Anaesthesiology Intensive Therapy, 2011,XLIII,3; 160-165

The ethics of resuscitation Ewa Rudnicka-Droak, *Anna Aftyka Emergency Medicine Unit, Medical University of Lublin Resuscitation should always be attempted in a patient who has at least a theoretical chance of survival. This assumes that there are patent cerebral, coronary and pulmonary vessels, a reasonable time from cardiac arrest has not been exceeded, and cardiac arrest did not occur as a result of a terminal condition caused by an untreatable disease. During resuscitation, medical personnel may face two dilemmas: when to start CPR, and when (and how) to stop it. Apart from various medical conditions, possible outcome and will of a victim has to be taken into consideration. CPR is frequently started without an adequate knowledge of the patients medical status. As soon as the latter is obtained, a decision about continuing CPR should be reconsidered. CPR and/or life-prolonging treatment can be stopped in several situations, i.e. lack of cardiovascular response or recognition of a life-limiting condition. The decision should be made by a team leader, acting in accordance with national or house guidelines. In terminal patients, a DNR order should be issued well in advance, usually by an attending physician. After that, the patient should be provided with palliative care, consisting of pain therapy, and treatment of dyspnoea, congestive cardiac failure, etc. In their review, the authors discuss various medical and ethical aspects of resuscitation, concluding that hospital ethics committees could be of great value in solving complicated questions relating to limitation of resuscitation and lifeprolonging treatment.
Resuscitation (from Latin resuscitare to revive, resurrect, bring back) is a range of actions undertaken to inhibit or reverse the dying process [1]. Although the first such procedures had been described before our era, the modern guidelines for resuscitation were described in the 60ties of the previous century [2]. Indications for resuscitation attempts include primary cardiac arrest, primary respiratory arrest or clinical death whenever there is a chance of victims survival, i.e. the cerebral, coronary and pulmonary vessels are patent, a reasonable time from cardiac arrest has not been exceeded, and cardiac arrest did not occur as a result of a terminal condition caused by an untreatable disease [3]. LEGAL AND ETHICAL DUTY TO RESCUE

The legal obligation to rescue is defined in the Penal Code, Article 162, 1, which states that anyone who fails to help a person who is in immediate danger of death or serious injury, where rendering such help is possible without the risk of death or serious injury to oneself, is liable to a punishment up to three years imprisonment [4]. The medical and nursing personnel are particularly obliged to provide suitable interventions in emergencies; such obligations are reflected in the respective codes of professional ethics. The Article 69 of the Code of Medical Ethics says that a physician cannot refuse medical treatment in emergency cases when a patient cannot obtain help from the institutions obligated to render help [5]. According to the Nursing and Midwifery Code of Ethics of the Republic of Poland, the chapter A nurse/midwife and a patient, a nurse/midwife serving his/her professional function is obliged to render first aid in emergencies and under life threatening conditions [6]. DECISION TO START RESUSCITATION In all cases of cardiac arrest, the medical personnel face two major dilemmas when to commence and when to continue or withdraw resuscitation attempts. In each, individual case, the decisions are made based on a difficult relationship between benefits, risks and costs the intervention will place on a patient, his/her family, society and healthcare system. The current medical standards define the circumstances in which resuscitation is to be initiated. While making such relevant decisions, ethical principles cannot be neglected. Resuscitation is inappropriate and should not be provided when there is clear evidence it will be futile or it is against the patients wishes [7]. In the hospital setting, the decision to undertake resuscitation in cardiac arrest is taken by the attending physician or nurse, when the former is absent. If on the initiation of rescue procedures, the data about the patient are not available, the basic rule is to undertake resuscitation in each case of cardiac arrest. The information about the patient should be gathered during resuscitation or after its completion; delayed institution or discontinuation to obtain information is unacceptable. The data obtained during history taking from the witnesses, family, ambulance team or personnel of the medical institution can be important to determine the causes of cardiac arrest and for the course of resuscitation [8]. Under ideal circumstances, resuscitation should be started only when a patient has high chances to survive and enjoy conscious, dignified life [9]. Based on multi-directional analyses, the factors deciding about successful resuscitation were identified and included: the period between cardiac arrest and initiation of resuscitation, proper provision of various basic