BLS ambulance services may have prolonged transport times before ALS can be instituted, making them unavailable for other calls. The risk of vehicular accidents during high-speed emergency transport must be weighed against the likelihood of successful resuscitation after prolonged BLS resuscitative efforts. State or local EMS authorities should be encouraged to develop protocols for initiation and withdrawal of BLS in areas where ALS is not readily available, taking into account local circumstances, resources, and risk to rescuers. Since defibrillators are now recommended as standard equipment on all ambulances, the absence of a "shockable" rhythm on the defibrillator after an adequate trial of CPR can be an additional criterion for withdrawing BLS. <A NAME="anchor42"></A> Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of ACLS. This determination should be made by EMS authorities and ambulance medical directors, who should generally ensure that (1) endotracheal intubation has been successfully accomplished, (2) intravenous access has been achieved and rhythm-appropriate medications and countershocks for ventricular fibrillation have been administered according to ACLS protocols, and (3) persistent asystole or agonal electrocardiographic patterns are present and no reversible causes are identified. The interval since cardiac arrest should be considered, but no specific duration of time predicts unsuccessful resuscitation. Studies have shown that rapid transport for in-hospital resuscitation after unsuccessful prehospital ACLS rarely if ever results in survival to hospital discharge and that the costs and risks associated with high-speed transport may outweigh the extremely small likelihood of benefit.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0033" TARGET="Footnote #33">33-35</A> Physician ambulance medical directors remain ultimately responsible for determination of death, and pronouncement of death in the field should have the concurrence of on-line medical control.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0036" TARGET= "Footnote #36">36</A> Although duration of resuscitation and the patient's age influence the success of resuscitation, by themselves they are not accurate predictors of outcome. Return of spontaneous circulation for even a brief period is a positive prognostic sign and warrants consideration of transport to a hospital. Transport may also be warranted in special circumstances such as profound hypothermia. <A NAME="anchor43"></A> In EMS systems where resuscitation is discontinued in the prehospital setting, mechanisms should be established for the pronouncement of death and appropriate disposition of the body by means other than EMS vehicles. EMS providers must be trained to deal sensitively with family and others present, and the involvement of a member of the clergy or a social worker should be considered. <A NAME="anchor44"></A> Ambulance and rescue personnel commonly encounter terminally ill patients in private homes, often in hospice programs. These patients may require treatment for acute medical illness or traumatic injuries, measures to relieve suffering, or simply ambulance transportation to a medical facility. Use of 911 telephone numbers and the emergency system may or may not be appropriate. Comprehensive policies should be adopted by local or state EMS authorities to allow persons to decline an attempt at resuscitation but still have access to other emergency medical treatments and ambulance transportation. A legally valid, widely recognized form or other method of identification should be available for presentation to prehospital personnel when they are called to the scene of a patient with a no-CPR order. <A NAME="anchor45"></A> Personal physicians should initiate predeath planning for patients entering the terminal stages of illness. Physicians must be knowledgeable about state laws related to death certification, pronouncement of death, the role of the coroner and police, and disposition of bodies.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0037" TARGET="Footnote #37">37</A> They may not realize that no-CPR orders written in the hospital may not be transferable to outside the hospital setting.<A HREF= "http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0037" TARGET="Footnote #37">37</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0038" TARGET="Footnote #38">38</A> Failure to address these issues may result in unnecessary conflict.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0039" TARGET="Footnote #39">39</A> <A NAME="anchor46"></A> Many patients prefer to die at home, surrounded by friends and loved ones. The hospice movement and many societies for specific diseases (eg, multiple sclerosis, AIDS, and muscular dystrophy) provide excellent models for planning an expected death at home and for answering questions from physicians and families.