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Ceasing Futile Resuscitation in the Field: Ethical Considerations

Ceasing Futile Resuscitation in the Field: Ethical Considerations Abstract This article explores ethical decision making in the prehospital emergency setting with particular attention to emergency cardiac care. The first sections argue in support of current efforts to develop portable do-not-resuscitate (DNR) policies enabling patients' wishes to be honored outside the hospital setting. We then turn to the topic of futile resuscitation, and elaborate and defend a proposal to allow emergency personnel to cease futile resuscitation in the field. We submit that unlike the decision to write a DNR order, the judgment that resuscitation is futile ought not to depend on a patient's prior wishes. Instead, it should reflect a professional consensus and receive support from reliable empirical data. Finally, we acknowledge the difficulty of rendering reliable determinations of futility in the field, and show through case examples and empirical studies how effective policies can be implemented. In emergency situations it is sometimes assumed that health care providers must use References 1. Pantridge JF, Geddes JS. Cardiac arrest after myocardial infarction . Lancet. 1966;1:807-808.Crossref 2. Pantridge JF, Geddes JS. A mobile intensivecare unit in the management of myocardial infarction . Lancet. 1967;2:271-273.Crossref 3. Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences-National Research Council. Cardiopulmonary resuscitation . JAMA. 1966;198:372-379.Crossref 4. American Medical Association. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC), VIII . JAMA. 1986;255:2905-2984.Crossref 5. Ayres RJ. Current controversies in prehospital resuscitation of the terminally ill patient . Prehosp Disaster Med. 1990;5:49-58. 6. Crimmins TJ. Ethics, law, and emergency medicine . Minn Med. 1988;71:708-709. 7. Crimmins TJ. The need for a prehospital DNR system . Prehosp Disaster Med. 1990;5:47-48. 8. Mott PD, Barker WH. Hospital and medical care use by nursing home patients . J Am Geriatr Soc. 1988;36:47-53. 9. Besdine RW. Decision to withhold treatment from nursing home residents . J Am Geriatr Soc. 1983;31:602-606. 10. American College of Emergency Physicians. Guidelines for 'do not resuscitate' orders in the prehospital setting . Ann Emerg Med. 1988;17:1106-1108.Crossref 11. American College of Emergency Physicians. Medical, moral, legal and ethical aspects of resuscitation for the patient who will have minimal ability to function or ultimately survive . Ann Emerg Med. 1985;14:919-926.Crossref 12. Sachs GA, Miles SH, Levin RA. Limiting resuscitation . Ann Intern Med. 1991;114:151-154.Crossref 13. Miles SH, Gomez CF. Protocols for Elective Use of Life-Sustaining Treatment . New York, NY: Springer Publishing Co Inc; 1989. 14. Hastings Center. Guidelines for the Termination of Life-Sustaining Treatment . Indianapolis, Ind: Indiana University Press; 1987. 15. Haynes BE, Niemann JT. Letting go: DNR orders in prehospital care . JAMA. 1985;254:532-533.Crossref 16. Iserson KV. Foregoing prehospital care . J Med Ethics. 1991;17:19-24.Crossref 17. Miles SH, Crimmins TJ. Orders to limit emergency treatment for an ambulance service in a large metropolitan area . JAMA. 1985;254:525-527.Crossref 18. Miles SH. Advanced directives to limit treatment: the need for portability . J Am Geriatr Soc. 1987;35:74-76. 19. Iserson KV. Prehospital DNR orders: commentary . Hastings Cent Rep. 1989;19:17-18.Crossref 20. Steiber SR. Right to die: public balks at deciding for others . Hospitals. 1987;61:72. 21. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness . Arch Intern Med. 1992;152:2114-2122.Crossref 22. Wrenn K, Brody SL. Do-not-resuscitate orders in the emergency department . Am J Med. 1992;92:129-133.Crossref 23. Fox E, Siegler M. Redefining the emergency physician's role in do-not-resuscitate decision-making . Am J Med. 1992;92:125-128.Crossref 24. Jecker NS, Pearlman RA. Medical futility: who decides? Arch Intern Med. 1992;152:1140-1144.Crossref 25. Brody B. Resuscitating a patient with no vital signs . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986. 