Chain of survival

The first step is a call to the emergency medical services (EMS) system. The bystander then needs to institute basic life support (BLS) while awaiting the arrival of EMS. The BLS procedures may be undertaken by personnel with little or no training. For the latter, most EMS dispatch centres are able to provide bystander CPR instructions via the telephone.

BLS generally includes interventions that involve minimal use of ancillary equipment, but may now include the application of a semi-automatic external defibrillator (SAED) if one is available close to the site of the cardiac arrest.

This chapter describes the current approach to BLS delivered by the bystander while awaiting the arrival of EMS or medical expertise that will be able to provide advanced life support (ALS) skills (see Ch. 1.2).

Australian Resuscitation Council (ARC) BLS guidelines

Subsequently, each national committee endorsed the guidelines, with minor regional variations to take into account local practices. The recommendations of the Australian Resuscitation Council (ARC) on BLS were published in 2006.^3–6

New Zealand Resuscitation Council (NZRC) BLS guidelines

The New Zealand Resuscitation Guidelines were also endorsed in 2006 (available at http://www.nzrc.org.nz/).

Check for dangers

As the patient is approached, the bystander should immediately consider any dangers that may be associated with the collapse of the patient. For example, the patient may have been electrocuted and there could be injuries to bystanders if the power source is not switched off prior to patient contact.

There may be a significant danger from collision with a passing vehicle in the case of a motor-vehicle accident where a patient is unconscious, as well as the potential risk of fire. Therefore, unless they are trapped, unconscious patients should be carefully removed from the vehicle prior to the arrival of emergency medical services, taking care to minimize movement of the neck unless they are trapped. It is considered that the risk of injury from fire or explosion exceeds the risk of moving an unconscious patient prior to immobilization of the cervical spine with a neck collar.

In the case of a patient who has collapsed in a confined space, the possibility of poisoning with a toxic gas such as carbon monoxide should be considered. Do not enter the scene until it can be made safe by emergency services, usually the fire brigade.

Finally, in current times of potential terrorist attack, if multiple victims are present, consider the possibility of the use of a chemical agent such as an organophosphate causing collapse and cardiac arrest. In this setting bystanders should immediately leave the area and await the arrival of EMS and a specialist hazardous agent team.

Check for response

The patient who has collapsed must be rapidly assessed to determine whether there is unconsciousness, indicating possible cardiac arrest. This is assessed by a gentle ‘shake and shout’ and observation of the patient’s response.

Suspect cardiac arrest if the patient is unresponsive to the ‘shake and shout’, and immediately telephone the emergency medical services (‘call first’). Alternatively, if the collapse is due to suspected airway obstruction (choking) or inadequate ventilation (drowning, hanging etc.), then commence resuscitation focusing on the airway for approximately 1 minute before calling the emergency medical services (‘call fast’).

Airway and breathing

Make an assessment of the airway and breathing if a patient has collapsed and is apparently unconscious.^3,4 Place the patient supine, check the airway by visual inspection, and open the airway with a head-tilt and/or a chin-lift manoeuvre.

Adequate respiration is assessed by visually inspecting the movement of the chest wall and listening for upper airway sounds. Occasional deep (agonal) respirations may continue for some minutes after the initial collapse in cases of cardiac arrest. These respirations are often mistaken for adequate breathing by untrained bystanders.

Cardiopulmonary resuscitation (CPR) will be required if the patient is found to have inadequate or absent breathing on initial assessment. On the other hand, when the initial assessment of an unconscious patient reveals adequate respiration, turn the victim on his/her side and maintain in the semi-prone recovery position. Make constant checks to ensure continued respiration while awaiting the arrival of the EMS.

Circulation

It was traditionally recommended that a bystander should attempt to palpate a pulse in order to diagnose cardiac arrest and, if absent, commence external cardiac compressions (ECC). It is now currently recommended that untrained bystanders do not attempt to palpate for a pulse,⁵ as there is good evidence that the pulse check is inaccurate in this setting.⁷ Therefore, cardiac arrest may instead be presumed if breathing is absent, and is highly likely if breathing is inadequate.

Airway obstruction

Make a careful sweep with a finger if inspection of the airway reveals visible foreign material or vomitus in the upper airway. Take particular care not to be bitten, not to cause pharyngeal trauma, and not to propel material down into the lower airway.

There are a number of manoeuvres proposed to clear the airway if it is completely obstructed by a foreign body. In many countries abdominal thrusts (the Heimlich manoeuvre) are endorsed as the technique of choice. However, this technique is associated with potential complications such as intra-abdominal injury. In Australia the recommended techniques for clearing an airway that is obstructed by a foreign body are back blows and/or chest thrusts. As there is insufficient evidence to recommend one treatment over another, it is recommended that each be tried in succession until the obstruction is relieved.

