Ethical Issues In

Cardiopulmonary
Resuscitation
Dr. DoHA RASHEEDY ALY
Lecturer of Geriatric Medicine
Department of Geriatric and
Gerontology
Ain Shams University
20/ 12/ 2012

CPR has the same goals as other

medical interventions:
to preserve life.
restore health.
relieve suffering.
limit disability.

One goal unique to CPR is the reversal of clinical

death, an outcome achieved in only a minority of
patients.

 The performance of CPR, may conflict with

the patients own desires or may not be in his
best interest.

Decisions concerning CPR are complicated and

often must be made within seconds by rescuers who
may not know the patient or know of the existence of
an advance directive.

In some instances resuscitation may not be

the best use of limited medical resources.

Concern about costs associated with prolonged

intensive care should not preclude emergency
resuscitative attempts in individual patients .

Prognosis of CPR
CPR has a grim prognosis at any age.
A 30 year Meta analysis of almost 20,000 cases of in
hospital CPR revealed that patients younger than 70
years of age had a success rate of 16.2 %versus 12.4
%for patients older than 70 years.

72.9 % of post-CPR deaths were within 72 hours and

1.6 % of successfully resuscitated patients had a
permanent neurological impairment.
Schneider A. et al. In-hospital Cardiopulmonary
30-year review. J Am Board Fam Pract. 1993;6(2):91-101

Resuscitation: a

 In frail elderly and demented patients survival

following CPR is dismal (0-4%) regardless of the
clinical setting and for patients in long term care
facilities CPR survival is essentially 0%.
Gordon M. CPR in Long Term Care: Mythical Reality or Necessary Ritual? Annals of Long-Term Care: Clinical
Care and Aging. 2003;11(4):41-49

Duration of CPR as well as the patients pre-arrest comorbidities

also significantly affect survival to hospital discharge
Rosenberg M, Wang C, Hoffman-Wilde S, et al. Results of cardiopulmonary resuscitation. Arch Intern Med
1993;153:13705.

Patients who are highly functional with fewer chronic illnesses,

hospitalized for a cardiac etiology, and closely monitored before the
arrest are more likely to benefit from CPR. In these circumstances,
CPR can be very successful, and elderly patients will benefit as much
as younger patients
Tresch DD, Thakur RK. Cardiopulmonary resuscitation in the elderly. Beneficial or an exercise in futility? Emerg
Med Clin North Am 1998;16:64963.

 Writing a DNR order can be very difficult for many

physicians. Feelings of giving up too soon or not
doing enough to ultimately save the patients life are
difficult to deal with professionally and personally
even when the situation is clearly futile because our
training and mind set are to defeat death and
disease at any cost.

Ethical Principles

Ethical Principles
Healthcare professionals should consider ethical, legal, and cultural
factors when caring for those in need of CPR.

They should be guided by:

1.
2.
3.
4.

science.
the individual patient or surrogate preferences.
local policy.
legal requirements.

 Autonomy:
Right of patient to accept or refuse treatment

Beneficence:
Are we providing benefit to patient or are we just delaying death
and prolonging suffering?

Non maleficence
Do no harm, or further harm, CPR should not be initiated in futile
cases

Justice
Duty to distribute limited health resources equally within a
society, and the decision of who gets what treatment

Dignity and honesty

Patients right to be treated with dignity
Honesty in revealing information

OUT OF HOSPITAL SETTINGS

Criteria for Not Starting CPR in

Out-of Hospital Cardiac Arrest
1. Situations where attempts to perform CPR would place the
rescuer at risk of serious injury.

2. Obvious clinical signs of irreversible death (eg, rigor mortis,

dependent lividity, decapitation, transection,or decomposition)

3. A valid, signed, and dated DNAR

Terminating Resuscitative
Efforts
in
Adult
OHCA
Rescuers who start BLS should continue resuscitation until one of
the following occurs:

1.Restoration of effective, spontaneous circulation

2.Care is transferred to a team providing advanced life support
3.The rescuer is unable to continue because of exhaustion, the
presence of dangerous environmental hazards, or because
continuation of the resuscitative efforts places others in jeopardy

4.Reliable and valid criteria of death

criteria for termination of

resuscitation

BLS
ALS

BLS termination-of-resuscitation
rule
adult
OHCA.23.
BLS of-resuscitation rule
forfor
adult
OHCA.23.

Morrison L J et al. Circulation 2010;122:S665-S675

Copyright American Heart Association

ALS termination-of-resuscitation
rule
adult
OHCA.33.
ALS of-resuscitation rule
forfor
adult
OHCA.23.

Morrison L J et al. Circulation 2010;122:S665-S675

Copyright American Heart Association

IN HOSPITAL SETTINGS

Criteria for Not Starting CPR in

Adult IHCA
Few criteria can accurately predict the futility of
continued resuscitation. In light of this uncertainty,
all adult patients who suffer cardiac arrest in the
hospital setting should have resuscitative attempts
initiated unless the patient has a valid DNAR order
or has objective signs of irreversible death (eg,
dependent lividity).

Oral DNAR orders are not acceptable.

 A DNAR order does not automatically preclude

interventions such as administration of parenteral
fluids, nutrition, oxygen, analgesia, sedation,
antiarrhythmics, or vasopressors, unless these
are included in the order. Some patients may
choose to accept defibrillation and chest
compressions but not intubation and mechanical
ventilation.

Contraindications
The only absolute contraindication to CPR is a do-not-resuscitate
(DNR) order .

A relative contraindication to performing CPR if medically futile,

although this is clearly a complex issue that is an active area of
research.
Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-ofhospital cardiac arrest. N Engl J Med. Aug 3 2006;355(5):478-87.

