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172 SECTION 4: Resuscitative Procedures Ethical Issues of Resuscitation Catherine A. Marco GENERAL PRINCIPLES OF MEDICAL ETHICS The study of ethics is an effort to understand and examine the moral life.1 The Hippocratic Oath is revered as one of the oldest codes of medical ethics. More recently, the American Medical Association Code of Ethics (earliest version in 1847) 2 and the American College of Emergency Physicians Code of Ethics (2016 and 2017) 3,4 have provided guidance to emergency physicians in the application of ethical principles to clinical practice. Principles of bioethics include beneficence (doing good); nonmaleficence (primum non nocere, or “do no harm”); respect for patient autonomy, confidentiality, and honesty; distributive justice; and respect for the law. Ethical dilemmas arise when there is a potential conflict between two principles, values, or individuals. Physicians resolve these dilemmas by gathering additional information; assessing patient capac ity; conducting meetings with other healthcare professionals, patients, and families; and applying an informed judgment in individual situa tions. In some circumstances, physicians may seek the involvement of the institutional ethics committee or the judicial system. CARDIAC RESUSCITATION AND OUTCOMES There are approximately 300,000 sudden deaths in the United States annually. 5 The outcome of resuscitative efforts for victims of cardiac arrest is uniformly poor but varies depending on a variety of factors, including time elapsed since arrest (down time), presenting rhythm, bystander CPR, and response to prehospital advanced cardiac life sup port protocols. Reported estimates of survival of out-of-hospital arrest vary significantly. Recent data suggest improved survival after cardiac arrest. Overall survival after out-of-hospital cardiac arrest was 5.6% in 2005 to 2006 and improved to 8.3% in 2012. Several variables are associated with improved outcome after out-ofhospital cardiac arrest, including witnessed arrest, shockable rhythm, lower age, lack of significant comorbidities, bystander CPR, early advanced cardiac life support early defibrillation, and targeted temperature management. 7-19  FUTILITY AND NONBENEFICIAL INTERVENTIONS An advance directive is any proactive document stating the patient’s wishes in various situations should the patient be unable to do so, yet most Americans do not have an advance directive, complicating the application of resuscitative interventions. 20-25 See Chapter 301, “Death Notification and Advance Directives, ” for further information; see also Chapter 303, “Legal Issues in Emergency Medicine. ” The term futility is subject to interpretation. Healthcare professionals may determine futile interventions to be those that carry an absolute impossibility of successful outcome, a low likelihood of return to spon taneous circulation, a low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of meaningful quality of life. Futility can be defined as “any effort to achieve a result that is possible, but that reasoning, or experience suggests is highly improbable and that cannot be systematically produced. ” 26 There is no consensus among physicians about the meaning of the term. It is probably more accurate to use terminology such as nonbeneficial, ineffectual, or low likelihood of success when discussing resuscitation with patients or families.

e suggests is highly improbable and that cannot be systematically produced. ” 26 There is no consensus among physicians about the meaning of the term. It is probably more accurate to use terminology such as nonbeneficial, ineffectual, or low likelihood of success when discussing resuscitation with patients or families. The American Medical Association Council on Ethical and Judicial Affairs stated that CPR may be withheld, even if requested by the patient, “when efforts to resuscitate a patient are judged by the treating physician to be futile. ” 27 Dilemmas regarding nonbeneficial interventions often arise due to inadequate or ineffective communication between the phy sician, patient, and family. This is of concern in emergency medicine, in which previous relationships with patients and family rarely exist and time is often inadequate to establish effective relationships. Thus, initial efforts should be directed to improve communication, education, and joint decision making. Emergency physicians’ judgments should be unbiased, based on available scientific evidence, mindful of societal and professional standards, and sensitive to differences of opinion regarding the value of medical intervention in various situations. Ultimately, the decision regarding CPR and its likelihood of benefit to the patient and decisions to provide, limit, or withhold resuscitative efforts are to be made by the emergency physician in the context of well-accepted research results, patient and family wishes, and professional judgment. Individual bias regarding quality of life or other related issues should be avoided. There are many situations in which dying can be accepted as a natural process, even in an emergency setting.  TERMINATION OF RESUSCITATIVE EFFORTS Several organizations have proposed criteria for withholding resuscitative efforts for patients with a very low likelihood of successful resus citation. Several validated decision rules incorporate related factors predictive of dismal outcome. 28-32 Prehospital resuscitative efforts may be terminated under circumstances delineated by the Basic Life Sup port Termination of Resuscitation Rule.33 This rule is recognized by the American Heart Association34; the National Association of EMS Physi cians has adopted these criteria, which are listed in Table 27-1.35 In accordance, American College of Emergency Physicians policy states, “Resuscitative efforts may be appropriately withheld, withdrawn, or limited in circumstances such as the lack of immediately available resuscitation resources, or when there is no realistic likelihood of benefit to the patient based on existing scientific evidence and reasonable medical judgment. ” FAMILY PRESENCE DURING RESUSCITATION Family presence during resuscitation may improve understanding and relieve family member guilt or disappointment and may be a helpful part of the grieving process. 37-44 Physicians should be sensitive to the possibility that this option may be difficult for certain family members or staff. If family members are invited to be present, provide a liaison to assist with communication and education about procedures and other medical issues. SPECIAL SITUATIONS  RESUSCITATION AFTER SUICIDE ATTEMPTS Following a suicide attempt, assessment of mental capacity is difficult or impossible. Because resuscitative efforts may be lifesaving, efforts should be undertaken in this setting. Potential issues regarding capacity, patient autonomy, and shared decision making can be addressed following successful resuscitative efforts.  PROCEDURES ON RECENTLY DECEASED PATIENTS The practices of teaching and performing procedures on recently deceased patients are controversial.

ld be undertaken in this setting. Potential issues regarding capacity, patient autonomy, and shared decision making can be addressed following successful resuscitative efforts.  PROCEDURES ON RECENTLY DECEASED PATIENTS The practices of teaching and performing procedures on recently deceased patients are controversial. The most important benefit of these practices is the opportunity for hands-on practice for students, CHAPTER TABLE 27-1 National Association of EMS Physicians Standards for Termination of Resuscitation in Nontraumatic Cardiopulmonary Arrest Termination of resuscitation may be considered when, at the time of decision of termination, all of the following conditions have been met: •  The  arrest was not witnessed by an EMS provider. •    There is no shockable rhythm identified by an automated external defibrillator (AED) or other electronic monitor. •  There  is no return of spontaneous circulation prior to EMS transport. Tintinalli_Sec04_p0143-0228.indd 172 7/31/19 1:43 PM