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Ethics and Law Ressuscitation

Ethics and Law Ressuscitation

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Published by: makintox on Nov 12, 2008
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09/07/2012

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Ethics and Law in Resuscitation
On November 17
th
and 18
th
2001 a congress on “Ethics and Law in Resuscitation”was held in Krakow (Poland). It was a joint scientific meeting of the EuropeanResuscitation Council and the Polish Resuscitation Council, which was launchedduring the opening of the symposium. The scientific programme covered severalimportant ethical and legal aspects in resuscitation. Some of the outstandingpresentations of the congress are summarised below.
“Protection of human rights and dignity - is there a common European way?”
 Yes, at least in principle, stated
Kettler 
(Goettingen, Germany) in his lecture anddemonstrated that the Council of Europe has set a unique framework to protectfundamental freedoms and human dignity. The Council’s most significantachievement is the European Convention on Human Rights which has come intoforce in 1953. It sets out the inalienable rights and freedoms of each individual andobliges states to guarantee these rights to everyone within their jurisdiction.Corresponding to this basic document, since 1999 the Parliamentary Assembly of theCouncil of Europe is dealing with a paper called “Protection of the human rights anddignity of the terminally ill and the dying”.
Kettler 
cited the recommendation of theAssembly that the Committee of Ministers encourages the member states of theCouncil of Europe to recognise and protect a terminally ill or dying person’s right tocomprehensive palliative care. This includes appropriate palliative care, ambulanthospice teams and networks, inter-professional co-ordinated teamwork, adequatepain relief, development and implementation of quality standards, research andtraining, and establishment of palliative medicine in public awareness. Respect andprotection of the dignity requires to respect the right of self-determination and touphold the prohibition against intentionally taking the life of terminally ill or dyingpersons.
Kettler 
underlined that the general framework given by the Council ofEurope offers only a certain range of interpretation, leading to different views on thelevel of national legal systems. In particular, the opinions on the value of self-determination are differing fundamentally throughout Europe. Nevertheless, thoughthe common European way is rather broad and with several options for deviations, itseems to lead into the right direction.
 
 Every competent patient has the right to say “keep your hands off”, as
Steen 
(Oslo,Norway) pointed out in his lecture on
“Patient self-determination and surrogatedecision-making”
. The right to refuse treatment persists even if life-threateningcardiac arrest occurs. However, certain requirements have to be met to qualify adecision as competent: the patient must be fully informed, should understand theinformation and the consequences of the options, should be free from externalpressures and consistent in his or her treatment choices. But patients are allowed tochange preferences, and people rapidly alter perception of quality of life and CPRpreferences with varying health condition. If competence is compromised, closerelatives or friends can become surrogate decision makers. Unlike living wills,surrogate status applies to all situations with incompetence.
Steen 
reported that thelegal situation of surrogates varies with country and with time. Surrogate decisionsshould be based on previously expressed patient preferences, but in many instancesthese are not known or not reflected by the surrogates. Advanced directives mighthelp to adjust the patient’s preferences, even in cardiac arrest when the situationgives the physician an urge to act. Advance directives offer patients the opportunityto express their thoughts and preferences for end-of-life care.
Steen 
criticised thatmany people do not wish to discuss advance directives or CPR. People rarely planfor future illness, and therefore, physicians do not know how to act in the patient’sbest interest. With regard to withholding resuscitative efforts there is no or only littlecorrelation between patients’ preferences and physicians’ decision just by intuition.In his lecture on “
Stress overload by CPR providers in emergency medicinepractice
Jakubaszko 
(Wroclaw, Poland) pointed out that in last few years a lot ofevidence has accumulated dealing with stress and traumatic stress experiences inemergency medicine practice. Every year, one hundred thousand rescuers in Polandface the danger of death or physical injury in the line of their duty. Those people whoexperience severe or long-lasting stress often have symptoms and problemsemerging afterwards.Stress is a generic term that refers to the temporary adaptation process that isaccompanied by mental and physical symptoms. Sources of stress in emergencymedical practice may include long hours of enduring work with little recognition,having to respond instantly, making life-and-death decisions, fearing serious errors,
 
dealing with dying people and grieving survivors, and last but not least greatresponsibility for lives of survivors.Most rescuers experience normal stress reactions to such strains for several days orweeks, which may include emotional reactions of fear, guilt, grief, anger, irritation,helplessness, feeling numb or having diminishe
d
interests and pleasure; cognitivereactions of confusion, disorientation, shortened attention span, and difficultyconcentrating; physical reactions of fatigue, tension, insomnia, edginess, and beingeasily startled or becoming overly alert.But those rescuers – police and fire fighters, emergency medical technicians, andphysicians – who may find themselves suddenly in danger are overcome withfeelings of fear, helplessness and guilt. In most instances these are normal reactionsto abnormal situations but as many as one in three rescuers may feel unable toregain control of their lives and experience severe symptoms, what in turn may leadto lasting PTSD, anxiety, or depression. Some common traumatic experiencesinclude multiple casualty incident, serious injury or death of a child, injury or death ofa co-worker, providing emergency care to a relative, abuse and neglect of infants andchildren, severe traumatic injury and amputation, intense media tension to anaccident.Particular symptoms may begin soon after the traumatic experience. The mainsymptoms are re-experiencing of the trauma and avoidance of trauma reminders(extreme attempts to avoid disturbing memories), accompanied by dissociativereactions (feeling completely unreal or outside, like in a dream), extreme emotionalnumbing, severe anxiety (paralysing worry, compulsions or obsessions). Togetherwith physiological this may result in a problem called posttraumatic stress disorder.Re-experiencing means that the rescuers continue to have some mental, emotional,and physical experiences that occurred just after the traumatic events or soon after.They are thinking about the trauma, seeing the horrific images, feeling agitated andhaving sensations like those occurring during the event. The results of such exposuremay lead to complex symptomatology in form of behavioural and adjustmentdisorder, or more severe, of posttraumatic stress reaction.How serious the symptoms and problems are afterwards depends on many thingsincluding a person’s life experiences before the trauma, a person’s own ability tocope with stress, and what kind of help or support a person gets from family, friends,or professional mental health assistance.

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