It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the (...) use of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field. (shrink)

Cardiopulmonary Resuscitation is the default response for persons who suffer cardiac or pulmonary arrest, except in cases in which there exists a do-not-resuscitate order. This default mindset is based on the rule of rescue and the ethical principle of beneficence. However, due to the lack of efficacy and the high risk of potential harm inherent in CPR, this procedure should not be the default intervention for cardiac or pulmonary arrest. Although CPR is a lifesaving medical intervention, it has (...) limited positive results and the potential for multiple harmful consequences. Given the limited potential of CPR as a medical procedure, clinicians and patients must be educated regarding its limited potential, and procedures must be developed to help determine when it is appropriate as a medical intervention. (shrink)

Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and (...) on substituted interest judgments. Patients’ known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR. (shrink)

SIRThere are some important flaws in Michael Ardagh's reasoning.11. Cardiopulmonary resuscitation is a “blanket term” for different interventions. Curative and supportive treatments have different ethical contexts and cannot be discussed at the same level. It is imperative to ascribe curative interventions within CPR the same status as any other curative intervention, such as antibiotics for infections or surgery for appendicitis. Then we will be able to discuss the ethical context of purely supportive measures such as chest compressions. To (...) address the “ethics of CPR” is a dangerous misnomer.The preferences of emergency personnel2 suggest the willingness to undergo curative interventions early during CPR, but not protracted supportive interventions. Conversely, withholding curative interventions during CPR should only be considered when any curative treatments would also be withheld.2. Cardiopulmonary resuscitation is performed to offer the patient a benefit. However, CPR as a whole is only marginally effective. …. (shrink)

One hundred inpatients on an acute hospital elderly care unit and 43 of their relatives were interviewed shortly before hospital discharge. Eighty per cent of elderly patients and their relatives were aware of cardiopulmonary resuscitation (CPR). Television drama was their main source of information. Patients and relatives overestimated the effectiveness of CPR. Eighty-six per cent of patients were willing to be routinely consulted by doctors about their own CPR status, but relatives were less enthusiastic about routine consultation. Patients' (...) and relatives' views about the appropriateness of CPR did not differ significantly. Seventeen percent of patients did not desire CPR. However, 64 per cent of patients were ultimately willing to follow their doctor's advice about the appropriateness of CPR. The conclusion reached is that mentally competent, elderly patients but not their relatives should be routinely consulted about their own desire for CPR in order to avoid resuscitating patients against their wishes. Further research is required to find out how patients would feel about resuscitation if they were terminally ill or chronically confused, and how carers would feel about resuscitating such patients. (shrink)

The guidelines on Decisions Relating to Cardiopulmonary Resuscitation begin with a reassuringly objective view of medicine: its “primary goal” is to benefit patients by “restoring or maintaining their health as far as possible, thereby maximising benefit and minimising harm”. Some might want to add that medicine has several goals, not all of which relate to promoting health; however, those who see the aim of the profession as more than consumer satisfaction will welcome the suggestion here that not just (...) any choice counts as medicine. In the same way, the statement which heads the next paragraph would be rejected by very few readers if “quality of life” were suitably defined. If all we mean by “quality of life” is the patient's level of wellbeing, with no suggestion that the value of his or her “being” can fall to zero or below, it is uncontroversial that “it is not an appropriate goal of medicine to prolong life at all costs with no regard to its quality or the burdens of treatment on the patient”. This is, however, an overly benign interpretation of “quality of life” observations as they appear in the guidelines. (shrink)

