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Most useful applied retrospectively Previous decisions applicable Varies from state to satate,nation to nation
Prospective consideration Based on certain principles
Ethical Issues In Cardiopulmonary Resuscitation • A whole of gamut of complicated dilemma. • Prolongation of suffering. • Successful v Unsuccessful. • Patients rights to die in dignity. • Decision in a matter of seconds. “European Resuscitation Council” . • Persistent vegetative state.
1994. Oxford: Oxford University Press. .Principle #1 Autonomy Does my action impinge on an individual's personal autonomy?Do all relevant parties consent to my action?Do I acknowledge and respect that others may choose differently? 1 Four Basic Principles Of Ethics 4 Principle #4: Justice Is my proposed action equitable? How can I make it more equitable? 2 Principle #2 Beneficence Who benefits from my action and in what way? Principle #3: Non-maleficene Which parties may be harmed by my action? What steps can I take to minimise this harm? Have I communicated risks involved in a truthful and open manner? 3 Beauchamp TL. Principles of biomedical Ethics. 4th ed. Childress JF.
Beauchamp and Childress Principles limitations….patient’s autonomy . Urgency to resuscitate vs to deliberate on decision making Impaired competence - complicates 1st BC principle …..
or outcome with poor quality of life .Harms of resuscitation Unnecessary…when it is not indicated (patient too well to be undergoing resuscitation or “too dead”-like in rigor mortis) Unsuccessful…death owing to advanced condition to patient.
to terminate resuscitation . to initiate resuscitation 2. to terminate resuscitation 4. to withdraw life support system (rarely) 1. NOT to initiate resuscitation 3. to initiate resuscitation 2.Cardiopulmonary Resuscitation: Ethical Issues Resuscitation Decisions for inhospital settings 1. NOT to initiate resuscitation 3.
The Principle of Patient Autonomy Advanced directives (DNAR) If patient preferences uncertain. The Principle of Futility Definition: physiological futility vs quantitative /qualitative measures .GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION A. emergency conditions should be treated until those preferences are known B.
CPR should not be attempted at all. sedation on required basis in terminal illnesses. Other treatment should be continued. pain relief.in the event of cardiopulmonary arrest. e.g. .DO NOT ATTEMPT RESUSCITATION (DNAR) ORDER DNAR order means just that .
perceived as respecting principle of beneficence but ignoring patient autonomy PROXY CONSENT .but the proxy might not reflect patient‟s views ….CONSENT IN RESUSCITATION PRESUMED CONSENT .or the proxy benefits from patient‟s death .consent from family member / caretaker who can speak on behalf of family….
ask the proxy what would the patient want. PRESUMED CONSENT USING PROFESSIONAL JUDGEMENT -Gather information regarding patient background. not what the proxy want . family wishes ..and based on knowledge of likely outcome from experience.CONSENT IN RESUSCITATION PROXY CONSENT WITH SUBSTITUTED JUDGEMENT . medical literture and make ethical judgement .(Would I want this treatment if I am the patient ?) .
decapitation. dependent lividity) No physiological benefit expected (futility) . decomposition.Patient with DNAR order Patient with signs of irreversible death (rigor mortis.
resuscitation should be continued as long as VF persists.Criteria To STOP CPR For In-Hospital Setting In general. And resuscitation should be terminated when ongoing asystole for more than 20 minutes in the absence of a reversible cause. and with all measures of BLS and ACLS in .
Often in intensive care units for clinical brain death patients 3. Not usually done in A&E department 2. after ruling out potentially reversible causes 4.Withdrawing Life Support 1. Detailed criteria can be found in MMC Brain death Guidelines . neurologists. Done by two specialists (usually anesthesiologists. Patient in deep coma for >24 hrs. neurosurgeons) on two assessments (6hrs apart) 5.
rigor mortis. Attempts to perform CPR would place the rescuer at risk of danger/physical injuries . A person with obvious clinical signs of irreversible death (e.Criteria For NOT Starting CPR In Out-of-Hospital Setting Paramedics are trained to start CPR at the very first instance upon a victim in cardiac arrest with the exception of: 1. dependent lividity.g. A person with clear DNAR order 3. decomposition) 2. decapitation.
A valid DNAR order is presented . spontaneous circulation and ventilation 2.Criteria To STOP CPR In Out-ofHospital Setting Restoration of effective. The rescuer is unable to continue because of exhaustion 4. Care is transferred to a more senior-level emergency medical professional 3. Reliable criteria indicating irreversible death 5.
but when the aim is no longer to save patient „s life is previous consent still valid? . Construed consent “if consent obtained for certain procedure before death then it is construed the consent applicable for related procedure after death” …. and rarely arrived to hospital on their own. Usually …only endotracheal intubation . Implied consent…but most ED patient‟s who need resus are in state of impaired competence. Ethically speaking…need consent .
don‟t tell” is ethically unjustifiable .PRACTISING ON NEWLY DEAD Proxy consent .procedure unlikely to take place . Our practice “don‟t ask . Presumed consent – appropriate when patient in impaired competence renders him/her incapable to make decisions -for this to be applicable community should be well informed so individuals have oppurtunity to decline consent if they desire .
You are called in to help out with the disaster. The relatives over there are shouting for you to come over and help. you realize that some rocks are still falling from where the man is trapped. However. Would be liable to be sued if you do not? . a man has stopped breathing at a distance not far from where you are standing.Case 1 A building has collapsed. At the disaster site.
If the relatives insist on you to actively resuscitate him but you do not. 1.Case 2 A 80-year old man with history of frequent exacerbation of COPD is diagnosed with acute pulmonary edema. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort. Would you have intubated him? 2. would you be liable to be sued? . All other treatment modalities fail to prevent his deterioration. currently complicated with respiratory failure Type 2.
is admitted for sudden onset of chest pain. the wife intervenes and insists that you stop the resuscitation process. What would you do? . Realizing what you are doing. previously healthy and active sportsman. She says that he has verbally stated his wish that he does not want to be actively resuscitated and a prolonged suffering the moment he dies. He collapses while being treated in the emergency department.Case 3 A 50-year old. You start CPR and defibrillation promptly.
the managing team decides to withdraw his support system in A&E. Clinical re-assessment 30 minutes later shows that the patient is manifesting signs of increased ICP and transtentorial herniation.Case 4 A 40-year old. He is mechanically ventilated. army is involved in a serious car accident. What do you think . On arrival to the emergency department. His vital signs are good. his GCS is 7/15. A CT scan brain is done . previously healthy.showing a massive intraparenchymal bleeding over the right hemisphere with midline shift and generalized cerebral edema. In view that his prognosis may not be good and that the ward resources are limited.
Person nominated as the person caring for the incapacitated patient 6. Any relative 5. Parent 4. Specialized care professionals Must act in best interest of patient .Spouse 2. Adult child 3.SURROGATE DECISION MAKERS (IN ORDER OF PRIORITY) 1.
always err on for the patient‟s benefit Always treat the patient with dignity and respect If you do not want this to be done to your own family member.CONCLUSION Decision making in cardiopulmonary resuscitation can be very complex due to the diversity of the cases It may have to be made in matters of seconds! If in doubt. you do not want it to be done on your patient .
Do not push the job to another team. Respect the solemn moment for the patient and relatives Do not laugh or joke when resuscitation is going on . you should also be responsible to document and sign your decisions and to answer any doubts from the family.And in the end……… If you or your team have made the decision to withdraw a life support system in emergency department. Treat the resuscitation process seriously..………….
Sources Australian resuscitation council British resuscitation council Emergency medicine –Peter Cameron .
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