First do no harm: an ethical approach to resuscitation

Sunday 4 June, 16h00-17h30 Room W

This three-part session during Sunday’s Euroanaesthesia programme is a joint symposium with the Intensive Care Subcommittee. The talks will be framed around Beauchamp and Childress´ four bioethical “pillars” examining resuscitation and end of life care: respect for autonomy, beneficence, non-maleficence and justice.

The first talk on “Autonomy: patient-centred decision-making regarding cardiopulmonary resuscitation (CPR)” will be given by Dr Élő Gábor, Assistant Professor at the Department of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary.

He will detail a study his team conducted which measured patients’ attitudes to invasive procedures, especially to CPR, and compared them with a better educated control group. 61 patients and 39 controls were asked to fill in a questionnaire about theoretically refused procedures in a case-control study. These procedures were renal replacement therapy, intensive care, mechanical ventilation, artefitial nutrition, amputation, transfusion, major analgesic administration and CPR respectively.

Among the conclusions Dr Gábor will discuss is that patients tend to refuse CPR more frequently compared to better educated control group. He says: “While Hungarian law supports patients autonomy, detailed regulations have blocked the emergence of ’do not resuscitate’ orders in medical practice. Our efforts to change the Hungarian Patient’s Rights Act on one hand and bioethically influnced medical education on the other can improve patients autonomy concerning CPR. Current attempts by the European Resuscitation Council to  harmonise  legislation, jurisdiction, terminology and practice, could help our efforts.”

The second talk “Non-maleficence: when to stop resuscitation” will be delivered by Jerry Nolan, Honorary Professor of Resuscitation Medicine, University of Bristol, UK and Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath, UK. He says: “Cardiopulmonary resuscitation (CPR) should be started if there is a realistic chance that it will result in sustained restoration of a pulse and breathing followed by recovery to a quality of life that the patient considers acceptable. Following the same principles, CPR that has been started should be continued for as long as there is realistic potential for meaningful recovery. The theory behind these principles is relatively straight forward but the practical application is much more complex.”

There are guidelines for stopping CPR out of hospital; the most well known is the Universal Termination of Resuscitation (TOR) Guideline that was derived and validated in North America. This states that resuscitation can be discontinued in the field by emergency medical services (EMS) providers if the following three criteria are met: (1) the cardiac arrest was not witnessed by EMS providers; (2) the patient did not have a return of spontaneous circulation (ROSC) despite attempted resuscitation; and (3) no shocks were delivered at any time before transport. The practicalities of this in various settings will be discussed.

Professor Nolan will also say that there are far fewer data on when to terminate in-hospital resuscitation attempts, which often leaves resuscitation teams having to make highly subjective decisions. Validated clinical decision tools for stopping in-hospital resuscitation exist, but are based on previous CPR guidelines, and are rarely used in clinical practice. And finally, the use of extracorporeal membrane oxygenation (ECMO) has further complicated CPR protocols, since this technology, although limited, allows patients to survive longer than before while the cause of their cardiac arrest is determined, and potentially corrected.

The final talk, “ICU admission in a culture of death denial”, will be given by Sharon Einav, Professor of Anaesthesia and Critical Care Medicine and Director of Surgical Intensive Care at the Shaare Zedek Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel.

The 2015 American Thoracic Society (ATS)/European Society for Intensive Care Medicine (ESICM)  recommendations urge a change in concept from “futile care” to “inappropriate care”. “The difference between the two is important for justifying expert medical decisions regarding triage for ICU admission and withholding and withdrawal of care in the ICU,” says Professor Einav.

The availability of ICU beds within developed countries ranges from 3 to 25 per 100,000 population. Various countries also have legislative differences regarding end of life medical decisions. Despite these differences, the level of care delivered to at least one ICU patient on a random day was perceived as inappropriate by 27% of ICU clinicians all across Europe, reflecting mostly frustration regarding delivery of a disproportionate amount of care.

“Provision of inappropriate care can be damaging not only to the patient, but also to their family and to society,” explains Professor Einav. “There are several causes of disproportionate care – including the specific hospital setting, staff demands, the patient and/or their family and societal demand.”

Using an example medical case (the classic “please admit this patient to your ICU” request), some of the literature on these issues will be presented, with special emphasis placed on attitudes towards death in Western culture based on evidence taken from art and architecture.