life-supporting procedures, administration of adrenaline and electrical cardiac defibrillation. Therefore, efforts should be made to use the time given most rationally [10]. DECISION HOW TO ADMINISTER RESUSCITATION The cardiopulmonary resuscitation knowledge and practice is a dynamically developing branch of medicine whose further development necessitates certain changes in medical practice and the ways the drugs are given. Everyone who practices medicine is personally responsible for the therapeutic methods used; their applications should be based on thorough knowledge and practical skills with all necessary safety conditions regarding personnel and patients preserved. The guidelines of cardiopulmonary resuscitation oblige the readers to familiarise with the current knowledge about management and pharmacotherapy, particularly information about the doses, time and routes of administration as well as side effects of the drugs provided by manufacturers [11]. This approach is in agreement with the concept of evidencebased practice (EBP). The concept in question may be applied to both evidence-based medicine (EBM) and evidence-based nursing (EBN) [12]. DECISION TO WITHDRAW RESUSCITATION The vast majority of resuscitation attempts do not succeed. The factors affecting the decision about their discontinuation include medical history, prognostication regarding survival, interval between cardiac arrest and institution of resuscitation by the bystanders and medical personnel, initial ECG rhythm, interval to defibrillation, no reversible causes of cardiac arrest and duration of advanced resuscitation actions with persisting asystole and no return of spontaneous circulation [7].

According to the annex to the Minister of Health statement on the criteria and measures to establish irreversible cardiac arrest of August 9, 2010, the pronouncement of death due to irreversible cardiac arrest is based on the 24-hour interpretation of medical history data and clinical symptoms of irreversible cardiac arrest. The guidelines contained in this document define the criteria for diagnosis and establishment of irreversible cardiac arrest before initiating the preparation procedures for harvesting cells, tissues or organs. Irreversible cardiac arrest can be diagnosed once several conditions have been fulfilled. The first of them is asystole or electromechanical dissociation for at least 20 min, in children <2 years for at least 45 min, with ongoing cardiopulmonary resuscitation according to the current medical knowledge. In the same period, it is necessary to confirm by palpation the lack of spontaneous pulse wave on the carotid or femoral arteries. The second stage is to confirm asystole or electromechanical dissociation and lack of spontaneous pulse wave on the carotid or femoral arteries during at least 5-minute observation after completion of failed cardiopulmonary resuscitation. When cardiac arrest occurs in the situation, in which the attending physician finds the resuscitation attempts futile (according to the current medical knowledge), irreversible cardiac arrest is diagnosed. However, when during the observation period ventricular fibrillation or palpation-confirmed return of spontaneous pulse wave on the carotid or femoral arteries is observed even for a moment, the period of cardiopulmonary resuscitation and subsequent observation should be calculated from the very beginning. After the completion of resuscitation, during the observation period, the absence of brain stem reflexes, i.e. lack of light, corneal, vestibule-ocular reflexes and respiratory activity or lack of any motor responses to a pain stimulus within the region of cranial innervation and within the region of face to pain stimulation within the region of spinal innervation, should be checked [13]. The decision to withdraw resuscitation is made by the resuscitation team leader after consultations with its members, whose arguments can help in the final decision-making [14]. When the resuscitation intervention is managed by a healthcare provider who is not a physician, the decision to withdraw resuscitation and pronounce death arouses much controversy. Undoubtedly, an official death certificate can be issued by a licensed physician and this should not be changed. However, it is proposed that in some situations the death can be established by a nurse or a paramedic. If such a decision is going to be accepted, one ought to be sure that death was not misdiagnosed and a person with even the slightest chances of survival is not deprived of resuscitation. The Emergency Management Committee, appointed by the British Association of Royal Medical Colleges, designed the guidelines for explicit identification of conditions undoubtedly relating to death (group A) and conditions, in which asystole should be confirmed by electrocardiography (group B). The conditions inevitably related to death include decapitation, extensive damage to the skull and brain, severed trunk or similarly massive injury, human body decomposition and burning, cadaveric rigidity and foetal maceration. The conditions in which asystole has to be confirmed electrographically are as follows: underwater immersion of an adult person (18 years of