Cardiopulmonary resuscitation (CPR)

The bystander should immediately commence cardiopulmonary resuscitation (CPR) if cardiac arrest is diagnosed and the EMS has been summoned, using both expired air resuscitation (EAR) and ECC until a defibrillator arrives.⁶

Expired air resuscitation (EAR) or ‘rescue breathing’

Since the first description in 1958, EAR has become the standard in BLS for patients who have absent or inadequate respirations. It is now more often referred to as ‘rescue breathing’. Two breaths should be delivered initially, followed by chest compressions (see later). Subsequently, deliver two breaths for every 30 chest compressions. However, there is often considerable reluctance by bystanders to perform EAR owing to the perceived difficulty of the procedure, the possibility of cross-infection and its disagreeable aesthetics.

External cardiac compressions (ECC)

Place the patient supine on a firm surface such as a backboard, firm mattress or even the floor to optimize the effectiveness of chest compressions. Perform compressions that allow equal time for the compression and relaxation phases, with compression being approximately 50% of the cycle. Depress the lower sternum at least 4–5 cm in the adult, with complete recoil of the chest after each compression. Perform ECC at a rate of 100 compressions per minute, to ensure the delivery of a minimum of about 80 compressions per minute when accounting for the period spent on ventilations.⁵ Recommendations are essentially to ‘push hard, push fast, allow complete release and minimize interruptions’.

Semi-automatic external defibrillation (SAED)

The semi-automatic external defibrillation (SAED) is now considered part of BLS. SAED devices are extremely accurate in diagnosing ventricular fibrillation or ventricular tachycardia, and are relatively simple for bystanders to use with minimal training. After switching the device on and applying the pads, the SAED will request confirmation of coma and absent respirations, and advise the bystander to ‘stand clear’. The bystander is then advised to manually press a button to deliver a shock.

Most SAEDs have an algorithm that initially requests the delivery of three countershocks if ventricular fibrillation persists. As the recent ILCOR guidelines now recommend a single shock followed by 1 minute of CPR (except when using a manual defibrillator at a witnessed arrest), it is expected that SAEDs will progressively have their electronics upgraded to follow the new recommendations.²

Non-medical personnel and the SAED

Changes to BLS

The main recent change to basic life support is the so-called DR ABCD approach: the performance of chest compressions at a rate of 100 per minute, with 30 compressions followed by two ventilations, or ‘30:2’, with no pause to determine the presence or absence of a pulse.¹⁶ The exceptions to this are resuscitation of the newborn (use a 3:1 ratio of 90 compressions and 30 inflations to achieve 120 ‘events’ per minute); and endotracheally intubated victims (use a ratio of 15:1 in adults and 15:2 in children). Also pulse checks and recovery checks are no longer performed, and CPR is only interrupted when signs of a return of spontaneous circulation are present.¹⁷

Chain of survival

The importance of rapid treatment for cardiac arrest has led clinicians to develop a systems management approach, represented by the concept of the ‘Chain of Survival’, which has become the widely accepted model for the emergency medical services (EMS) systems.⁴ The Chain of Survival concept implies that more people survive sudden cardiac arrest when a cluster or sequence of events is set up as rapidly as possible. This Chain of Survival sequence includes:

All the links must be connected, as weakness in any link of the chain reduces the probability of patient survival. ALS involves the continuation of BLS as necessary, but with the addition of manual defibrillation, advanced invasive airway and vascular access techniques, and the administration of pharmacological agents.

Aetiology

The commonest cause of sudden cardiac arrest in adults is ischaemic heart disease.^1,2,5 Other causes include respiratory failure, drug overdose, metabolic derangements, trauma, hypovolaemia, immersion and hypothermia.

Incidence

The population incidence of sudden cardiac death (within 24 hours of the onset of any symptoms) has been estimated as 1.24:1000/year in the USA.⁶ The incidence of cardiac arrest notified to ambulances in western metropolitan Melbourne, Australia, in 1995 was approximately 0.72:1000/year.⁷ From among 20 communities in developed nations worldwide a population average of 0.62:1000/year received attempted resuscitation after out-of-hospital cardiac arrest.⁶

International Liaison Committee on Resuscitation (ILCOR)

In 2000, the American Heart Association, in collaboration with the International Liaison Committee on Resuscitation (ILCOR), convened the International Guidelines 2000 Conference on CPR and Emergency Cardiac Care (ECC). This was the first international assembly gathered specifically to produce international resuscitation guidelines, where the International Guidelines 2000 for CPR and ECC were developed and then published.⁸ These guidelines represented a consensus of expert individuals and resuscitation councils and organizations across many countries, cultures and disciplines. The underlying principle guiding decision-making was that additions to existing guidelines had to pass a rigorous evidence-based review. Revisions or deletions occurred because of:

