The American Journal of Bioethics

Resuscitation Strategies in the United States: Realities of Hospital and Prehospital Treatment
Kenneth V. Iserson, McMurdo General Hospital, Antarctica
Despite claims to the contrary, differences in DNAR (do-notattempt-resuscitation) and CPR (cardiopulmonary resuscitation) implementation vary more by institution or medical care system within the United States and the United Kingdom than between the countries. New York State, often used as an example of automatically doing CPR in most circumstances (Bishop et al. 2010), actually represents the extreme outlier. In most of the United States, custom, law, and clinical practice have led to reasonable use of CPR, one of the ultimate resuscitation modalities (Iserson 2010). It is tragic to prolong a patient’s dying by providing inappropriate resuscitative measures. Even so, when discussing whether to initiate CPR, we must remember that if there is any doubt about whether a patient should be resuscitated, begin CPR. Life support can always be withdrawn if more information surfaces. Not initiating resuscitative procedures and discontinuing life-sustaining treatment are, under most circumstances, ethically equivalent, if sufficient information is available at the time these decisions are made (Iserson 2009). Two relatively common practices, already used by U.S. clinicians and bioethicists, mirror those that Bishop and colleagues (2010) suggest would ameliorate problems with DNAR orders and CPR: limitation-of-treatment orders, and time-limited trials of therapy. Limitation-of-treatment orders specify which resuscitation interventions (e.g., cardioversion, intubation, mechanical ventilation, or the administration of parenteral fluids or nutrition, oxygen, antibiotics, blood products, sedation, antiarrhythmics, or vasopressors) clinicians may employ for a particular patient. (As an ethical matter, appropriate analgesia should never be withheld.) Generating this type of medical order also encourages in-depth discussion about prognosis and the usefulness of various interventions with patients or surrogates, and clearly transmits information about end-of-life treatments among treating clinicians (Iserson 2009). On occasion, problems arise when these orders are inconsistent with rational medical treatment. Some patients, for example, may choose to accept defibrillation and chest compressions but not intubation and artificial ventilation. Such conflicts arise when clinicians have not fully briefed patients or surrogates on the nature of the proposed medical treatments. It is the attending physician’s responsibility to ascertain that the order set is rational and that the patient or surrogate understands why it is being written as it is (Iserson 2009). Time-limited trials of therapy identify specific goals for treatment of uncertain efficacy. This transforms abstract futility discussions and their associated frustrations into empirical clinical tests. Patients or, more commonly, surrogate decision makers discuss and come to an agreement with the clinician about treatment goals, specific treatments, and the amount of time that the treatments will be tried until the goal must be reached. Often used in end-of-life care, especially in critical care units, time-limited treatment balances the need to “try everything”—including CPR—with an understanding that interventions must prove their usefulness to be continued. As was noted by the European Resuscitation Council, in situations in which the prognosis is uncertain, a trial of treatment should be considered while further information is gathered to help determine the likelihood of survival and the expected clinical course (European Resuscitation Council 2000). PREHOSPITAL/EMERGENCY DEPARTMENT CPR POLICIES Although dismissed as beyond the paper’s scope, the U.S. emergency medical systems (ambulance and emergency departments) have developed two patient-centered responses to CPR and DNAR that seem to best serve patients, the community, and professional integrity: (1) acknowledging differences between withholding and withdrawing treatment (especially CPR and related interventions) and (2) prehospital advance directives. These inpatient and prehospital strategies that are already widely used answer many of the concerns that the Bishop and colleagues (2010) article raises. Acknowledging Differences Between Withholding and Withdrawing Treatment Initiating CPR is, and should be, the default action in emergency medical care—both in emergency departments and in the prehospital (ambulance) system. Society has special expectations about the nature of emergency treatment. These expectations not only make withholding medical treatment much more problematic than later withdrawing unwanted or useless interventions, but also attach a morally significant difference to the interventions.