Whether to allow the presence of family members during cardiopulmonary resuscitation has been a highly contentious topic in recent years. Even though a great deal of evidence and professional guidelines support the option of family presence during resuscitation , many healthcare professionals still oppose it. One of the main arguments espoused by the latter is that family members should not be allowed for the sake of the patient's best interests, whether it is to increase his chances of (...) survival, respect his privacy or leave his family with a last positive impression of him. In this paper, we examine the issue of FPDR from the patient's point of view. Since the patient requires CPR, he is invariably unconscious and therefore incompetent. We discuss the Autonomy Principle and the Three-Tiered process for surrogate decision making, as well as the Beneficence Principle and show that these are limited in providing us with an adequate tool for decision making in this particular case. Rather, we rely on a novel principle and a novel integrated model for surrogate decision making. We show that this model is more satisfactory in taking the patient's true wishes under consideration and encourages a joint decision making process by all parties involved. (shrink)

Background:The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.Research objective:To explore what the nurse’s advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).Research (...) design:An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.Participants:Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).Ethical considerations:Approval was obtained from the Basque Country Clinical Research Ethics Committee.Findings:Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.Discussion:The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses’ advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.Conclusion:This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians. (shrink)

Since the last generation medical ethics has seen a remarkable shift from benign medical paternalism to patient rights and autonomy. Whereas once it might have been acceptable for doctors to decide, largely on their own, what was in the best interests of their patients, today senior health professionals are expected to make decisions jointly both with patients or their carers and with other health professionals. Patient autonomy and justice, and not simply beneficence, are usually thought to be crucial to medical (...) ethics today.Although I strongly support this shift in medical ethics, I believe it is important to recognise that it has some cost to medical professionals, to patients and even at times to the National Health Service . Medical paternalism, when it was genuinely benign, did have some benefits both for doctors and for their patients. Yet precisely because most of us are no longer prepared to be at the receiving end of such paternalism, these particular benefits are now largely lost to us.The new joint statement, Decisions Relating to Cardiopulmonary Resuscitation,1 illustrates this point well. At the outset it admits that “health professionals are aware that decisions about attempting resuscitation raise very sensitive and potentially distressing issues for the patient and people emotionally close to the patient”. It was because of these sensitive and potentially distressing issues that it was once thought acceptable to make do not attempt resuscitation orders without consulting either patients or their families and with the knowledge that the latter would probably never discover that such orders had ever been made. Now, however, health workers are warned frankly that they “should remember …. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

In March of this year the British Medical Association , the Resuscitation Council and the Royal College of Nursing published guidelines outlining the legal and ethical standards for decision making in relation to cardiopulmonary resuscitation .1 The guidance follows a year of increasing public awareness and concern about the issue and builds upon joint guidance issued by these institutions in June 1999.In April 2000 Age Concern issued a press release stating that “some doctors are ignoring national guidelines (...) on the resuscitation of older people” and indicating that they had information on cases that had come to light in their campaign against age discrimination. Age Concern went on to say that older people have found “not for resuscitation” recorded in their medical notes without their agreement or knowledge.During the same month Professor Shah Ebrahim wrote a leader in the British Medical Journal stating that doctors regularly issue “do not resuscitate” orders for patients without their knowledge.2 He claimed that black people, alcohol mis-users, non-English speakers and those with HIV are more likely to get a “do not resuscitate” order, suggesting that prejudice is influencing medical decisions.This combination of events was followed by intense press and media interest in the way in which decisions were being made about cardiopulmonary resuscitation. Such was the level of concern that a health service circular was issued to all National Health Service trust chief executives in September 2000 asking that appropriate resuscitation policies be in place which respect patients' rights, are understood by …. (shrink)

