Perspective

In the United States, universal presumed consent for cardiopulmonary resuscitation (CPR) after cardiac arrest is standard medical practice unless patients have previously expressed an explicit desire to be treated otherwise. Once a patient is in the hospital setting, however, the ethical choice to initiate or continue CPR and other life-prolonging measures should be based on the clinician’s best prediction of expected medical outcomes, as well as the wishes and goals of the patient and his or her designated medical decision maker.

CPR holds a unique position in medicine and society. It is the only medical intervention that the patient must take steps to refuse in advance because of presumed consent, even if the clinician does not believe that it is beneficial or medically warranted. Ethical dilemmas surrounding the initiation, continuation, and cessation of resuscitation are common.

Patient autonomy, nonmaleficence (doing no harm), beneficence (promoting good or well-being), and justice (being fair) are the guiding principles of medical ethics.¹ For a patient to make autonomous decisions about resuscitation preferences, the patient (or designated medical decision maker) should be given the best information available to weigh his or her medical care options. The Jonsen model for ethical decision making suggests that the following four “ethical quadrants” be weighed: medical indications, patient preferences, quality of life, and contextual features.²

Despite much debate and discussion, medicine and society have not been able to agree on a common and accepted definition of the term medical futility.³ One suggested paradigm of medical futility characterizes a medical intervention as futile when its goal will not probably be achieved.³ Although one common medical goal of clinicians who perform CPR after cardiac arrest is return of spontaneous circulation, the patient, surrogate, and clinician may have other equally important goals, including neurologic outcome and quality of life after resuscitation. Timely discussion between the clinician and the patient or his or her designated decision maker regarding the goals of care is paramount to ensure quality end-of-life care.

Noninitiation of CPR is increasingly being described as “allow natural death.” It is of utmost importance for clinicians to understand that before CPR, a host of interventions may be used to extend life but, in the event of death, the option may be to not attempt CPR. For example, research suggests that in cancer patients for whom all aggressive interventions (antibiotics, fluids, pressors, airway support) have been tried, in the event of death the success of CPR in achieving survival to discharge is zero.⁴

On the road to eventual death, patients may have a constellation of physical, psychologic, and emotional symptoms that can be treated. The majority of patients who are critically ill are not in active cardiac arrest at initial encounter but are at high risk for it. Emergency physicians (EPs) most often care for these patients at high risk for cardiac arrest and may find themselves ethically driven to discuss with patients and families the appropriateness of resuscitative efforts to reverse death in the event of cardiopulmonary arrest.

Epidemiology

Out-of-hospital cardiac arrest (OHCA) has an incidence of 52.1 per 100,000 population, which makes it the third leading cause of death in North America.⁵ The survival rate of patients experiencing OHCA after treatment by emergency medical services is approximately 8%, but it varies widely among regions.⁵ For patients who suffer in-hospital pulseless cardiac arrest, survival to hospital discharge depends widely on the characteristics of the arrest and patient comorbid conditions (Table 214.1). Research suggests that when talking with patients, physicians can describe the overall likelihood of survival to discharge as 1 in 8 for patients who undergo CPR and 1 in 3 for patients who survive CPR.⁶ Many of the patients who survive to discharge will be discharged to institutionalized settings. Poor prognostic indicators of survival after cardiac arrest include cancer, dementia, sepsis, cardiac disease, elevated serum creatinine, and African American race.⁶