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0040" TARGET="Footnote #40">40</A> Physicians, patients, and family members together should discuss measures of comfort, pain control, terminal support, and hygiene; when (and when not) to call 911; use of a local hospice; and when and how to contact the personal physician. Funeral plans, disposition of the body, psychological concerns surrounding death and dying, and availability of counseling services and ministerial support should be discussed. Such knowledge and discussions will reduce and even eliminate many of the ethical and medicolegal issues related to CPR. <A NAME="anchor47"></A> Nursing home facilities should develop and implement institutional guidelines for providing CPR to their residents. A nursing home should be considered a prehospital setting, and residents should be provided with 911 emergency service if medically indicated. Advance directives and living wills should be considered when developing treatment plans for residents lacking decision-making capacity. The treatment plans should include specific orders (DNR/DNAR/no CPR) to limit emergency care, if this accords with the patient's request. Physician orders and treatment plans to limit ECC should be provided to EMS personnel and transferred with the patient from the long-term care facility to the hospital. <A NAME="anchor48"></A> <H2>16.3.2 Organ and Tissue Donation</H2> The AHA supports efforts to answer the national need for increased organ and tissue donation. EMS agencies should consider prospectively contacting the organ procurement organization in their region about the need for tissue from donors pronounced dead in the field. Permission must be obtained from next of kin for organ and tissue donation. Federal guidelines for organ and tissue procurement in hospitals should be consulted.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0041" TARGET="Footnote #41">41</A> Although this is an area of considerable sensitivity, EMS medical directors and prehospital providers should be alert to clinical situations where organ procurement may be appropriate. The appropriateness of initiating life support on a dying patient solely for organ procurement requires further public discussion. <A NAME="anchor49"></A> <H2>16.3.3 Ethics of Practicing Intubation Skills</H2> The public and healthcare professionals share an important interest in developing and maintaining a high level of technical skill in rescuers. Providing healthcare professionals with a closely supervised intubation practice using the newly deceased, especially small infants, is a common teaching method. This practice is ethically justifiable in that it is nonmutilating, brief, beneficial to others, and an effective teaching technique.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0042" TARGET="Footnote #42">42</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0043" TARGET="Footnote #43">43</A> However, the sensibilities of family and staff should be compassionately respected and consent obtained whenever practical.<HR ALIGN=LEFT> <A NAME="anchor50"></A> <H1><A NAME="anchor147201"></A>16.4 Resuscitation and Life Support in the Hospital</H1> <H2>16.4.1 Determining Appropriate Level of Care</H2> Hospitalized patients should periodically have an evaluation to determine the "appropriate level of care." The levels to consider are (1) aggressive emergency resuscitation; (2) intensive care monitoring and life support (prolonged life support); (3) general medical care, including medication, surgery, artificial nutrition, and hydration; (4) general nursing care; and (5) terminal care. Selection of the appropriate level of care is a medical decision made in accordance with an informed patient's or surrogate's consent. <A NAME="anchor51"></A> <H2>16.4.2 Initiating Resuscitation in Hospitals</H2> Prompt institution of CPR is indicated in hospitalized patients outside the intensive care unit (ICU) who develop airway obstruction, apnea, or pulselessness. Resuscitative efforts should be withheld when there is a no-CPR order; when, in the judgment of the physician, such efforts cannot restore and sustain cardiopulmonary function; or when widely accepted scientific data indicate there is no likelihood of survival. This prediction should be based on several credible published studies of sufficient numbers with 100% no-survival rate. The patient, surrogate, or family should be informed of the decision to withhold CPR. CPR may be discontinued after an adequate trial of ACLS or a valid no-CPR order is presented. <A NAME="anchor52"></A> In the hospital or delivery room, CPR may be discontinued after a full trial according to accepted clinical protocols. Sufficient data have not yet accumulated to support a recommendation on the appropriate duration of CPR efforts in children before discontinuance. There is evidence that infants resuscitated in the delivery room whose Apgar scores remain 0 after 10 minutes will not survive.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0044" TARGET="Footnote #44">44</A> <A NAME="anchor53"></A> In the delivery room, resuscitation may be withheld from infants judged to be not resuscitable at birth<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0045" TARGET="Footnote #45">45</A> or with imminently fatal malformations. In pediatric cases in general, parents should share in the decision making whenever possible. When the potential need for CPR can be anticipated, early discussion and preplanning promote shared decision making. Physicians must discuss with parents their determination that a CPR attempt would be futile and should be withheld. The general presumption in favor of initiating attempts at resuscitation provides an important opportunity to gather and document clinical and other data to support a decision about continuing or withdrawing those efforts. <A NAME="anchor54"></A> If cardiac arrest occurs in an ICU or critical care unit (CCU), the interval from arrest to restoration of spontaneous circulation should be extremely short because of close monitoring by personnel and immediate attempts to reverse the arrest.