age) for over 3 h, permanent asystole despite cardiopulmonary resuscitation provided for more than 20 min in a normothermic person and in those not resuscitated for at least 15 min after loss of consciousness, and no pulse or respiration found by healthcare providers present at the scene. To apply the above rules, the times, mentioned in the guidelines, should be precisely determined. The ECG recording confirming asystole has to be artefact-free. Moreover, the use of sedatives, hypnotics, anti-anxiety drugs, anaesthetics, and opioids within 24 h should be excluded [15]. The intoxication with drugs depressing the nervous system, just like hypothermia, down-regulates the metabolism of neurons and is an indication for prolonged resuscitation [16]. In hypothermic patients, the rule is that death can be recognised only after body warming, with an exception of victims with deadly injuries or cases of freezing [17]. According to the annex to the Minister of Health statement on criteria and measures to establish irreversible cardiac arrest, in hypothermia cases the body temperature should be elevated to 35 C with ongoing resuscitation. Once the suitable temperature has been achieved, the time of unsuccessful cardiopulmonary resuscitation can be started to be calculated [13]. When during resuscitation, the terminal stage of an untreatable disease inevitably leading to death is recognized based on medical records, the continuation of resuscitation attempts is pointless [16].

DECISION TO WITHHOLD RESUSCITATION IN TERMINALLY ILL PATIENTS In accordance with the Patients Charter of Rights designed by the Ministry of Health and Social Welfare, one of the key rights of a patient is to die with peace and dignity [18]. This right is reflected in the Code of Medical Ethics, Art. 30, which states that a physician should spare no efforts to provide humane terminal care and dignified dying conditions; the Art. 32 says that in terminal conditions, a physician is not obliged to attempt and continue resuscitation or persistent therapy or to use the extraordinary measures [19]. The duty to rescue does not cover the dying stage and medical interventions prolonging the agony are unethical as they violate the right to die with dignity. Artificial prolongation of agony multiplies unnecessary suffering and destroys the individual, personal nature of death [20]. The decision to withhold resuscitation in cardiac arrest or respiratory arrest cases is made by the attending physician. Before the decision is taken, the attending physician should consult another physician, who can help to assess objectively the situation; furthermore, the patients wishes concerning resuscitation attempts ought to be considered and the situation discussed with the patients family. During discussions with families, it should be stressed that the final decision will be that of the physician placing the burden of decision-making on a relative is neither reasonable nor fair [7]. The decision to withhold resuscitation has to be recorded in the medical history and signed by a specialist, preferably by a specialist and a senior registrar. The records of withholding resuscitation should be dated and discussed with the personnel. It is essential to place the suitable notes in the nursing documentation [21]. Irrespective of the decision to withhold persistent therapy, including the decision to abandon the resuscitation attempts, there is no ethical justification for withholding ordinary treatment, which includes the use of antibiotics for infections, management of bedsores, therapy of circulatory and respiratory failure, administration of analgesics, antidepressants, sedatives or other forms of palliative care, even in terminal conditions [22]. PRINCIPIALISM The guidelines of 2010 for cardiopulmonary resuscitation recommended by the European and Polish Resuscitation Council [7] include four key principles of ethics: autonomy, beneficence, nonmaleficence and justice. Autonomy is the right of a patient to make conscious decisions on his/her own behalf and not being subjected to decisions made by physicians and nurses. Patients should be adequately informed, competent to make decisions, free from undue pressure; moreover, their decisions and preferences should be consistent. To emphasize the autonomy of a patient, many countries introduced living wills or powers of attorney, enabling the patients to express their wishes about future therapy, especially end-of-life treatment. The living will can specify the limitations of terminal care, including the do-not-attempt-resuscitation (DNAR) order. The order can be written and certified by a notary or suitable decisions can be taken during discussions with the family, nurses or physicians. However, the essential problem is that the desire to live is underestimated and patients frequently change their minds with changes in circumstances; therefore, the living will should be most recent, consider the possible changes and precisely define when the intervention should be withheld or discontinued. For instance, many patients may refuse cardiopulmonary resuscitation in terminal multi-organ failure with no possibly reversible cause yet accept the resuscitation attempts should