Background There is lack of consensus in the bioethics literature regarding the use of cardiopulmonary resuscitation (CPR) for organ-preserving purposes. In this study, we assessed the perspectives of clinicians in critical care settings to better inform donor management policy and practice.Methods An online anonymous survey of members of the Society of Critical Care Medicine that presented various scenarios about CPR for organ preservation.Results The email was sent to 10,340 members. It was opened by 5,416 (52%) of members and (...) 405 members (4%) completed the survey with few missing data. A majority of respondents (81%) answered that donation status should not influence whether CPR is performed on an imminently dying patient. There was very strong agreement (>85%) that 1) CPR should be performed on a registered donor who experiences a cardiac arrest with an unknown code status before death by neurological criteria (DNC) and 2) CPR should be performed if the patient is not a registered donor and experiences cardiac arrest but the surrogate/power of attorney (POA) has not yet been approached regarding code status and donation. When a registered donor with a DNR order experiences cardiac arrest before DNC, 98% of respondents would not perform CPR. However, after DNC, respondents were evenly divided on whether they would (49%) or would not (51%) perform CPR on a registered donor with an undocumented code status. When asked whether consent should be required for CPR for organ-preserving purposes, 39% answered “Yes” when a patient arrests before DNC and 48% answered “Yes” when a patient arrests after DNC (P = 0.2).Conclusions The majority of respondents did not consider donor status relevant to CPR decisions before DNC, and virtually all would respect a DNR order in a registered donor before DNC. Respondents were divided about the need for an affirmative consent for CPR for organ-preserving purposes both before and after DNC. (shrink)

Aim: The primary aim of the study was to evaluate two different methods of communicating information on cardiopulmonary resuscitation to patients admitted to general medical and elderly care wards. The information was either in the form of a detailed information leaflet or a summary document . The study examined the willingness of patients in seeking detailed information on cardiopulmonary issues.Setting: The study was conducted over three months on a general medical ward and an acute elderly care ward (...) in two district general hospitals.Methods: A detailed information leaflet on CPR was provided to the nursing staff on the wards. An A4 summary document summarising the CPR decision making process and basic information on cardiopulmonary issues was placed in a folder at the foot of each bed on the elderly care ward. On the general medical ward it was displayed prominently over the head of all beds.Results: Out of the 274 patients admitted to the general medical ward only two requests were received for the detailed information leaflet. On the elderly care ward there were 182 admissions but no patients or their relatives requested the leaflet.Conclusions: Availability of basic information on cardiopulmonary resuscitation to all patients is practical and does not lead to unnecessary distress or offence to patients or their carers. It makes the decision making process more transparent. Detailed information leaflets are of value for a minority of hospitalised patients. (shrink)

Most professional guidelines advocate family presence during resuscitation (FPDR). Many clinicians, however, are still reluctant to implement this recommendation. In this article I present the most comprehensive case for FPDR to date. I review the little that has been written about the ethics of FPDR, as well as the available empirical evidence. More importantly, I present and defend three arguments for FPDR: adherence to professional guidelines, benefit to patients and relatives, and patients’ autonomy. I conclude with suggestions for future (...) research. (shrink)

Background Cardiopulmonary Resuscitation (CPR) is one of the areas in which moral issues are of great significance, especially with respect to the nursing profession, because CPR requires quick decision-making and prompt action and is associated with special complications due to the patients’ unconsciousness. In such circumstances, nurses’ ability in terms of moral sensitivity can be determinative in the success of the procedure. Identifying the components of moral sensitivity in nurses in this context can promote moral awareness and improve (...) moral performance. Objective This study was conducted to explore and identify the experiences of critical care nurses about moral sensitivity components in CPR. Research design and methods This study was implemented with a qualitative approach. Data were collected via 22 in-depth semi-structured interviews held with 20 eligible participants with maximum variation. The data were then analyzed using the grounded theory approach. Participants and research context In total, thirteen clinical nurses, three head nurses, two educational supervisors, and two faculty members from different universities of Iran were interviewed. Ethical considerations This study was conducted with the ethical approval (IR.UMSU.REC.1399.337) of the Ethics Committee of Urmia University of Medical Sciences. Findings Four themes and 12 sub-themes were extracted from the analysis of the data, including “Consciously and compassionate attention to resuscitate the patient,” “Awareness of families’ anxiety,” “Understanding the teamwork and interactive guidance of the CPR process,” and “Compulsory violation of moral principles.” Discussion It is anticipated that this discussion will prompt further debate, raise awareness and help clarify the dimensions of moral sensitivity in unconscious patients especially during CPR, so that it can be more clearly named and defended as a moral authority in CPR. Conclusion identifying the components of moral sensitivity in nurses, facilitates their encounter with moral issues and can improve their moral performance and encourage right decisions. (shrink)

