Suresh Naidu PPUM

2010

Law
Most useful applied retrospectively Previous decisions applicable Varies from state to satate,nation to nation

vs

Ethics

Prospective consideration Based on certain principles

Internationally applicable

Ethical Issues In Cardiopulmonary Resuscitation

A whole of gamut of complicated dilemma.

Successful v Unsuccessful.
Prolongation of suffering. Persistent vegetative state. Patients rights to die in dignity. Decision in a matter of seconds.

European Resuscitation Council

Principle #1 Autonomy Does my action impinge on an individual's personal autonomy?Do all relevant parties consent to my action?Do I acknowledge and respect that others may choose differently?

Four Basic Principles Of Ethics

4
Principle #4: Justice Is my proposed action equitable? How can I make it more equitable?

Principle #2 Beneficence Who benefits from my action and in what way?

Principle #3: Non-maleficene

Which parties may be harmed by my action? What steps can I take to minimise this harm? Have I communicated risks involved in a truthful and open manner?

Beauchamp TL, Childress JF. Principles of biomedical Ethics. 4th ed. Oxford: Oxford University Press, 1994.

Beauchamp and Childress Principles limitations.

Urgency to resuscitate vs to

deliberate on decision making

Impaired competence -

complicates 1st BC principle ..patients autonomy

Harms of resuscitation
Unnecessarywhen it is not indicated (patient too well to be undergoing resuscitation or too dead-like in rigor mortis)

Unsuccessfuldeath owing to advanced condition to patient, or outcome with poor quality of life

Cardiopulmonary Resuscitation: Ethical Issues

Resuscitation Decisions for inhospital settings
1. to initiate resuscitation

2. NOT to initiate resuscitation

3. to terminate resuscitation 4. to withdraw life support system (rarely)

1. to initiate resuscitation 2. NOT to initiate resuscitation 3. to terminate resuscitation

GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION

A. The Principle of Patient Autonomy Advanced directives (DNAR) If patient preferences uncertain, emergency conditions should be treated until those preferences are known B. The Principle of Futility Definition: physiological futility vs quantitative /qualitative measures

DO NOT ATTEMPT RESUSCITATION (DNAR) ORDER

DNAR order means just that - in the event of cardiopulmonary arrest, CPR should not be attempted at all.
Other treatment should be continued; e.g. pain relief, sedation on required basis in terminal illnesses.

CONSENT IN RESUSCITATION

PRESUMED CONSENT - perceived as respecting principle of beneficence but ignoring patient autonomy

PROXY CONSENT - consent from family member / caretaker who can speak on behalf of family.but the proxy might not reflect patients views .or the proxy benefits from patients death

CONSENT IN RESUSCITATION
PROXY CONSENT WITH SUBSTITUTED JUDGEMENT - - ask the proxy what would the patient want, not what the proxy want .

PRESUMED CONSENT USING PROFESSIONAL JUDGEMENT -Gather information regarding patient background, family wishes ,and based on knowledge of likely outcome from experience, medical literture and make ethical judgement .(Would I want this treatment if I am the patient ?)

Patient with DNAR order

Patient with signs of irreversible death (rigor mortis, decapitation, decomposition, dependent lividity)

No physiological benefit expected (futility)

Criteria To STOP CPR For In-Hospital Setting

In general,

resuscitation should be continued as long as VF persists.

And resuscitation

should be terminated when ongoing asystole for more than 20 minutes in the absence of a reversible cause, and with all measures of BLS and ACLS in

Withdrawing Life Support

1. Not usually done in A&E department 2. Often in intensive care units for clinical

brain death patients 3. Patient in deep coma for >24 hrs, after ruling out potentially reversible causes 4. Done by two specialists (usually anesthesiologists, neurologists, neurosurgeons) on two assessments (6hrs apart) 5. Detailed criteria can be found in MMC Brain death Guidelines

Criteria For NOT Starting CPR In Out-of-Hospital Setting

Paramedics are trained to start CPR at the very first instance upon a victim in cardiac arrest with the exception of:
1. A person with obvious clinical signs of

irreversible death (e.g. rigor mortis, dependent lividity, decapitation, decomposition) 2. A person with clear DNAR order 3. Attempts to perform CPR would place the rescuer at risk of danger/physical injuries

Criteria To STOP CPR In Out-ofHospital Setting

Restoration of effective, spontaneous

circulation and ventilation 2. Care is transferred to a more senior-level emergency medical professional 3. The rescuer is unable to continue because of exhaustion 4. Reliable criteria indicating irreversible death 5. A valid DNAR order is presented

 Usually only endotracheal intubation .

Ethically speakingneed consent .

Implied consentbut most ED patients who need

resus are in state of impaired competence, and rarely arrived to hospital on their own. Construed consent if consent obtained for certain procedure before death then it is construed the consent applicable for related procedure after death .but when the aim is no longer to save patient s life is previous consent still valid?

PRACTISING ON NEWLY DEAD

Proxy consent - procedure unlikely to take place

. Presumed consent appropriate when patient in impaired competence renders him/her incapable to make decisions -for this to be applicable community should be well informed so individuals have oppurtunity to decline consent if they desire .
Our practice dont ask ,dont tell is ethically unjustifiable

Case 1
A building has collapsed. You are called in to help

out with the disaster. At the disaster site, a man has stopped breathing at a distance not far from where you are standing. The relatives over there are shouting for you to come over and help. However, you realize that some rocks are still falling from where the man is trapped. Would be liable to be sued if you do not?

Case 2
A 80-year old man with history of frequent

exacerbation of COPD is diagnosed with acute pulmonary edema, currently complicated with respiratory failure Type 2. All other treatment modalities fail to prevent his deterioration. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort. 1. Would you have intubated him? 2. If the relatives insist on you to actively resuscitate him but you do not, would you be liable to be sued?

Case 3
A 50-year old, previously healthy and active

sportsman, is admitted for sudden onset of chest pain. He collapses while being treated in the emergency department. You start CPR and defibrillation promptly. Realizing what you are doing, the wife intervenes and insists that you stop the resuscitation process. She says that he has verbally stated his wish that he does not want to be actively resuscitated and a prolonged suffering the moment he dies.
What would you do?

Case 4
A 40-year old, previously healthy, army is involved

in a serious car accident. On arrival to the emergency department, his GCS is 7/15. He is mechanically ventilated. His vital signs are good. A CT scan brain is done - showing a massive intraparenchymal bleeding over the right hemisphere with midline shift and generalized cerebral edema. Clinical re-assessment 30 minutes later shows that the patient is manifesting signs of increased ICP and transtentorial herniation. In view that his prognosis may not be good and that the ward resources are limited, the managing team decides to withdraw his support system in A&E. What do you think

SURROGATE DECISION MAKERS (IN ORDER OF PRIORITY)

1.Spouse 2. Adult child 3. Parent 4. Any relative 5. Person nominated as the person caring for

the incapacitated patient 6. Specialized care professionals

Must act in best interest of patient

CONCLUSION
Decision making in cardiopulmonary

resuscitation can be very complex due to the diversity of the cases It may have to be made in matters of seconds! If in doubt, always err on for the patients benefit Always treat the patient with dignity and respect If you do not want this to be done to your own family member, you do not want it to be done on your patient

..And in the end

If you or your team have made the decision to

withdraw a life support system in emergency department, you should also be responsible to document and sign your decisions and to answer any doubts from the family. Do not push the job to another team. Treat the resuscitation process seriously. Respect the solemn moment for the patient and relatives
Do not laugh or joke when resuscitation is going

on

Sources
Australian resuscitation council

British resuscitation council

Emergency medicine Peter Cameron