ventricular fibrillation develops. Another principle is beneficence after benefits and losses have been balanced. In most cases, this implies undertaking rather than withholding or withdrawing of resuscitation. The principle of nonmaleficence, on the other hand, suggests that resuscitation should not be undertaken in futile cases or against the patients wishes. The principle of justice implies the obligation to distribute equally the available resources in the society and consider the related risks. According to this principle, resuscitation should be available to all who will benefit [7, 23]. Unfortunately, extreme absolutisation of autonomism gave birth to the models of medical ethics, which distorted the meaning of the doctor-patient relationship (legalistic, economic, consumer, negotiative) and the aim of medicine. Absolutisation of autonomism enabled some bioethicists, like Singer, Engelhardt or Szawarski, to exclude certain individuals from the circle of human

beings; thus, the right to live of human embryos, children with severe defects, terminally ill patients incompetent to express autonomy-related wishes and take responsibility for their future and interests, was questioned. Another issue is the influence of autonomism on healthcare professionals it destroys the physicians freedom and conscience. Physicians should be neutral, eliminate their system of values, including the system resulting from the ethos of their profession, and their conscience while accepting the patients wishes. In this way, medicine and physicians become some kind of a service agency fulfilling the wishes of society and directives of the country [24]. Furthermore, according to this theory, the origin of ethical principles should be searched for in the common morality; there is no single rule, notion or idea of the highest good that the remaining morality elements could be derived from [25], which obviously raises objections. JUSTIFICATION OF MORAL NORMS IN BIOETHICS The main ethical obligation of physicians is based on the salus aegroti suprema lex esto maxim (the well-being of a patient is the supreme issue) [26]. In everyday practice, there is a commonsense notion of good and moral standards shaped by the moral and cultural tradition of a family. However, conclusions drawn from dramatic social turbulences, e.g. Nazism or Communism, clearly demonstrate that the moral behaviour patterns should be based on deeper reasons than mere obedience to the country, community or ideology [27]. Bioethics is a specialised part of philosophical particular ethics, which establishes the evaluations and moral norms in connection with interference in human life in the situation of its origin (biogenesis), duration (biotherapy) and death (thanatology). In the philosophical ethics, three competing ethical concepts can be found: eudaimonistic (the essence of the moral good is the acts capacity to provide happiness), utilitarian (something is good because it is beneficial, useful), deontonomic (something is good as it is in agreement with the command of some autonomic subject or legislator), and personalistic (something is morally good when it affirms the persons dignity ) [28]. UTILITARIANISM In utilitarianism, the criterion of any conduct is its utility [29]. The classical utilitarianism is based on an assumption that the only aim we should strive after is to maximise the benefits for possibly the highest number of people. Currently, utilitarianism in its various forms, e.g. proportionalism, consequentialism, or quality of life ethics, attempts to compare benefits and losses related to a given action using various principles. Consequentialism states that we should always take such actions, which lead to the best consequences. According to professionalism, the objective good does not exist, thus, it cannot be the criterion of conduct; the rule of balancing benefits and losses should be used instead. Ethics of quality of life assumes that the only notable good of man is the quality of life, which can be described using empiric and psychological categories. The advocates of quality of life ethics suggest the use of qualitative criteria towards terminally ill patients, those permanently unconscious, unborn or severely retarded children, who lacking the defined features and traits cannot be considered as individuals, subjects with the right to live [30]. Extreme utilitarianism leads to the situation in which the other person is not valued for what he/she is but what the person possesses and accomplishes or what benefits he/she can bring. The country stops to be the common home, where everyone lives according to the basic rules of equality; it changes into the tyrannical country, usurping the right to govern the lives of the weaker and vulnerable, unborn children and the elderly in the name of social benefit, which actually means the interest of a particular group [31]. In practice, the basic rule for medical segregation is based on utilitarian ethics - everything possibly best should be provided for the largest number of victims at proper place and time [32]. DEONTONOMISM Deontonomism assumes that the moral obligations should be decided by a suitable authority [33]. The authority can be a country, as proposed by Hobbes, i.e. the morality is imposed from the outside by the country and the laws established, which is called heteronymous deontonomism. In autonomism, man is the authority for himself/herself, as Kant wanted, and defines his/her responsibilities. Neither deontonomism nor autonomism justifies moral obligations, leaving the solution for a country, race, social class, social habits or individual decisions. It should be emphasized, however, that neither social processes, nor national laws could justify the morality; otherwise, the actions of Nazi physicians, in accordance with the law