26. Gray WA, Capone RJ, Most AS. Unsuccessful emergency medical resuscitation . N Engl J Med. 1991;325:1393-1398.Crossref 27. Bonnin MJ, Swor RA. Outcomes in unsuccessful field resuscitation attempts . Ann Emerg Med. 1989;18:507-512.Crossref 28. Kellerman AL, Staves DR, Hackman BB. In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support . Ann Emerg Med. 1988;17:589-594.Crossref 29. Eliastam M, Duralde T, Martinez F, Schwartz D. Cardiac arrest in the emergency medical service system: guidelines for resusciation . J Am Coll Emerg Phys. 1977;6:525-529.Crossref 30. Tomlinson T, BrodyH. Futilityand the ethics of resuscitation . JAMA. 1990;264:1276-1280.Crossref 31. Lantos JD, Miles SH, Silverstein MD. Survival after cardiopulmonary resuscitation in babies of very low birth weight: is CPR futile therapy? N Engl J Med. 1988;318:91-95.Crossref 32. Ruark JE, Raffin TA. The Stanford University Medical Center committee on ethics . N Engl J Med. 1988;318:25-30.Crossref 33. Schneiderman LJ, Spragg RG. Ethical decisions in discontinuing mechanical ventilation . N Engl J Med. 1988;318:984-988.Crossref 34. Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital . N Engl J Med. 1983;309:569-576.Crossref 35. Hackler JC, Hiller FC. Family consent to orders not to resuscitate . JAMA. 1990;264:1281-1283.Crossref 36. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Resuscitations decisions for hospitalized patients. In: President's Commission: Deciding to Forgo Life-Sustaining Treatment. Washington, DC: Government Printing Office; 1983:231-258. 37. Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation . JAMA. 1988;260:2069-2072.Crossref 38. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications . Ann Intern Med. 1990;112:949-954.Crossref 39. Blackhall LJ. Must we always use CPR? N Engl J Med. 1987;317:1281-1284.Crossref 40. Miles SH. Informed demand for non-beneficial' medical treatment . N Engl J Med. 1991;325:512-515.Crossref 41. Angell M. The case of Helga Wanglie: a new kind of 'right to die' case . N Engl J Med. 1991;325:511-512.Crossref 42. Podrid PJ. Resuscitation in the elderly . Ann Intern Med. 1989;111:193-195.Crossref 43. Murphy DJ, Murray AM, Robinson BE. Outcomes of cardiopulmonary resuscitation in the elderly . Ann Intern Med. 1989;111:199-205.Crossref 44. Jecker NS. Knowing when to stop: the limits of medicine . Hastings Cent Rep. 1991;21:5-8.Crossref 45. Sanders AB. Unique aspects of ethics in emergency medicine . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:9-12. 46. Crimmins TJ. The ethics of resuscitation . In: Tintinalli JE, Krome RL, Ruiz E,eds. Emergency Medicine: A Comprehensive Study Guide . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988:977-978. 47. Meisel A. The 'exceptions' to the informed consent doctrine . Wis Law Rev. 1979:413-488. 48. Faden RR, Beauchamp TL. A History and Theory of Informed Consent . New York, NY: Oxford University Press Inc; 1986:36. 49. Appleton W. Legal aspects of emergency medicine . In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988:979-985. 50. Marshall L. Resuscitating the terminally ill . J Emerg Med Serv. 1985;11:24-28. 51. Capron AM. Legal setting of emergency medicine . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:13-27. 52. National Association of Emergency Medicine. Emergency medical technician's code of ethics . Reprinted in: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:252-253. 53. Jecker NS, Schneiderman LJ. Rationing and futility . Am J Med. 1992;92:189-196.Crossref 54. Weaver WD. Resuscitation outside the hospital: what's lacking? N Engl J Med. 1991;325:1437-1439.Crossref 55. Auerbach PS, Morris JA, Phillips JB, Redlinger SR, Vaughn WK. An analysis of ambulance accidents in Tennessee . JAMA. 1987;258:1487-1490.Crossref 56. Maggiore WA. Withholding resuscitation . J Emerg Med Services. 1991;16:94-98. 57. Veatch RM. Contemporary bioethics and the demise of modern medicine . In: Ormiston GL, Sassower R, eds. Prescriptions: The Dissemination of Medical Authority . New York, NY: Greenwood Press; 1990:23-40. 58. Faber-Langendoen K. Resuscitation of patients with metastatic cancer: is transient benefit still futile? Arch Intern Med. 1991;151:235-239.Crossref 59. Annas GJ. CPR: when the beat should stop . Hastings Cent Rep. 1982;12:30-31.Crossref 60. Emergency Medical Control and Protocols Committee. Control of prehospital care at the scene of emergencies . Minn Med. 1986;69:86-88. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Ceasing Futile Resuscitation in the Field: Ethical Considerations

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References (73)

Publisher
