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ALS Subcommittee 2010
ETHICAL ISSUES in
Cardiopulmonary Resuscitation
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical issues
• CPR is a therapy
• KEY principles of ethics include:
- autonomy
- beneficence
- non maleficence
- justice
- dignity and honesty
• Withholding and withdrawal therapy
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles – Patient Autonomy
• Recognized ethically and legally
• Right of patient to accept or refuse treatment
• Applied to those capable of making decision
• Decision based on understanding of disease, patient condition, nature of treatment, alternative therapy, risks and benefits
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles – Beneficence
Benefit provided to patient while balancing risks and benefits
Are we providing benefit to patient or are we just delaying death and prolonging suffering?
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles – Non-maleficence
Do no harm, or further harm
- CPR should not be initiated in futile cases
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles – Justice
Duty to distribute limited health resources equally within a society, and the decision of who gets what treatment
If resuscitation is provided, it should be available to all who will benefit from it within the available resources
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles – Dignity and Honesty
Patient’s right to be treated with dignity
Honesty in revealing information
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles
Advanced directives
• ‘Living will’, wishes or expression for end of life care
• Based on conversational or written directives
• Periodic consideration needed as patient’s desire and condition may change
ALS Subcommittee 2010 ALS Subcommittee 2010
Ethical principles
Surrogate decision maker
• ‘Nominated’ decision maker when patient is incapable of making one
• Spouse, adult child, parent, close relative
• ? friend
ALS Subcommittee 2010 ALS Subcommittee 2010
MEDICAL FUTILITY
• When an intervention is highly unlikely to benefit the patient
or
• When an intervention does not achieve patient’s intended quality goals or physician’s physiological goals
• Key determinants
- Length
- Quality of life
ALS Subcommittee 2010 ALS Subcommittee 2010
PRINCIPLE OF FUTILITY
• Withholding resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent
• If the prognosis is uncertain, a trial of treatment should be considered while further information is gathered to help determine the likelihood of survival and expected clinical course
ALS Subcommittee 2010 ALS Subcommittee 2010
When Not to Start CPR
• Advanced directives by patient or surrogate decision maker
• Valid DNAR by attending physician
• Obvious signs of death e.g. Rigor mortis
• Algo mortis - steady lowering temperature
• Injuries incompatible with life
ALS Subcommittee 2010 ALS Subcommittee 2010
When NOT to Stop
• Drug intoxication
• Hypothermia
• Ventricular fibrillation
ALS Subcommittee 2010 ALS Subcommittee 2010
When to Stop CPR
• Return of spontaneous circulation (ROSC)
• Too exhausted to continue, or dangerous
• Obvious signs of death are apparent
• Decision to cease resuscitation effort are often made on a case to case basis
ALS Subcommittee 2010 ALS Subcommittee 2010
THANK YOU NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
Dr Tan Cheng Cheng
Dr Luah Lean Wah
Dr Ismail Tan
Dr Wan Nasrudin
Dr Chong Yoon Sin
Dr Priya Gill
Dr Ridzuan bin Dato’ Mohd Isa
Dr Thohiroh Abdul Razak
Dr Adi Osman