Researchers from the ILCOR member councils continued to apply and develop the above evidence evaluation process, which culminated in the publication in 2005 of the Consensus on Science and Treatment Recommendations (CoSTR).¹

Consensus on Science and Treatment Recommendations (CoSTR)

Each ILCOR member body has used the CoSTR documents to develop its own guidelines for local use. Thus in 2006 both the Australian Resuscitation Council (ARC)⁵ and the New Zealand Resuscitation Council (NZRC)⁹ published their local guidelines. The ARC guideline on Adult Advanced Life Support² includes an Adult Cardiorespiratory Arrest algorithm (Fig. 1.2.1). This is clear, concise, and easy to memorize and adapt into poster format, and is readily applied clinically.

Fig. 1.2.1 Algorithm for management of adult cardiorespiratory arrest.

(Reproduced with permission from the Australian Resuscitation Council.)

However, resuscitation knowledge is still incomplete, and some of the ALS techniques currently in use are not supported by the highest levels of scientific rigour. Thus strict adherence to any guidelines should be guided by common sense. Individuals with specialist knowledge may modify them according to the level of their expertise and the specific clinical situation or environment in which they practise.¹⁰

Automated external defibrillator

Apply the self-adhesive pads in the standard anteroapical positions for defibrillation (see below) using an automated external defibrillator (AED). An internal microprocessor analyses the ECG signal and, if VF/VT are detected, it causes the AED to display a warning and then either deliver a shock (automatic) or advise the operator to do so (semi-automatic).^2,11,12

Manual external defibrillator

The critical decision for the rescuer after applying the self-adhesive pads or paddles of a manual external defibrillator is whether or not the cardiac rhythm is VF/VT.^1,2 Up to 70% of patients with an out-of-hospital cardiac arrest will be in VF/VT at the time of arrival of EMS personnel and a monitor/defibrillator.¹¹ The vast majority of cardiac arrest survivors come from this group.^1,2,4

Rhythm recognition

Placement of pads or paddles

Pads or paddles are often identified as ‘sternum’ and ‘apex’, or ‘anterior’ and ‘posterior’, which is of no relevance for emergency transthoracic defibrillation. It simply allows detection by the pads/paddles of the correct orientation of certain perfusing cardiac rhythms prior to synchronized cardioversion.^1,2,11,12,13

Timing of shocks

Waveform and energy of shocks

Two main types of waveform are available from cardiac defibrillators.

Optimizing transthoracic impedance

A critical myocardial mass must be depolarized synchronously for defibrillation to be successful. This interrupts the fibrillation and allows recapture by a single pacemaker. Thus the transthoracic impedance must be minimized in order to maximize the probability of success.^1,2,11–13

Current-based defibrillation

Conventional defibrillators are designed to deliver a specified amount of energy measured in joules. Depolarization of myocardial tissue is accomplished by the passage of electrical current through the heart; clinical studies have determined that the optimal current is 30–40 amperes (A).^11,13 The current delivered at a fixed energy is inversely related to the transthoracic impedance, so a standard energy dose of 200 J delivers about 30 A to the average patient. The current generated may be inadequate in patients with greater than average impedance, whereas patients with smaller transthoracic impedance may sustain myocardial damage from excessive current flow.^11–13

Some newer current-based defibrillators automatically measure transthoracic impedance and then predict and adjust the energy delivered to avoid inappropriately high or low transmyocardial current. These devices have defibrillation success rates comparable to those of conventional defibrillators while cumulatively delivering less energy. The reduced energy should result in less myocardial damage and may reduce post-defibrillation complications.^11–13

Automated external defibrillators (AED)

AEDs were first introduced in 1979 and have become standard equipment in EMS systems for use outside hospital, as well as within hospital in many circumstances.