Address correspondence to Kenneth V. Iserson. E-mail:

72 ajob

January, Volume 10, Number 1, 2010

et al. Journal of the American Geriatrics Society. Amsterdam. M. Philadelphia. V. Iserson. 2010. Bossaert. 21998. American Journal of Bioethics 10(1): 61–67. In The ethics of resuscitation in clinical practice.. ed. K. 2nd ed. Annals of Emergency Medicine 28(1): 51–55. PHAD laws need not be complex. Perry. Tilden VP. not achieve the patient’s goals of therapy and only prolong the dying process. European Resuscitation Council. Iserson. V. Withholding and withdrawing medical treatment: An emergency medicine perspective. patients who lack decision-making capacity cannot communicate to emergency medical services system and emergency department personnel their wish not to be the recipient of advanced life support procedures (Tolle et al. decapitation) or it is burned beyond recognition (Iserson 2001). J.. in emergency medicine. However. PA: Mosby Elsevier. or other non-standard advance directives (Iserson 2010. S. In The textbook of emergency cardiovascular care and CPR. K. Iserson. J. K. 7th ed. Brothers. lawyer or personally written. L. 2010. administration of CPR may sometimes conflict with a patient’s desires or best interests. A.. Prehospital Advance Directives Many of the deaths that occur outside hospitals or chronic care facilities in the United States are not only expected but also welcomed as relief from terminal disease. A. 2010 ajob 73 . Bioethics. ed. 1993. bystanders and EMS personnel should adhere only to standard. Nelson CA. European Resuscitation Council guidelines for resuscitation. EMS system-approved forms. 46: 1097–1102. Netherlands: Elsevier. Iserson 1993. R. a morally significant difference rightfully persists between withholding and withdrawing medical treatment. Ethics in emergency cardiovascular care. 567–585. Pt 2: Ethical aspects of CPR and ECC. Bossaert 1998). A prospective study of the efficacy of the physician order form for lifesustaining treatment. Reviving the conversation around CPR/DNR.Prehospital (and emergency department) personnel may not be able to determine whether resuscitation should be initiated or continued. K. PA: Lippincott Williams and Wilkins. No one in the prehospital setting should attempt to interpret unique. these laws strike a balance between the needs of the citizens and the unfounded fears of lawyers wary of any potential liability for the state or the emergency medical services system (Iserson 1993). clinicians in both the United States and the United Kingdom now employ multiple strategies to avoid using CPR and other resuscitation strategies indiscriminately. Marx. Volume 10.. A simplified prehospital advance directive law: Arizona’s approach. Tucson. In emergency medicine. Iserson. PHADs allow terminally ill patients to simply describe their wish not to be resuscitated to any prehospital personnel that may (inadvertently or by protocol) be sent to their bedside. Developed and first enacted into law in the early 1990s. J. Hockberger. Tolle.. S. Death to dust: What happens to dead bodies?. P. medical condition. M. 2000. 2009. AZ: Galen Press. C. As a result. 2001. REFERENCES Bishop. E. K. 1996. V. January. R. In Rosen’s emergency medicine: Concepts and clinical practice. either in their language or in their implementation requirements. Number 1. livor mortis. et al. Some of these laws and the accompanying forms are simple enough to be easily interpreted by both providers and patients. Used successfully for nearly two decades. In sum. However. Field. which they understand will. W. Walls. 1998). K. V. Iserson. and A. or injuries incompatible with life (e. P. Resuscitation 46: 17–27. This is because. V. Ahmad. V. 206–217. and wishes needed to make an informed decision about withholding treatment (Iserson 1996). Prehospital advance directives (PHAD) offer patients an opportunity to clarify that situation. CPR decisions are often made in seconds by rescuers who may not know the patient or whether an advance directive exists. in some cases. J. B.g. 1998. 2554–2568. Philadelphia. Annals of Emergency Medicine 22(11): 1703– 1710. clinicians often lack the information about the patient’s identity.Reviving the Conversation Around CPR/DNR The primary exceptions to initiating CPR for patients without documentation to the contrary are when the body exhibits rigor mortis.

. or email articles for individual use. users may print.Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However. download.