Ethical Dilemmas Regarding Cardiac Resuscitation

The lengthy history of attempted resuscitation of the dying is summarized nicely at the ukdivers.net site and extends from the Bible description through the years with many and various methods to the current cardio-pulmonary resuscitation (CPR).

The first apparent attempt at resuscitation interestingly enough was recorded around 800 BC. The first resuscitation was Elijah's mouth to mouth (Bible, 2 Kings, iv, 34.).
"...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm."

A visitor came to my blog today from a search engine requesting information about “ethical dilemmas regarding cardiac resuscitation” Unfortunately, I hadn’t put up anything on this blog previously but thought this would be an appropriate time to begin the discussion.

I would say that the most common ethical dilemmas regarding CPR is when to perform it and when not to. Unfortunately, making the decision has been made a dilemma because some years ago when CPR was beginning to be widely used there was an informal tendency for it to be applied by default to any person who appeared in cardio-pulmonary arrest. This was because of the almost uniformly successful results. However, the success was because the very earliest use of CPR was applied only in conditions that were readily reversible such as in healthy young people who nearly drowned or had been subjected to severe electric shock. The default use of CPR still continues today in and out of the hospital unless there is a written order or advance directive not to attempt resuscitation. But the outlook for recovery from CPR is much worse now that CPR is used in patients who have uncorrected severe metabolic abnormalities and/or chronic underlying disease of vital organs or end-stage cancer. The result of attempted CPR currently is either no response or poor recovery with dying simply prolonged often associated with rib fractures or liver trauma or brain damage. Not many patients leave the hospital recovered.

Thus when a medical team arrives at the bedside of a patient with cardiac arrest the first questions include the diagnosis and whether a “do not attempt resuscitation” order has been written. If no such order has been found, the team must begin CPR but with questions as to whether it is the “right” thing to do especially when such treatment appears futile. Sometimes, this leads to a “half-hearted” attempt at CPR that is really unprofessional and which subjects the patient to unnecessary additional trauma with no intent to achieve the goal of full resuscitation. More rare is a situation in which there is a “do not resuscitate” directive by the patient or family and the medical staff may disagree, believing that the patient can be rehabilitated. The staff must consider in this situation that carrying out a CPR attempt in face of such a directive may represent legal battery.

What can be done to avoid uncertainties in responding to cardiac arrest situations? One would be if there were general consensus that at least in the hospital situation the default policy is that no patient receives CPR unless there is a specific order before hand readily available to the contrary. Every patient admitted to the hospital must get an evaluation and then reevaluated throughout the hospital course for CPR. The other would be, if CPR is to remain as the default order for all patients, all patients (along with their families) should be informed and make decisions about not receiving CPR and if that decision is made, there should be readily available documentation confirming that no resuscitation should be performed.

Unfortunately, most considerations about CPR or no CPR occur too late in the hospital course when the patient is no longer competent to decide and the family is not able or willing to take responsibility to decide. And when left to the last second.. well..good luck! ..Maurice.