AEDs are highly accurate, some models demonstrating 100% specificity and 90–92% sensitivity in correctly identifying coarse VF.¹² Their precision is less for fine VF and least for VT, but overall accuracy is comparable to that of an experienced cardiologist.¹¹ EMS systems equipped with AEDs are able to deliver the first shock up to 1 minute faster than when using conventional defibrillators. Rates of survival to hospital discharge are equivalent to those achieved when more highly trained first responders use manual defibrillators.⁴

The major advantage of AEDs over manual defibrillators is their simplicity, which reduces the time and expense of initial training and continuing education, and increases the number of persons who can operate the device.^4,11–12 Members of the public have been trained to use AEDs in a variety of community settings, and have demonstrated that they can retain skills for up to 1 year.⁴ Encouraging results have been produced when AEDs have been placed with community responders such as firefighters, police officers, casino staff, security guards at large public assemblies and public transport vehicle crews.^4,11

The Australasian College for Emergency Medicine recommends that all clinical staff in healthcare settings should have rapid access to an AED or a defibrillator with AED capability.¹⁴

Technical problems

Whenever attempted defibrillation is not accompanied by skeletal muscle contraction take care to ensure good contact, and that the defibrillator is turned on, charged up, develops sufficient power and is not in synchronized mode. The operational status of defibrillators should be checked regularly, and a standby machine should be available at all times. The majority of defibrillator problems are due to operator error or faulty care and maintenance.¹²

Complications of defibrillation

Rationale for resumption of CPR

The rationale for this is that after one defibrillator shock there is typically a delay of several seconds before a diagnostic-quality ECG trace is obtained. Additionally, even when defibrillation is successful, there is often a temporary impairment of cardiac function from seconds to minutes, associated with a weak or impalpable pulse. Thus waiting for a recognizable ECG rhythm or palpating for a pulse that may not be present anyway after successful defibrillation will unnecessarily delay the recommencement of CPR. This is detrimental to the patient who does not yet have ROSC.^1,2

Algorithm loops

Pay attention to each of the following, either continuously or after each loop of the algorithm:^1,2

PEA or asystole

Reassess the ECG rhythm after 2 minutes of CPR and, when appropriate, the pulse. Give a single shock without delay if VF/pulseless VT persist.^1,2,9 However, when PEA or asystole are present on ECG rhythm and/or pulse assessment, do not defibrillate as it may be deleterious.^1,2,11,12

The prognosis for PEA or asystole is much worse than for VF/VT, and unless there are potentially reversible causes (4Hs and 4Ts), the application of other ALS interventions (see below) is indicated, but seldom of value.^1,2

Advanced airway management

Endotracheal intubation is considered the best technique for airway management during cardiac arrest and is recommended in the ARC guidelines.² However, no randomized controlled study exists that shows an improved outcome with endotracheal intubation compared to basic airway management.^1,2,10,15,16 Other advanced airway devices studied during CPR as alternatives to the endotracheal tube include the laryngeal mask airway (LMA), and the oesophageal–tracheal combitube (Combitube). None is definitely superior to basic airway management during cardiac arrest in terms of consistently improved survival.^1,2

Ventilation and oxygenation

Cardiac arrest and CPR cause an increase in dead space and a reduction in lung compliance that compromise gas exchange. Therefore, a fractional inspired oxygen concentration (FIO₂) of 1.0 (100% oxygen delivery system) is essential in cardiac arrest to optimize oxygen delivery.^1,2,17

Vascular access and drug delivery

Intratracheal route

The intratracheal instillation of drugs is an alternative during cardiopulmonary resuscitation, especially when tracheal intubation precedes venous access. Epinephrine (adrenaline), lignocaine (lidocaine) and atropine may be safely administered through the endotracheal tube if there is a delay in achieving vascular access.

The ideal dose and dilution of drugs given by this route are unknown, but recommendations include using 3–10 times the standard i.v. drug dose diluted in 10 mL of water or normal saline. The drug should be delivered via a catheter or quill placed beyond the tip of the endotracheal tube, and followed by ventilations to aid dispersion.^1,2,18

Fluid therapy

Crystalloid solutions are used as standard for the i.v. delivery of drugs during CPR. Glucose-containing solutions are avoided during CPR as they may contribute to post-arrest hyperglycaemia, which reduces or impairs cerebral recovery.¹⁸

Epinephrine (adrenaline)^{1,2,9,10,15,16}

The putative beneficial actions of epinephrine in cardiac arrest relate to its α-adrenergic effects, which result in an increased aortic blood pressure with increased perfusion of the cerebral and coronary vascular beds, and reduced blood flow to splanchnic and limb vessels. Epinephrine is considered the ‘standard’ vasopressor in cardiac arrest.

Amiodarone^1,2

Amiodarone has some benefit in refractory VF/VT in the setting of out-of-hospital cardiac arrest. Additionally, studies show an improvement in defibrillation response when amiodarone is given in VF or haemodynamically unstable VT. Consider amiodarone for refractory VF/VT.

Atropine^1,2

Atropine has no consistent benefits in cardiac arrest, but may be considered in certain circumstances.

Calcium^1,2

Calcium is only indicated when the cardiac arrest is caused or exacerbated by the specific conditions listed below.