Some health care organizations allow physicians to withhold cardiopulmonary resuscitation from a patient, despite patient or surrogate requests that it be provided, when they believe it will be more harmful than beneficial. Such cases usually involve patients with terminal diagnoses whose medical teams argue that aggressive treatments are medically inappropriate or likely to be harmful. Although there is state-to-state variability and a considerable judicial gray area about the conditions and mechanisms for refusals to perform CPR, medical teams typically (...) follow a set of clearly defined procedures for these decisions. The procedures are based on the principle of nonmaleficence and typically include consultation with hospital ethics committees, reflecting the guidelines of relevant professional associations. Ethical debates about when CPR can and should be limited tend to rely more on discussions of theory, principles, and case studies than systematic empirical study of the situations in which such limitations are applied. Sociologists of bioethics call for empirical study, arguing that what ethicists and health professionals believe they are doing when they draft policies or invoke principles does not always mirror what is happening on the ground. In this article, we begin the task of modeling the empirical analyses sociologists call for, focusing on a cohort at Massachusetts General Hospital. We inductively analyzed ethics committee notes and medical records of nineteen patients whose surrogates did not accept the decision to withhold CPR. (shrink)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp (...) good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated. (shrink)

Background: Certain factors may facilitate or inhibit the formation of moral sensitivity in nurses performing cardiopulmonary resuscitation (CPR). The identification of these factors in the context can help develop strategies to promote nurses’ moral sensitivity and offer new insights into the consequences of their moral decisions. Objective: Taking into account the possibly multi-factorial nature of moral sensitivity, this study aimed to identify the factors affecting the formation of nurses’ moral sensitivity in CPR settings. Research design and methods: This (...) study performed a conventional qualitative content analysis. Twenty-one participants were selected via purposive and theoretical sampling. The data were collected through in-depth semi-structured interviews and simultaneously analyzed via content analysis. Participants and research context: In total, twenty-one participants (fourteen clinical care nurses, three head nurses, two educational supervisors, and two faculty members) from different cities of Iran were interviewed. Ethical considerations: The research was approved by the Ethics Committee of Urmia University of Medical Sciences in Iran (IR.UMSU.REC.1399.337). Findings: Four categories (underlying factors, professional factors, organizational inhibitors of ethics, and professional limitations) and 13 sub-categories were extracted. Discussion: The formation of moral sensitivity requires a range of ethical standards and their maintenance, not only at the individual level but also at the profession, organization, and community levels. So eliminating inhibitors of ethics in these contexts can improve nurse’s ethical performance in CPR settings. Conclusion: Any measures taken or decisions made by nurses in CPR are driven by numerous ethical issues to which nurses must be morally sensitive. Some factors facilitate and some inhibit the formation of moral sensitivity in nurses. (shrink)

It is now a default obligation to provide cardiopulmonary resuscitation (CPR), in the absence of knowledge of a patient’s or surrogate’s wishes to the contrary. We submit that it is time to reevaluate this position. Attempting CPR should be subject to the same scrutiny demanded of other medical interventions that involve balancing a great benefit against grievous harms.