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0046" TARGET="Footnote #46">46</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0047" TARGET="Footnote #47">47</A> In ICUs and CCUs every possible effort should be made to minimize the likelihood of accidental airway obstruction, hypoventilation, or pulselessness by recognizing problems with tubes or ventilators and by promptly evaluating arrhythmias. Admitting patients with no-CPR orders to ICUs and CCUs may be appropriate when care outside the ICU or CCU is difficult or impossible for logistic reasons or when a temporary and potentially reversible problem develops in a patient with an underlying irreversible illness.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0027" TARGET="Footnote #27">27</A> The appropriateness of resuscitative efforts for the patient in the ICU or CCU should be reviewed regularly and modified as the patient's condition changes. <A NAME="anchor55"></A> <H2>16.4.3 Withdrawal of Life Support</H2> Although withdrawal of life support may be a more emotionally complex decision for family and staff, withholding and withdrawing are ethically the same. Decisions to withhold or withdraw life support are justifiable in the final stages of terminal illness when the patient, adult or child, will remain permanently unconscious, when the burden to the patient of continued treatment would exceed any benefits, or when widely accepted scientific data suggest that the chances for successful resuscitation are remote. Caution must be exercised in determining the prognosis of infants with neurological impairment. <A NAME="anchor56"></A> Brain death cannot be determined during emergency resuscitative attempts. Determination of brain death must be governed by nationally accepted guidelines.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0048" TARGET="Footnote #48">48</A> Care providers should not forget the need for organ donation, which the AHA encourages. Once a patient is determined to be brain dead, life-sustaining treatment should be withdrawn unless consent for cadaveric organ donation has been given. If such consent has been given, previous no-CPR orders should be rescinded until organs have been procured. <A NAME="anchor57"></A> In children the clinical criteria for brain death are in most circumstances the same as in adults. However, determination of brain death should not be made until at least 7 days of age.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0049" TARGET="Footnote #49">49</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0050" TARGET="Footnote #50">50</A> It is recommended that hospitals develop policies and guidelines for the determination of death by brain death criteria that reflect current consensus and address areas of controversy. <A NAME="anchor58"></A> Persistent vegetative state is the irreversible cessation of the integrating function of the cerebral cortex while brainstem function remains intact.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0048" TARGET="Footnote #48">48</A> After cardiac arrest and restoration of spontaneous circulation by CPR, some patients may not regain consciousness. The prognosis for adults in persistent vegetative state following cardiac arrest can be predicted with high accuracy after 3 to 7 days.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0051" TARGET="Footnote #51">51</A> Withdrawal of life support, including artificially administered nutrition and hydration, is ethically permissible under these circumstances, in accordance with the previously discussed guidelines for making decisions for patients who lack decision-making capacity.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0052" TARGET="Footnote #52">52-55</A> <A NAME="anchor59"></A> The conscious or unconscious patient in the terminal state of an incurable disease for whom terminal care is determined to be appropriate should have care that ensures comfort and dignity.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0006" TARGET="_blank">6</A> Care should be provided to minimize the suffering associated with pain, dyspnea, delirium, convulsions, and other terminal complications. For such patients it is ethical to gradually increase the dosage of narcotics and sedatives to relieve pain and other symptoms, even to dosages that might also shorten the patient's life.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0054" TARGET="Footnote #54">54</A>,<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0055" TARGET="Footnote #55">55</A> <A NAME="anchor60"></A> <H2>16.4.4 Hospital No-CPR Policies</H2> Hospitals must have written policies for no-CPR orders, as the Joint Commission on the Accreditation of Healthcare Organizations requires. These policies need to be reviewed periodically to reflect developments in medical technology, changes in guidelines for ECC and ALS, or changes in the law. <A NAME="anchor61"></A> The attending physician should write no-CPR orders in the patient's chart. The rationale for the no-CPR order and other specific limits to care should be documented in the progress notes. Oral no-CPR orders may be misunderstood and may place nurses and other healthcare workers in legal and ethical jeopardy. If the attending physician is not physically present, nurses may accept a no-CPR order over the telephone, with the understanding that the