Lignocaine (lidocaine)^1,2

The antiarrhythmic properties of lignocaine in cardiac arrest are inconsistent. Its continued use is based purely on familiarity and historical precedent. The role of lignocaine in the prophylaxis of VF/VT is also unclear and at best equivocal.

Magnesium^1,2,10

Magnesium is indicated when the cardiac arrest is caused or exacerbated by the specific conditions listed below. There is no support for its routine use at present.

Sodium bicarbonate^1,2

Sodium bicarbonate is only indicated when the cardiac arrest is caused or exacerbated by the specific conditions listed below. There is no support for its routine use in cardiac arrest.

Vasopressin^1,2,19

Vasopressin is an alternative vasopressor to epinephrine. There is currently insufficient evidence to support or refute its use either alone or in combination with adrenaline in any cardiac arrest rhythm.

End-tidal CO₂ (ETCO₂)^1,2,10,20

Animal and clinical studies indicate that measuring ETCO₂ is an effective and informative technique for determining progress during CPR, particularly if there is ROSC.

ETCO₂ typically falls to less than 10 mmHg at the onset of cardiac arrest. It can rise to between one-quarter and one-third of normal with effective CPR, and rises to normal or supranormal levels over the next minute following ROSC. The changes in ETCO₂ parallel similar proportionate increases in cardiac output.

Arterial blood gases^1,2

Arterial blood gas (ABG) monitoring during cardiac arrest is a useful indicator of oxygenation and the adequacy of ventilation, but is not an accurate measure of tissue acidosis. An increase in PaCO₂ may indicate improved tissue perfusion during CPR or with ROSC, if ventilation is constant. The measurement of ABGs should not interfere with the overall performance of good CPR.

Ceasing CPR pre-hospital

A recommendation made in 1993 for out-of-hospital cardiac arrest in the normothermic patient was that resuscitation should cease if there was no ROSC after 25 minutes of ALS.²² Two important exceptions to this guide are:

These recommendations were applied and considered valid in a prospective study in that same year.²³

In-hospital cardiac arrest outcomes

There are no early absolute predictors of futility in the resuscitation of patients with in-hospital cardiac arrest. Some variables are, however, associated with a greater or lesser chance of survival to discharge. Better outcomes are linked to ventricular tachyarrhythmias, the commencement of resuscitation within 5 minutes of collapse, and ROSC within 15 minutes of CPR.

Outcome of prolonged ALS

ALS resuscitation efforts lasting more than 30 minutes without ROSC at any stage are so uniformly unsuccessful that resuscitation should be abandoned, except in certain special circumstances such as hypothermia, possibly some drug overdoses, and following thrombolysis in suspected massive pulmonary embolism (PE).^10,25 The return of spontaneous circulation at any time during the resuscitation process resets the clock to time zero.^1,5

Out-of-hospital cardiac arrest

Some variation in survival after an out-of-hospital cardiac arrest is due to differences in EMS systems, as well as to differing research methodology and data reporting. In a 1996 meta-analysis of 36 articles published between 1973 and 1992 describing 41 EMS systems in six countries,²⁶ survival varied from 0% to 21%, with an overall mean survival of 8%.

In-hospital cardiac arrest

The prognosis for survival from in-hospital cardiac arrest is only marginally better, with survival to discharge averaging 13.8% of 12 961 patients described in reports published between 1961 and 1984.²⁴ However, in a further seven reports published between 1978 and 1989 this dropped to 11% of 1804 patients.²⁵

Medical ethics

This chapter discusses the ethical issues surrounding resuscitation. A working definition of ethics is ‘the study of morality’. It is reasonable to describe moral behaviour as that which is ‘the right thing to do’. Thus, medical ethical deliberation is the process of determining what is the right thing to do, when considering any of the dilemmas that arise in medical practice.

The law

The law also considers ‘what is the right thing’, but in a different way. Statutes and precedents (that is, previous decisions) can be applied to a given case, and particularly to the detailed events of that case, so that a definitive determination of ‘right’ can be made. The law is most useful when applied retrospectively, because of the application of different legal perspectives to the specifics of a case. In contrast, ethics has less well defined parameters for differentiating right from wrong (for example principles), and thus may struggle to come to a definitive determination.

Ethics and the clinician

However, owing to the relative simplicity of its tools (principles) and their general applicability, ethics is better suited to the prospective consideration of ‘the right thing to do’ by a clinician with a patient in front of them. In addition, ethics is more internationally applicable, whereas the law will vary from state to state and from country to country. Therefore, ethics (rather than the law) is generally what clinicians use when deciding what is the right thing to do.