In clinical ethics, there remains a great deal of uncertainty regarding the appropriateness of attempting cardiopulmonary resuscitation (CPR) for certain patients. Although the issue continues to receive ample attention and various frameworks have been proposed for navigating such cases, most discussions draw heavily on the notion of harm as a central consideration. In the following, I use emerging philosophical literature on the notion of harm to argue that the ambiguities and disagreement about harm create important and oft-overlooked challenges (...) for the ethics of CPR. I begin by elucidating the standard account of harm, called the Counterfactual Comparative Account (CCA). I then show that three challenges to the CCA—preemptive harms, the harm of death, and non-experiential harms—are particularly salient when assessing potential harms for candidates of CPR and likely impact-related decision-making and communication. I extend this argument to explore how the ambiguities of harm might extend to other realms of clinical decision-making, such as the use and limitations of life-sustaining treatments. To address these challenges, I propose two strategies for identifying and minimizing the impact of such uncertainty: first, clinicians and ethicists ought to promote pluralistic conversations that account for different understandings of harm; second, they ought to invoke harm-independent considerations when discussing the ethics of CPR in order to reflect the nuances of such conversations. These strategies, coupled with a richer philosophical understanding of harm, promise to help clinicians and ethicists navigate the prevalent and difficult cases involving patient resuscitation and many other harm-based decisions in the clinical setting. (shrink)

The Institute of Medicine and the American Heart Association have issued a “call to action” to expand the performance of cardiopulmonary resuscitation in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the “improved” results when nonprofessional bystanders (...) are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes. (shrink)

Cardiopulmonary resuscitation is frequently performed on patients who, in retrospect, had a very low chance of survival. This is because all patients are ‘For cardiopulmonary resuscitation’ on admission to hospital by default, and delays occur before cardiopulmonary resuscitation can be ‘de-prescribed’. This article reviews the nature of potential harms caused by futile cardiopulmonary resuscitation, the reasons why de-prescription may be delayed, recent legal judgements relevant to timely do not attempt cardiopulmonary (...) class='Hi'>resuscitation decision making, and the possible detrimental effects of do not attempt cardiopulmonary resuscitation discussions on end of life care. The moral and operational feasibility of a model in which informed consent must be obtained before cardiopulmonary resuscitation is attempted in some patient groups is then explored. (shrink)

Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors (...) of ethics consult outcomes were analyzed. In 42 of the 116 cases, the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying. The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants’ recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients. (shrink)

Relatives’ presence in connection with cardiopulmonary resuscitation and sudden death at the intensive care unit Within Norwegian intensive care units it is common to focus on the needs of the next of kin of patients undergoing end‐of‐life care. Offering emotional and practical support to relatives is regarded as assisting them in the initial stages of their grief process. It has also become usual to encourage relatives to be present at the time of death of close relatives. How can (...) dignified end‐of‐life care coexist with the sometimes turbulent and dramatic character of intensive care in the highly technological environment of intensive care units? This paper describes a case study based on an incident that took place at the intensive care unit (ICU) of Trondheim University Hospital, Norway, in which the relatives of a newly deceased patient voiced unusually strong dissatisfaction with the way they were excluded in connection with cardiopulmonary resuscitation (CPR). The next of kin's criticism highlights an important paradox as well as a degree of inconsistency in lifesaving and end‐of‐life care at the ICU. I argue that an investigation of the multiple identities within medical practice can illuminate the potential for clashes between lifesaving and end‐of‐life care, as described and analysed in this paper. (shrink)

(2010). Insult to Injury: Ethical Confusion in American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The American Journal of Bioethics: Vol. 10, No. 1, pp. 68-70.

The Delegation for Medical Ethics within the Swedish Society of Medicine has taken the initiative to create national ethical guidelines on cardiopulmonary resuscitation. The reasons behind this initiative were indications of differences in the way decisions about cardiopulmonary resuscitation were made and documented and requests expressed by health-care professionals for new national ethical guidelines. During the process of creating the guidelines, a number of workshops were held with representatives from the delegation and clinical experts from various (...) branches of medicine. Several versions of the working document were sent to consultation bodies with requests for comments. We therefore believe that the final guidelines are well supported by the medical profession in Sweden. The purpose of this article is to present ethical issues on which it was difficult to reach consensus due to divergent opinions expressed by the people and organisations involved. The arguments for and against a particular point of... (shrink)