American Medical Association
Copyright
Copyright © 1992 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1992.00400240016002
Publisher site
See Article on Publisher Site

Abstract

Abstract This article explores ethical decision making in the prehospital emergency setting with particular attention to emergency cardiac care. The first sections argue in support of current efforts to develop portable do-not-resuscitate (DNR) policies enabling patients' wishes to be honored outside the hospital setting. We then turn to the topic of futile resuscitation, and elaborate and defend a proposal to allow emergency personnel to cease futile resuscitation in the field. We submit that unlike the decision to write a DNR order, the judgment that resuscitation is futile ought not to depend on a patient's prior wishes. Instead, it should reflect a professional consensus and receive support from reliable empirical data. Finally, we acknowledge the difficulty of rendering reliable determinations of futility in the field, and show through case examples and empirical studies how effective policies can be implemented. In emergency situations it is sometimes assumed that health care providers must use References 1. Pantridge JF, Geddes JS. Cardiac arrest after myocardial infarction . Lancet. 1966;1:807-808.Crossref 2. Pantridge JF, Geddes JS. A mobile intensivecare unit in the management of myocardial infarction . Lancet. 1967;2:271-273.Crossref 3. Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences-National Research Council. Cardiopulmonary resuscitation . JAMA. 1966;198:372-379.Crossref 4. American Medical Association. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC), VIII . JAMA. 1986;255:2905-2984.Crossref 5. Ayres RJ. Current controversies in prehospital resuscitation of the terminally ill patient . Prehosp Disaster Med. 1990;5:49-58. 6. Crimmins TJ. Ethics, law, and emergency medicine . Minn Med. 1988;71:708-709. 7. Crimmins TJ. The need for a prehospital DNR system . Prehosp Disaster Med. 1990;5:47-48. 8. Mott PD, Barker WH. Hospital and medical care use by nursing home patients . J Am Geriatr Soc. 1988;36:47-53. 9. Besdine RW. Decision to withhold treatment from nursing home residents . J Am Geriatr Soc. 1983;31:602-606. 10. American College of Emergency Physicians. Guidelines for 'do not resuscitate' orders in the prehospital setting . Ann Emerg Med. 1988;17:1106-1108.Crossref 11. American College of Emergency Physicians. Medical, moral, legal and ethical aspects of resuscitation for the patient who will have minimal ability to function or ultimately survive . Ann Emerg Med. 1985;14:919-926.Crossref 12. Sachs GA, Miles SH, Levin RA. Limiting resuscitation . Ann Intern Med. 1991;114:151-154.Crossref 13. Miles SH, Gomez CF. Protocols for Elective Use of Life-Sustaining Treatment . New York, NY: Springer Publishing Co Inc; 1989. 14. Hastings Center. Guidelines for the Termination of Life-Sustaining Treatment . Indianapolis, Ind: Indiana University Press; 1987. 15. Haynes BE, Niemann JT. Letting go: DNR orders in prehospital care . JAMA. 1985;254:532-533.Crossref 16. Iserson KV. Foregoing prehospital care . J Med Ethics. 1991;17:19-24.Crossref 17. Miles SH, Crimmins TJ. Orders to limit emergency treatment for an ambulance service in a large metropolitan area . JAMA. 1985;254:525-527.Crossref 18. Miles SH. Advanced directives to limit treatment: the need for portability . J Am Geriatr Soc. 1987;35:74-76. 19. Iserson KV. Prehospital DNR orders: commentary . Hastings Cent Rep. 1989;19:17-18.Crossref 20. Steiber SR. Right to die: public balks at deciding for others . Hospitals. 1987;61:72. 21. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness . Arch Intern Med. 1992;152:2114-2122.Crossref 22. Wrenn K, Brody SL. Do-not-resuscitate orders in the emergency department . Am J Med. 1992;92:129-133.Crossref 23. Fox E, Siegler M. Redefining the emergency physician's role in do-not-resuscitate decision-making . Am J Med. 1992;92:125-128.Crossref 24. Jecker NS, Pearlman RA. Medical futility: who decides? Arch Intern Med. 1992;152:1140-1144.Crossref 25. Brody B. Resuscitating a patient with no vital signs . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986. 