Some guidance about legal issues related to resuscitation in an Australasian context may be accessed in publications such as those from the Australian Resuscitation Council Guidelines¹ and in the summary statement from the Medical Council of New Zealand.²

Philosophical models

The approach to ethical dilemmas may vary according to the philosophical perspective adopted.³ Although there are a variety of models describing moral decision making, only a pragmatic overview will be given here. In general terms, a utilitarian approach may be adopted which values the positive balance of good over bad brought about by any action; or, alternatively, a deontological approach, which values actions that adhere to overriding moral principles. However, moral philosophers have recognized that moral principles may compete against each other when specific actions are considered. Moral principles should be honoured, but when they are competing in a given circumstance, we should then consider the relative balance of good and bad that ensues from the application of each principle. Thus, we have a composite philosophy wherein both the principles and the consequences of their application may be considered.

The principles of Beauchamp and Childress

Beauchamp and Childress⁴ developed this further into a practical framework for medical ethical deliberation. They described four principles that should be honoured in medical decision making, and when these principles compete, the relative balance of good and bad should be considered. These four principles are:

Urgency

Urgency may be a barrier to the application of these principles in any given case. It is often appropriate to perform resuscitation assuming these deliberations might take place more fully when time permits, rather than withhold resuscitation on the basis of limited deliberation.

Impaired competence

The impaired competence of patients undergoing resuscitation complicates the principle of respect for autonomy, as the patient is commonly impaired in his or her ability to receive information, comprehend it, consider it in context, and then make a rational decision on the basis of that consideration. It is common practice not to seek or to ignore the wishes of the patient, and instead to presume that resuscitation is the right thing to do, based on arguments of beneficence and non-maleficence.

Thus, it is generally perceived that consent is not required for resuscitation because resuscitation brings benefit and prevents harm, and because the patient is not in a position to give or withhold consent. Although this approach usually does not mean that bad things are done, from an ethical perspective it is flawed. Resuscitation may be harmful in a number of ways, and some form of consent must be obtained, just as for any other medical intervention.

The harms of resuscitation

The benefits of resuscitation include the avoidance of death and the restoration of good health. The harms of resuscitation may be of the following five types:⁵

Advance directives

In the setting of some form of an advance directive, three questions should be considered:

If the answers to any of these questions suggest some doubt as to how applicable the Advance Directive is to the resuscitation at this time, then it should be considered an indication of the patient’s wishes, rather than morally binding.

Considering the harms

The harms of resuscitation must be considered when weighing the relative merits of the principles of respect for patient autonomy, beneficence, non-maleficence and justice. An ill-considered approach will lead to underrepresentation of patient autonomy in these deliberations, and an inadequate appreciation of the extent of harm that may ensue from resuscitation efforts.

Deriving futility

The word futile is derived from the Latin futilis, meaning ‘that which easily pours or melts’. The current usage stems from the story in which the daughters of the King of Argos murdered their husbands and were then condemned to collect water for eternity in leaking buckets. To arrive at your destination with an empty bucket when the intention of the journey was to bring water is undoubtedly a futile endeavour. However, futility in medicine is much more difficult to define.

Defining futility

Some emphasize physiological futility, meaning the inability to produce a physiological outcome objective, for example if CPR produces no pulse, or transfusion produces no blood pressure. The proponents of this definition suggest that it has the least risk of unilaterally imposed physician value judgements.

Others consider futility in terms of quantitative or qualitative measures. A quantitative estimate of futility is one in which an intervention is considered futile if it has failed in, for example, the last 100 attempts. The qualitative component describes futility if the patient’s resultant quality of life falls below a threshold considered minimal by general professional judgement. It is unlikely that there will ever be agreement as to what physiological measure or quality of outcome measures are most appropriate, and what threshold measure separates futility from benefit. Although these arguments are interesting, it is unfortunate that they have taken on more importance than they merit.

The balance of benefit and harm

Futility defines the absence of acceptable benefit for any given intervention, whereas reasonable ethical deliberation demands that we consider the ratio of benefit to harm. If there is no benefit, any harm at all would make the benefit:harm ratio unfavourable. However, even if the endeavour is not futile and brings about measurable benefit, this does not necessarily mean that the endeavour is the right thing to do, as the amount of harm that ensues, as defined above, may outweigh any benefit. It is the benefit:harm balance, as assessed by considering the four ethical principles and the five types of harm described above, that has the most relevance in determining whether to start or to stop a resuscitation.

Presumed consent

Presumed consent uses the concept that a reasonable patient under similar circumstances – or this patient if he or she were able to – would consent to the resuscitation endeavours proposed. This form of consent has merit and is commonly employed, but occasionally attracts criticism from bioethicists as being a form of medical paternalism, in that it may be perceived to be respecting the principle of beneficence, as the resuscitators perceive it, while ignoring respect for patient autonomy.