physician will sign the order promptly. No-CPR orders should be reviewed periodically, particularly if the patient's condition changes. <A NAME="anchor62"></A> "Show codes" or "slow codes" appear to provide CPR while not actually doing so or while doing so in a way that is known to be ineffective. Slow codes, particularly when done to deceive the relatives and friends of a patient, compromise the ethical integrity of healthcare professionals and undermine the physician-patient or nurse-patient relationship. Such codes should not be done. <A NAME="anchor63"></A> Orders to limit resuscitative efforts, such as to withhold defibrillation or endotracheal intubation, are appropriate in some circumstances. For example, an informed patient or surrogate may want only limited resuscitative efforts, realizing that this may decrease the chances of successful resuscitation. <A NAME="anchor64"></A> A no-CPR order means only that CPR will not be initiated. It does not mean that other care should be limited. These orders should not lead to abandonment of patients or denial of appropriate medical and nursing care. They do not constitute "giving up." The same reasons that make CPR inappropriate, however, may also render other treatments unsuitable. After a no-CPR order is written, the attending physician should clarify plans for further care with nurses, consultants, and house staff, as well as with the patient or surrogate. For many patients, interventions for diagnosis or treatment remain appropriate after a no-CPR order is written. In CCUs it is important to clarify how to respond to physiological abnormalities, such as arrhythmia or hypotension, that could lead to cardiopulmonary arrest if not treated. Basic nursing care, such as oral hygiene, skin care, and patient positioning, and measures to relieve pain and other symptoms should be continued.<HR ALIGN=LEFT> <A NAME="anchor65"></A> <H1><A NAME="anchor147939"></A>16.5 Role of Hospital Ethics Committees</H1> Hospitals are now required to have advisers such as ethics committees and bioethicists who can respond to requests for resolution of ethical questions. Ethics committees traditionally have been consultative and advisory and have been effective in organizing educational programs and developing hospital policies and guidelines. There is considerable variability among hospitals with respect to committee responsibilities, authority, membership, access, and procedural protocols, and hospitals should develop explicit statements on these issues.<HR ALIGN=LEFT> <A NAME="anchor66"></A> <H1><A NAME="anchor148249"></A>16.6 Legal Considerations in CPR and ECC</H1> The ethical and legal aspects of CPR and ECC can be conceptualized in terms of two periods. From the national implementation of CPR after the first national conference on CPR in 1973 until 1990, many physicians were greatly concerned with malpractice liability for withholding or withdrawing CPR. The second period was initiated in 1990 by the US Supreme Court decision in the Cruzan case and the passage of the Patient Self-Determination Act.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0013" TARGET="Footnote #13">13</A> In the Cruzan case the court assumed that competent patients have a constitutionally protected liberty interest to refuse unwanted medical treatment. The ruling permitted states to adopt procedural requirements for withholding life-sustaining treatment. The Cruzan decision, together with the Patient Self-Determination Act, shifted the discussion to how to support the right of patients to make decisions about their medical care and to make advance directives more effective. Physicians need to take responsibility for maximizing the benefits of advance directives and the Patient Self-Determination Act while minimizing undesirable outcomes. <A NAME="anchor67"></A> The Patient Self-Determination Act, effective December 1, 1991, was intended to encourage discussion about advance directives.<A HREF="http://localhost:8032/servlet/lp?url=Book_ACLS/ACLS_ch16/ch16_ref.htx#anchor0013" TARGET="Footnote #13">13</A> This act applies to hospitals, home health agencies, skilled nursing facilities, hospices, and health maintenance organizations that participate in Medicaid and Medicare. Such providers must establish written policies and procedures to inform all adult patients of their rights "to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate an advance directive." This information must be provided at the time of admission to the hospital or nursing home, at the time treatment is provided by the home health agency, or at the time of enrollment in a health maintenance organization. These institutions or agencies must document in the medical record the existence of an advance directive and must respect such directives to the fullest extent possible under state law. Physicians should take advantage of these requirements of the act to talk with patients about their preferences regarding CPR in various clinical situations. <A NAME="anchor68"></A> Good Samaritan laws have been expanded in a number of jurisdictions to protect from liability laypersons and health professionals who do not have a duty to respond, who are acting "in good faith," and who are not guilty of gross negligence. Such laws were intended to minimize fear of legal consequences for providing CPR, which might hinder multilevel community ECC programs.<HR ALIGN=LEFT> <A NAME="anchor69"></A> end of Chapter 16 </BODY> </HTML>