BackgroundDoctors and the Sri Lanka Medical Association recognise the importance of do not attempt cardiopulmonary resuscitation decisions and disclosure; however, few previous studies exist examining these practices in Sri Lanka. Resuscitation decisions have seen significant changes in the UK in recent years, with a legal imperative for clear communication and a move to understand patients’ preferred outcomes before recommending clinical guidance.MethodsParticipants from two Sri Lankan hospitals were selected purposively to represent a range of specialties and seniorities for (...) semi-structured interview.ResultsFifteen participants of varying seniorities were recruited. Practice of do not resuscitate and informing patients is highly variable; there is no definitive guidance published on best practice of these issues in Sri Lanka. Participants felt that inpatients were generally not aware of their medical conditions or treatments. With the poor social and palliative care service provision in Sri Lanka comes... (shrink)

BackgroundFamily presence during adult cardiopulmonary resuscitation is still not widely implemented. Based on empirical evidence, various national and international professional organizations recommend allowing relatives to be present during resuscitation. However, healthcare providers worldwide are still reluctant to make it standard care.PurposeThis paper is a part of an ongoing cross-cultural study that aims to solicit attitudes of healthcare providers working in emergency departments towards family presence during cardiopulmonary resuscitation. This paper reports the qualitative data from surveying (...) healthcare providers working in an emergency department at a university-affiliated hospital in Singapore.MethodHealthcare workers were asked to fill out an online survey, including both quantitative and qualitative questions. Their attitudes were critically analyzed and compared with existing empirical data.ResultsMajority of healthcare workers believed that relatives should not be present during c... (shrink)

The presence of patients’ families during cardiopulmonary resuscitation (CPR) is a controversial topic, due to its repercussions for clinical practice. While family members’ presence may help them to overcome their grief, it could be detrimental, as it may case posttraumatic stress disorder (PTSD), and there is the possibility that family members may interfere with the procedure. For these reasons, families’ presence during CPR has rejected by some healthcare providers.To research concerns about families’ presence among providers dealing with CPR (...) in the Fundación Hospital Alcorcón (Madrid), I performed this study. Of the 190 providers surveyed, 115 submitted a complete questionnaire. The most frequently reported concerns were interference (78.3 percent of respondents), and PTSD (69.6 percent of respondents). Fewer pediatric providers were concerned about PTSD than other providers (41.2% percent versus 74.5 percent, p = 0.01). Providers were reluctant to offer families the option of being present unless they had requested it, and would only permit it under certain conditions. Having a staff member to support the family was of great value to most respondents. The author believes families have a negative right to be present during CPR and so should be invited to stay. (shrink)

Background The ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest. Methods Cross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members (...) in their country. The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation. Results Of the 675 questionnaires distributed, 617 were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84, p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life. In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12, p = 0.003]. Conclusions In unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency. (shrink)

The context in which the British Medical Association first considered publishing specific guidelines on decisions about attempting cardiopulmonary resuscitation , in the early 1990s, needs to be remembered. At that time the subject was often seen as far too sensitive to be mentioned to patients. Many hospitals had no formal policy about how CPR decisions should be made, apart from an expectation that these were purely medical matters. Advance decision making about CPR, where it existed, appears to have (...) been generally on an ad hoc basis by doctors. Patients, their relatives and the rest of the health care team were often unaware of it. After several cases in which nurses had been disciplined–unfairly in the eyes of some–for complying with their patients' known wishes about non-resuscitation in cases where no advance medical decision had been recorded, there was a demand for guidance.The BMA was approached by nurses' representatives with a view to publishing some very basic advice. This advice, issued in 1993 jointly with the Royal College of Nursing, and in association with the Resuscitation Council, was under 1000 words. Whether this brevity reflects difficulties in achieving consensus or lower expectations about what was required is a matter for speculation. Throughout the 1990s the guidance was distributed widely and used as a basis for many hospitals' local policies. Recently, however, the demands on the BMA and other professional bodies for ethical advice have changed and grown. Discussion of sensitive decisions about potentially life-prolonging interventions is now …. (shrink)