Proxy consent

Proxy consent involves obtaining consent for resuscitation from a family member or other person who is perceived to be able to speak on behalf of the patient. Proxy consent avoids the criticism of medical paternalism as the decision is taken out of the physician’s hands, but it suffers as a model as the decision maker may be unable to adequately receive information, understand it, and deliberate over it during a hurried and rapidly evolving resuscitation.

In addition, the proxy may not reflect the views of the patient. There may be occasional circumstances where the proxy declines resuscitation because of some financial or other benefit that would accrue from the patient’s death. More commonly, proxies have a tendency to demand more resuscitation than the patient would have wanted, for fear of becoming responsible for their death. When this form of consent is used there is greater scope for the harms of resuscitation.

Proxy consent with substitued judgement

A modification of proxy consent that better addresses the issue of respect for patient autonomy is proxy consent with substituted judgement. This involves not asking what the proxy would want done for the patient, but instead what the proxy thinks the patient would want done. In other words, it attempts to see the resuscitation from the patient’s perspective, as viewed by the proxy.

Presumed consent using professional substituted judgement

A modification of presumed consent is presumed consent using professional substituted judgement.⁷ This means the resuscitators gather as much information about the patient as they possibly can to attempt to understand how the patient would view this decision. This usually involves speaking with the patient’s loved ones. Then, with some knowledge of the likely outcome of the proposed resuscitation, based on previous experience and a knowledge of the medical literature, they can exercise their moral imagination by asking ‘Would I want this treatment if I was this patient?’ In this way the patient’s autonomy is as best respected as it can be under difficult circumstances, by combining a knowledge of the harms and benefits of the resuscitation with an appreciation of this balance from the patient’s perspective.

The resuscitation cannot proceed if presumed consent using professional substituted judgement is employed and the answer to the question is ‘No’. To resuscitate without regard for the patient’s explicit or perceived wishes is a harmful disrespect for their autonomy.

Often, and appropriately, a decision to proceed will be made on the basis of a perceived marginal benefit over harm. This balance is made more appealing by the alternative of certain death if resuscitation is not undertaken. However, the balance is dynamic, with a clearer view of the likely benefits and harms only emerging as the patient responds or not to the resuscitation. All concerned should be willing to minimize the ongoing harms of resuscitation by withdrawing treatment if that treatment does not procure the hoped-for benefits, as the balance becomes more unfavourable.

Withholding and withdrawing treatment

The concept of withholding and withdrawing treatment is somewhat misdirected in that it implies a need for permission to stop the intervention, whereas the precedent in medicine is to obtain permission to proceed. It is wrong to withhold a resuscitation endeavour because of the concern that the life-saving treatment cannot be withdrawn at a later date if things are not going well. When resuscitation is withheld, a small but significant number of patients may miss out on the opportunity for a good outcome had the resuscitation been offered to them. Similarly, it is wrong to be unable to withdraw treatment because of the ill-conceived concept that once resuscitation has begun it must continue.

The resuscitators should recognize when the balance of benefit and harm becomes unfavourable from the patient’s perspective, by employing professional substituted judgement. At this point they have a moral obligation to withdraw resuscitation, as they can no longer presume the patient’s consent. The harms of resuscitation medicine will be minimized by appreciating the benefits and harms of resuscitation, the use of professional substituted judgement to view these from the patient’s perspective, and by a commitment to stop resuscitation when the patient’s consent cannot be presumed.

The content of NFR orders

Most large Australasian hospitals have a policy about NFR orders and an increasing number use standardized forms to record the resuscitation status of patients. In addition, many provide information leaflets for patients and relatives explaining the NFR process and status.⁸ Local policy, including the completion of standardized forms, should be followed.

Usually the NFR form will include the patient’s diagnosis, the reasons for an NFR order, the date of issue, the date when it should be reviewed, the nature of the discussion with the patient and/or the relatives, or reasons why such a discussion did not occur. In addition, it should record exactly what is intended by the NFR status (for example, not for cardiopulmonary resuscitation in the event of cardiac arrest, or not for intensive care), including clarification that all other care will be provided as required. There is some evidence that those who have NFR orders may be denied other care owing to a perception that there is ‘nothing more to offer them’.⁹ It is most important that an ethically sound decision about resuscitation not being what the patient wants does not lead to an immoral neglect to provide good care. The nature of what care can and should still be delivered – for example analgesia, intravenous fluids, non-invasive ventilation etc. – should be clearly documented.