26. Gray WA, Capone RJ, Most AS. Unsuccessful emergency medical resuscitation . N Engl J Med. 1991;325:1393-1398.Crossref 27. Bonnin MJ, Swor RA. Outcomes in unsuccessful field resuscitation attempts . Ann Emerg Med. 1989;18:507-512.Crossref 28. Kellerman AL, Staves DR, Hackman BB. In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support . Ann Emerg Med. 1988;17:589-594.Crossref 29. Eliastam M, Duralde T, Martinez F, Schwartz D. Cardiac arrest in the emergency medical service system: guidelines for resusciation . J Am Coll Emerg Phys. 1977;6:525-529.Crossref 30. Tomlinson T, BrodyH. Futilityand the ethics of resuscitation . JAMA. 1990;264:1276-1280.Crossref 31. Lantos JD, Miles SH, Silverstein MD. Survival after cardiopulmonary resuscitation in babies of very low birth weight: is CPR futile therapy? N Engl J Med. 1988;318:91-95.Crossref 32. Ruark JE, Raffin TA. The Stanford University Medical Center committee on ethics . N Engl J Med. 1988;318:25-30.Crossref 33. Schneiderman LJ, Spragg RG. Ethical decisions in discontinuing mechanical ventilation . N Engl J Med. 1988;318:984-988.Crossref 34. Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital . N Engl J Med. 1983;309:569-576.Crossref 35. Hackler JC, Hiller FC. Family consent to orders not to resuscitate . JAMA. 1990;264:1281-1283.Crossref 36. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Resuscitations decisions for hospitalized patients. In: President's Commission: Deciding to Forgo Life-Sustaining Treatment. Washington, DC: Government Printing Office; 1983:231-258. 37. Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation . JAMA. 1988;260:2069-2072.Crossref 38. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications . Ann Intern Med. 1990;112:949-954.Crossref 39. Blackhall LJ. Must we always use CPR? N Engl J Med. 1987;317:1281-1284.Crossref 40. Miles SH. Informed demand for non-beneficial' medical treatment . N Engl J Med. 1991;325:512-515.Crossref 41. Angell M. The case of Helga Wanglie: a new kind of 'right to die' case . N Engl J Med. 1991;325:511-512.Crossref 42. Podrid PJ. Resuscitation in the elderly . Ann Intern Med. 1989;111:193-195.Crossref 43. Murphy DJ, Murray AM, Robinson BE. Outcomes of cardiopulmonary resuscitation in the elderly . Ann Intern Med. 1989;111:199-205.Crossref 44. Jecker NS. Knowing when to stop: the limits of medicine . Hastings Cent Rep. 1991;21:5-8.Crossref 45. Sanders AB. Unique aspects of ethics in emergency medicine . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:9-12. 46. Crimmins TJ. The ethics of resuscitation . In: Tintinalli JE, Krome RL, Ruiz E,eds. Emergency Medicine: A Comprehensive Study Guide . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988:977-978. 47. Meisel A. The 'exceptions' to the informed consent doctrine . Wis Law Rev. 1979:413-488. 48. Faden RR, Beauchamp TL. A History and Theory of Informed Consent . New York, NY: Oxford University Press Inc; 1986:36. 49. Appleton W. Legal aspects of emergency medicine . In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988:979-985. 50. Marshall L. Resuscitating the terminally ill . J Emerg Med Serv. 1985;11:24-28. 51. Capron AM. Legal setting of emergency medicine . In: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:13-27. 52. National Association of Emergency Medicine. Emergency medical technician's code of ethics . Reprinted in: Iserson KV, Sanders AB, Mathieu DR, Buchanan AE, eds. Ethics in Emergency Medicine . Baltimore, Md: Williams & Wilkins; 1986:252-253. 53. Jecker NS, Schneiderman LJ. Rationing and futility . Am J Med. 1992;92:189-196.Crossref 54. Weaver WD. Resuscitation outside the hospital: what's lacking? N Engl J Med. 1991;325:1437-1439.Crossref 55. Auerbach PS, Morris JA, Phillips JB, Redlinger SR, Vaughn WK. An analysis of ambulance accidents in Tennessee . JAMA. 1987;258:1487-1490.Crossref 56. Maggiore WA. Withholding resuscitation . J Emerg Med Services. 1991;16:94-98. 57. Veatch RM. Contemporary bioethics and the demise of modern medicine . In: Ormiston GL, Sassower R, eds. Prescriptions: The Dissemination of Medical Authority . New York, NY: Greenwood Press; 1990:23-40. 58. Faber-Langendoen K. Resuscitation of patients with metastatic cancer: is transient benefit still futile? Arch Intern Med. 1991;151:235-239.Crossref 59. Annas GJ. CPR: when the beat should stop . Hastings Cent Rep. 1982;12:30-31.Crossref 60. Emergency Medical Control and Protocols Committee. Control of prehospital care at the scene of emergencies . Minn Med. 1986;69:86-88.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Dec 1, 1992

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