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing (...) nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations. (shrink)

Few clinical situations arouse more emotion and drama and lead to more conflict in decision-making than cardio-pulmonary resuscitation . The procedure was described as potentially beneficial more than 40 years ago. However, its efficacy and place in the care of the frail elderly have taken a long time to be established. In the world of secular medical practice, there are many situations when CPR may be provided to elderly, frail and cognitively compromised individuals for whom its clinical benefit is (...) questionable. In those patients suffering from dementia, surrogates are responsible for decision-making, which complicates the process. When the clinical uncertainty is coupled with strong cultural and religious influences, as within Orthodox Judaism, the development of an acceptable approach to cardiac arrest is more challenging. A clinically sound, ethically defensible and religiously sensitive approach to CPR requires a deep understanding of all the factors involved in the decision-making process and may require periodic re-evaluation not only by clinicians but by religious scholars and leaders. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 24-25, November 2011.

Background Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care. Objective To explore nurses’ experiences of ethical and legal issues in post-resuscitation care. Research design This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis. Participants and research context In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data (...) were analyzed by conventional content analysis. Ethical considerations The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected. Findings Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care. Conclusion There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges. (shrink)

Decisions about cardiopulmonary resuscitation may be based on medical prognosis, quality of life and patients' choices. Low survival rates indicate its overuse. Although the concept of medical futility has limitations, several strong predictors of non-survival have been identified and prognostic indices developed. Early results indicate that consideration of resuscitation in the elderly should be very selective, and support "opt-in" policies. In this minority of patients, quality of life is the principal issue. This is subjective and best assessed (...) by the individual in question. Patients' attitudes cannot be predicted reliably and surrogate decision-making is inadequate. Lay knowledge is poor. However, patients can use prognostic information to make rational choices. The majority welcome discussion of resuscitation and prefer this to be initiated by their doctors; many wish to decide for themselves. There is little evidence that this causes distress. The views of such patients, if competent, should be sought actively. (shrink)

In the context of 'Do-not-resuscitate' (DNR) decisions, there is a lack of information in the UK on the opinions of patients and prospective patients. Written anonymous responses to questionnaires issued to 322 out-patient subjects showed that 97 per cent would opt for cardiopulmonary resuscitation (CPR) in their current state of health. In the hypothetical circumstance of having advanced senile dementia only 10 per cent would definitely want CPR, with 75 per cent preferring not to have CPR. There were (...) no significant correlations between the responses and sex or age. Of 270 patients asked verbally if they found the questions disturbing, none said they did. These findings show that the great majority of patients would not wish CPR if severely senile, and that patients are not disturbed by questions relating to their choice for or against CPR. This should encourage further investigations of patients' opinions on CPR in a broader range of conditions, and greater use of DNR orders. (shrink)

Many families of patients hold the view that it is their right to be present during a loved one's resuscitation, while the majority of patients also express the comfort and support they would feel by having them there. Currently, family presence is more commonly accepted in paediatric cardiopulmonary resuscitation than adult CPR. Even though many guidelines are in favour of this practice and recognise potential benefits, healthcare professionals are hesitant to support adult family presence to the extent (...) that paediatric family presence is supported. However, in this paper, we suggest that the ethical case to justify family presence during paediatric resuscitation is weaker than the justification of family presence during adult resuscitation. We go on to support this claim using three main arguments that people use in clinical ethics to justify FPDR. These include scarcity of evidence documenting disruption, psychological benefits to family members following the incident and respect for patient autonomy. We demonstrate that these arguments actually apply more strongly to A-FPDR compared with P-FPDR, thereby questioning the common attitude of healthcare professionals of allowing the latter while mostly opposing A-FPDR. Importantly, we do not wish to suggest that P-FPDR should not be allowed. Rather, we suggest that since P-FPDR is commonly allowed, so should A-FPDR. This is because the aforementioned arguments that are used to justify FPDR in general actually make a stronger case for A-FPDR. (shrink)