Morrison LJ, Verbeek PR, Vermeulen MJ, et al. Derivation and evaluation of a termination of
resuscitation clinical prediction rule for advanced life support providers. Resuscitation. Aug
2007;74(2):266-75.

Withholding
Withholding and
and Withdrawing
Withdrawing CPR
CPR (Termination
(Termination of
of Resuscitative
Resuscitative
Efforts)
Efforts) Related
Related To
To In-Hospital
In-Hospital Cardiac
Cardiac Arrest
Arrest

Physicians decision is based on consideration of

many factors:
1.witnessed versus unwitnessed arrest,
2.time to CPR,
3. initial arrest rhythm,
4.time to defibrillation,
5.comorbid disease
6.prearrest state
7.there is ROSC at some point during the resuscitative efforts.

When is CPR not of benefit?

Knowledge of the probability of success with CPR could be used to
determine its futility.

University of Washington School of Medicine

CPR has been shown to be have a 0% probability of success in the

following clinical circumstances:

Septic shock
Acute stroke
Metastatic cancer
Severe pneumonia

In other clinical situations, survival from CPR is extremely limited:

Hypotension (2% survival)
Renal failure (3%)
AIDS (2%)
Homebound lifestyle (4%)
Age greater than 70 (4% survival to discharge from hospital)

Clinical Features That Change Predictive

Accuracy
Young age
Toxins or electrolyte abnormalities
Profound hypothermia
Drug overdose

CPR IN DEMENTIA

OHCA
The impact of dementia on survival after cardiac arrest was
investigated by Dull et al. These authors considered CPR in the
presence of dementia unwanted because of poor survival
rates. only 3% of the residents survived to hospital discharge.

In other studies, the discharge rate of nursing home residents

from the hospital after cardiac arrest ranged from 0 to 3.4% .

IHCA
Even in a hospital, CPR is three times less likely to be
successful in patients with dementia than in patients who are
cognitively intact, and the success rate is almost as low as in
metastatic cancer (Ebell MH, Becker LA, Barry HC, Hagen M. Survival after inhospital cardiopulmonary resuscitation. A meta-analysis. J Gen Int Med 1998;
13(12):805-816.

Age is another factor that decreases the success rate of CPR.

According to Red Cross

all patients in cardiac arrest should receive resuscitation
unless:
(1) the patient has a valid "Do Not Attempt Resucitation" (DNAR)
order.
(2) the patient has signs of irreversible death such as rigor
mortis, decapitation, or dependent lividity.
(3) if there is no physiological benefit that can be expected
because the vital functions have deteriorated despite maximal
therapy for such conditions as progressive septic or cardiogenic
shock.
(4) A patient with a fractured rib may also be contraindicated for
CPR to avoid puncturing of vital organs by the fractured rib.

SUCCESS RATES OF CPR

 Various studies have found that initial in-hospital CPR success

rates range from 16.8 to 44%.

Long-term survival (discharge from hospital) rates

range from 3.1 to 16.5%.

Brooks, S.C. et al. (2010). Out-of-hospital cardiac arrest frequency and survival: Evidence for
temporal variability. Resuscitation, 81(2) 175-181.
Myrianthefs, P. et al. (2003). Efficacy of CPR in a general, adult ICU. Resuscitation, 57(1) 43-48.

Withdrawal of life support is ethically

permissible under these circumstances
A recent meta-analysis of 33 studies of outcome of anoxic-ischemic
coma documented the following 3 factors to be associated with poor
outcome:

1.absence of pupillary response to light on the third day.

2.absence of motor response to pain by the third day.
3. bilateral absence of cortical response to median somatosensory
evoked potentials with the first week

Brain stem death

UK's Department of Health Code of Practice governing use of
that procedure for the diagnosis of death:

There should be no doubt that the patients condition deeply

comatose, unresponsive and requiring artificial ventilation is due to
irreversible brain damage of known aetiology.

There should be no evidence that this state is due to depressant drugs.

Primary hypothermia as the cause of unconsciousness must have
been excluded.

Potentially reversible circulatory, metabolic and endocrine disturbances

must have been excluded.

Potentially reversible causes of apnoea (dependence on the ventilator),

such as muscle relaxants and cervical cord injury, must be excluded.

the definitive criteria are:

Fixed pupils which do not respond to sharp changes in the intensity of
incident light.

No corneal reflex.
Absent oculovestibular reflexes no eye movements following the
slow injection of at least 50ml of ice-cold water into each ear in turn
(the caloric reflex test).

No response to supraorbital pressure.

No cough reflex to bronchial stimulation or gagging response to
pharyngeal stimulation.

 No observed respiratory effort in response to disconnection of the

ventilator for long enough (typically 5 minutes) to ensure elevation of
the arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5
kPa in patients with chronic carbon dioxide retention).

Two doctors, of specified status and experience, are required to act

together to diagnose death on these criteria and the tests must be
repeated after a short period of time ... to allow return of the patients
arterial blood gases and baseline parameters to the pre-test state.
These criteria for the diagnosis of death are not applicable to infants
below the age of two months

Patient in deep apnoeic coma

 (
)
.



:
: .
:
.
:
.
:

.
:
.
:


.

.

, ,
, :

:




.

 :





.

 ):


:

,
. .

...):


(

 :




.


:

..
.
:

:
.
:


, .
: :

.
:

.

)1412( :
" )(

.
)(
"

.

 :
.

.
:

. .


) (.
:
.

.
:
.


.
.

 -


.
.

.
.


.
.

3/6/1409

THANK YOU