and national ideology, would not be considered as genocide [34]. PERSONALISM The main principle of personalism is based on two maxims: homo homini res sacra (man is a sacred thing for man), as stoics used to say, and persona est affirmanda propter se ipsam (the person must be affirmed for its own sake). Hence, in personalism the basis of morality is the dignity of a person together with his/her personal nature [35]. The act is morally good when it affirms the persons dignity and morally right when it promotes the development of mans personal nature. The value of a person should be differentiated from the intrinsic value. The person`s value cannot be lost; it belongs to a criminal and a saint, a healthy, ill or disable individual. The proper attitude to man involves the affirmation of his/her physical and mental virtues and affirmation of the person. This proper attitude evidences itself in treating someone as a person, not a thing, as a neighbour, not an enemy. Therefore, it is unethical to deny anybody, either an embryo with defects or a terminally ill person, the right to live. The recognition of the inborn personal dignity conditions the equality among people [27]. In personalistic bioethics, dignity of a person is the basis of morality. The principle of dignity was introduced to constitutions of many nations in the 20th century and is reflected in the European Ethics Charters, conventions on human rights and suitable documents. Moreover, dignity is the essential notion in the Declaration of Human Rights of December 10, 1948 [36]. The personalistic norm precedes and organizes the prima facie rules [37]. The personalistic norm precedes the rule of nonmaleficence, beneficence, justice and autonomy and is norma normans for the remaining rules as it bids that a person is the basis of moral behaviours and not some extra-personal reality, e.g. legal, social or moral obligations [38]. In bioethics related to personalistic ethics, the principles of not harming, holism, solidarity and double effect are stressed [39]. Decision-making about undertaking risky therapies may be facilitated once ordinary and extra measures are distinguished, or better so, measures proportional and disproportional to anticipated benefits [40]. The measures are considered ordinary when their use gives rational hope for recovery and does not cause unbearable suffering or inconvenience for the patient. In contrast to that, extraordinary measures are those forms of treatment, whose use does not result in rational hope for recovery and pain alleviation or those that induce adverse effects in the form of unbearable suffering or inconvenience [41]. HOSPITAL ETHICAL COMMITTEES The General Assembly of the Polish Bioethical Society in September 2009 passed the Statement on Hospital Ethics Committees, initiating the discussion on the sense of organizing such committees and their potential functions. The bioethics committee is the team of professionals appointed to take care of ethical quality of clinical decisions through educational, regulatory and consultative activities. From the practical point of view, an important advantage of the committee should be its assistance in determining ethically relevant facts to be considered while making clinical decisions; hence, the decision-making would be easier for the medical personnel [42]. According to the study performed by Kornas, the majority of physicians recognize the need to appoint the committees helpful in decisions to undertake or withhold the treatment with the patients consent and respecting the existing regulations. The respondents reported dealing with the patients of extremely complex clinical pictures, difficult to diagnose and to treat, when they had to make certain decisions by themselves or after consulting the colleagues, taking the moral, professional, sometimes criminal responsibility [43]. The presence of hospital bioethical committees should minimise the likelihood of therapeutic errors and the responsibility for treatment-related consequences or their lack would be differently distributed [44]. As far as the resuscitation issues are concerned, ethical committees would be helpful in solving numerous dilemmas, particularly those regarding patients` wishes and decisions to withhold resuscitation. Furthermore, such committees would be invaluably useful in determining the range of treatment of ITU patients. ........................................................................................................................................ ...................... REFERENCES

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