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 Despite these well-publicized numbers in the medical literature, EPs should be aware that patients and their families may have very different expectations of resuscitative efforts after cardiac arrest. Popular U.S. television programs, for example, incorrectly suggest that the immediate survival rate after cardiac arrest approaches 75%, with 67% of patients being portrayed as surviving to hospital discharge.⁷

Table 214.1 Survival After In-Hospital Cardiopulmonary Resuscitation *

Incidence of in-hospital cardiopulmonary resuscitation	2.73 events per 1000 admissions
Incidence higher for nonwhite patients	2.53/1000 in white patients 4.35/1000 in black patients 3.85/1000 for other races

Survival to discharge 18.3% Lower survival rates for patients who were:

Men

Older

Not white

Categorized as having a higher chronic illness burden

Admitted from a skilled nursing facility

Received care in a metropolitan or teaching hospital

^* Medicare data from 1992 to 2005 involving 433,895 cases of in-hospital cardiopulmonary resuscitation in patients 65 years or older.

Data from Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31.

Pathophysiology

Cardiac arrest is the sudden, abrupt loss of heart function.⁸ The most common underlying reason for patients to die suddenly after cardiac arrest is coronary heart disease. Most cardiac arrests that lead to sudden death occur as a result of arrhythmias such as ventricular tachycardia or ventricular fibrillation. A patient’s chances of survival after cardiac arrest are reduced by 7% to 10% with every minute that passes without CPR and defibrillation. Few attempts at resuscitation succeed after 10 minutes.⁸

Presenting Signs and Symptoms

One classic scenario illustrating many of the ethical dilemmas surrounding resuscitation is a patient who arrives at the ED critically ill with possible impending cardiac arrest or with signs of active dying (Table 214.2). Decisions must be made quickly regarding which life-extending measures will be used while also simultaneously ensuring relief of patient distress. If a patient is likely to deteriorate rapidly or shows signs of imminent death, a discussion regarding resuscitation should be initiated with the patient or the appropriate surrogate. The EP should make a clinical assessment that includes evaluation of the goals of care, determination of the presence or absence of an advance directive, and a recommendation regarding the utility of CPR to meet the patient’s goals of care. Table 214.2 lists the signs of active dying in the setting of a chronic progressive incurable illness, such as late-stage cancer, dementia, or failure to thrive.

Table 214.2 Signs of Active Dying in Patients with Chronic Illness

Differential Diagnosis and Medical Decision Making

Before discussions with patients and families about critical illness, the EP may be able to initiate several easy medical interventions to provide important and valued information for patients and their families to inform the medical recommendation. Bedside glucose testing and pulse oxygen saturation measurements, for example, may be sought. Rapid measurement of serum electrolytes (potassium in particular) may yield a quick overview of the patient’s renal or acid-base status. Bedside ultrasonography is a minimally invasive way to diagnose potentially lethal catastrophes such as pericardial tamponade and rupture of an abdominal aortic aneurysm. Bedside electrocardiography may detect myocardial infarction. Good clinical information can help guide decision making.

Tips and Tricks

Prognostication

The safest prognostication that the emergency physician can make about a patient’s outcome is that at best the patient may return to his or her baseline or the condition in which he or she was right before the precipitating event that brought the patient to the emergency department. For example, if the patient has end-stage dementia at baseline and is unable to care for himself, the best outcome from cardiac arrest would be survival to return to his previous baseline end-stage dementia, with the same level of assistance still being needed.

Goals of Care Assessment

The emergency physician should be prepared to assess the goals of care to make a recommendation regarding resuscitation: (1) establish what the patient or surrogate understands; (2) determine what the patient or surrogate expects; (3) discuss resuscitation in plain language, void of medical jargon; (4) respond to emotion; and (5) make a clinical recommendation or plan.

Do-Not-Resuscitate Orders

Such orders should not imply limits on any other interventions besides cardiopulmonary resuscitation in the event of cardiac arrest. The emergency physician should clearly distinguish other therapies that will be used, aside from cardiopulmonary resuscitation, in the event of death. It is a common mistake to “overinterpret” the meaning of “do not resuscitate” to exclude a host of life-sustaining treatments before cardiac arrest.

Treatment

Temporizing measures that might “buy time” for discussion of the medical and ethical grounds for resuscitation, for examination of the medical record, or for contact of a provider more familiar with the patient should be considered on a case-by-case basis.

Red Flags

Emergency physicians should advise patients and surrogates on the utility of resuscitation based on best available evidence to achieve a patient-centered meaningful outcome.

Patients who have do-not-resuscitate orders may desire life-sustaining treatments up to and until cardiac arrest.

Follow-Up, Next Steps in Care, and Patient Education

The medical condition and comorbid conditions of individual patients make each person’s survival rate highly variable. Discharge survival rates and function in patients with chronic, progressive terminal illnesses such as end-stage cancer, heart failure, and pulmonary and neurologic diseases, for example, tend to be extremely poor. Increasingly, language such as “allow natural death” and “do not resuscitate” suggests that no attempt be made to initiate CPR in the event of physiologic death. However, other measures—oxygen, fluids, nutrition, pain control—may still be initiated to support patient comfort.

Patients or their medical decision makers who choose to forgo measures such as CPR may also, but not necessarily, choose a more global comfort approach to their end-of-life care. The EP should be able to provide palliative measures and support this comfort care (Table 214.3). It is important to recognize, however, that these patients may still need intensive in-hospital care. In some cases, transfer of a patient from the emergency department to a hospice may be possible. More often, patients are admitted to the hospital and may require temporary intensive care to assess the goals of care and adequately achieve comfort. For a patient who is undergoing advanced life support measures, such as invasive ventilation and cardioactive drugs, a time-limited trial may help the patient and his or her family feel more comfortable delineating the goals of care.

Table 214.3 Support of a Comfort Approach

Clearly define the goals of treatment	Once imminent death is recognized, discuss with family and confirm the treatment goals. When assuming a comfort approach, make a supportive statement, such as “You are doing the right thing.”
Clearly define the goals of treatment	Discuss with family stopping interventions that do not contribute to comfort.
Provide good palliative care	To contral oral/respiratory secrections (“death cattle”), use antimuscarinic blockers such as glycopyrrolate, 0.2 mg intravenously (onset, 1 min); atropine, 0.1 mg intravenously (onset, 1 min); atropine eyedrop 1%, 2 drops sublingually (onset, 30 min); or hyoscyamine hydrobromide, 1.5 mg transdermally (onset, 12 hr).
	Use morphine (1-2 mg IV/SC every 5 min or 5 mg orally every 1 hr as starting dose) to control dyspnea or tachypnea. It can be very disturbing for family members to see loved ones in a coma breathing at 40 breaths/min. The goal should be to keep the respiratory rate in the range of 10 to 15 breaths/min.
	Provide excellent mouth and skin care.
Determine disposition	According to symptom burden, patients may require assignment to the intensive care unit to ensure that the treatment goals remain on target and that the medical aspects of palliative care are met (control of pain and dyspnea, for example) despite a “do-not-resuscitate” status.

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