Establishing an NFR order

The process of establishing NFR status includes a consideration of the beneficence and non-maleficence of the resuscitation interventions in question, and then a determination that the patient does not consent to them. The NFR order should be completed with them if the patient has the capacity to make decisions, analogous to any informed consent process. However, the nature of this consent process has added dificulties. Patients need careful information about the poor prognosis of resuscitation interventions such as cardiopulmonary resuscitation, and about the often unappreciated harms that might ensue. Great care needs to be taken to ensure the patient does not percieve the discussion to be a message of impending death (if this is not the case), and they should be reassured that all other care will be delivered, including ensuring that they are kept comfortable.

There is some debate about having an NFR order without discussion with the patient, and some suggest that there should be a presumption of resuscitation for all who have not agreed to an NFR.¹⁰ This view is counter to the arguments discussed above, which propose that some form of consent needs to be obtained for resuscitation to proceed, just as it is needed for all other medical interventions. There will be occasions when discussion with the patient is not undertaken, particularly if the patient is without decision-making capacity, or resuscitation is clearly without benefit. No rational person would consent to an intervention that is clearly more harmful than beneficial, and so lack of consent can be presumed, as discussed above. These details should be recorded.

Keeping an NFR order current

Like ‘Advance Directives’ or ‘Living Wills’, an NFR order may lose validity if the patient’s condition changes, or they have a change of mind. An old NFR order (for example one made during a previous admission) will be influential to decision making, but is not binding if it is percieved that the patient would now consent. Consequently, NFR orders should be updated regularly, particularly if circumstances change.

Consent for practising resuscitation procedures on the newly dead

Practising resuscitation procedures on the newly dead requires permission before it may proceed, just like all other interventions in medicine. Informed consent may be obtained from the terminally ill for permission to perform procedures after they die, but this has limited relevance to the practice as it occurs in many emergency departments.

Implied consent argues that consent is implicit in the fact that the patient used the emergency services and therefore agreed to all that this entails, including being used for teaching. Implied consent criteria are commonly used for those who present of their own volition for non-invasive medical care. However, patients who die in the emergency department most often do not present of their own volition, but instead are brought in by others – usually ambulance staff – in a state of impaired competence. Furthermore, implied consent confers the right to administer treatment that the patient would reasonably expect at the time of presentation. Therefore, if a patient’s attendance is involuntary, with impaired competence or with ignorance of the procedure, he or she cannot imply consent and medical staff cannot infer it.

‘Construed consent’ is a modification of implied consent, suggesting that if consent was obtained for a certain procedure it can be construed for a related procedure. If it is conceded that a form of consent (presumed consent, as suggested above) is obtained to intubate a patient during resuscitation, can it be construed that consent also applies to intubation after death? There is a superficial logic to this, as to perform the same procedure on the same patient with the same equipment one minute before, and one minute after, death seems a continuum of the same therapeutic relationship. However, on close analysis there is a sufficiently significant difference as to render previous consent null and void. The consent to resuscitate is based on a contract between medical staff and the patient dedicated to helping the patient. When the objective is no longer to help the patient, the previous contract is irrelevant and a new one must be entered into. Intubating the deceased under the old contract is a violation of the trust inherent in the previously formed therapeutic relationship. An appreciation of this violation contributes to the repugnance towards the procedure.

Presumed consent is appropriate when impaired competence renders the patient unable to give informed consent. Although it is likely that most would consent to postmortem procedures for the benefit of medical staff and subsequent patients, presumed consent does disadvantage the minority who would not. Formal application of a presumed consent rule for performing procedures on the recently dead mandates that the community should be well informed, so that individuals have the opportunity to explicitly decline consent if they so desire.

Proxy consent has also been argued in relation to this procedure. However, when proxy consent rules have been enforced the procedure tends not to take place, because staff are uncomfortable about obtaining consent in this way, or because relatives decline consent in an effort to protect their loved one from further harm.

May endotracheal intubation be practised on the newly dead?

The value of practising endotracheal intubation and other procedures on the newly dead is well argued, and therefore if it is disallowed there is a cost. However, the current pervading policy of ‘don’t ask, don’t tell’ is ethically unjustifiable. If a patient’s consent is presumed and not sought, we are obliged to tell. The significant minority who would not consent are thereby protected by an opportunity to decline. Therefore, to proceed with presumed consent there must be a well-informed public, and preferably a statute to formalize consent. An extrapolation of this, which is the most convincing solution, is called ‘mandated choice’, which proposes a process whereby, as a matter of public policy, individuals must choose on a variety of issues, with these choices being recorded on, for example, their driving licence. This process informs and honours individual choice, gives the significant minority the opportunity to decline, and avoids deception. However, in the absence of a suitably informed public from whom consent can be presumed, or a mandated choice, we do not have permission to proceed with postmortem resuscitation practice. Therefore, to do so is ethically wrong.