1. Resuscitation
ETHICAL
DILEMMAS K.S. Chew
School of Medical Sciences
Universiti Sains Malaysia

2. Emergency Procedures Without Written Consent - The
Doctrine of Necessity
Three Groups of Incompetent
Five Things To Be Explained To the
Patients to Give Informed
Patient in an Informed Consent
Consent
Four Basic Five Essential
Biomedical Elements of a Valid
Bolam Test
Informed Consent
Principles
Bolitho Test
Proving Medical
General Concepts of
Negligence
Biomedical Ethics

3. Principle #1 AutonomyDoes my action
Four Basic
impinge on an individual's personal
1
autonomy?Do all relevant parties consent to
Principles
my action?Do I acknowledge and respect
that others may choose differently?
Of Ethics
Principle #2 BeneficenceWho benefits from
2 my action and in what way?
4
Principle #3: Non-maleficene
Principle #4:
Justice Which parties may be harmed by my action?
What steps can I take to minimise this harm?
Is my Have I communicated risks involved in a truthful
proposed and open manner?
3
action
equitable?
How can I
Beauchamp TL, Childress JF. Principles of biomedical Ethics.
make it more
4th ed. Oxford: Oxford University Press, 1994.
equitable?

4. Ethical Issues In
Cardiopulmonary
Resuscitation

5. Biomedical Ethics
in Resuscitation
A whole of gamut of
complicated dilemma
Successful v Unsuccessful
(70 - 95%)
Prolonging
Suffering
Persistent Vegetative State
Patient’s right to
die in dignity
Decisions in matter of
seconds!

6. Case Scenario 1
You are rushing to catch your flight in another 30 minutes. As
you are heading to your departing gate, you witness a crowd of
people, and one of them actually recognizes you as a doctor
and says that a man has just collapsed and they need your
help in the resuscitation.
However, two things are going on in your mind - you have not
been performing CPR for a long time since your ACLS course
5 years ago and you have a plane to catch. What would you
do? If you do not help out in the resuscitation process, would
you be liable for medical negligence in the future?

7. Case Scenario 2
A building has collapsed. You are called in to
help out with the disaster. At the disaster site,
a man has stopped breathing at a distance
not far from where you are standing. The
relatives over there are shouting for you to
come over and help. However, you realize
that some rocks are still falling from where
the man is trapped. Would be liable to be
sued if you do not?

8. Case Scenario 3
A 80-year old man with history of frequent exacerbation of
COPD is diagnosed with acute pulmonary edema,
currently complicated with respiratory failure Type 2. All
other treatment modalities fail to prevent his deterioration.
You know that his prognosis is not good but he needs
mechanical ventilation to support his worsening respiratory
effort.
1. Would you have intubated him?
2. If the relatives insist on you to actively resuscitate him
but you do not, would you be liable to be sued?

9. Case Scenario 4
A 50-year old, previously healthy and active sportsman, is
admitted for sudden onset of chest pain. He collapses
while being treated in the emergency department. You
start CPR and defibrillation promptly. Realizing what you
are doing, the wife intervenes and insists that you stop the
resuscitation process. She says that he has verbally stated
his wish that he does not want to be actively resuscitated
and a prolonged suffering the moment he dies.
What would you do?

10. Case Scenario 5
A 40-year old, previously healthy, army is involved in a
serious car accident. On arrival to the emergency
department, his GCS is 7/15. He is mechanically
ventilated. His vital signs are good. A CT scan brain is
done - showing a massive intraparenchymal bleeding over
the right hemisphere with midline shift and generalized
cerebral edema. Clinical re-assessment 30 minutes later
shows that the patient is manifesting signs of increased
ICP and transtentorial herniation. In view that his prognosis
may not be good and that the ward resources are limited,
the managing team decides to withdraw his support
system in A&E. What do you think?

11. Cardiopulmonary
Resuscitation: Ethical Issues
Resuscitation Decisions
Resuscitation Decisions
for out-of- hospital
for in-hospital settings
settings
1. to initiate resuscitation
1. to initiate
2. NOT to initiate
resuscitation
resuscitation
2. NOT to initiate
3. to terminate
resuscitation
resuscitation
3. to terminate
4. to withdraw life
resuscitation
support system (rarely)

12. GENERAL PRINCIPLES GOVERNING
RESUSCITATION DECISION
Is governed by two important principles:
A. The Principle of Patient Autonomy
Advanced directives (DNAR)
If patient preferences uncertain, emergency
conditions should be treated until those preferences
are known

13. GENERAL PRINCIPLES GOVERNING
RESUSCITATION DECISION
B. The Principle of Futility
Definition: If the purpose of a medical treatment
cannot be achieved, the treatment is considered
futile.
The key determinants - duration remaining in
cardiac arrest, length and quality of life expected

15. “Physicians are NOT obliged to
provide care when there is
scientific and social consensus
that the treatment is
ineffective.”
- American Heart Association

16. “Whereas patients have a
right to refuse treatment, they
do not have automatic right to
demand treatment; they
cannot insist that
resuscitation must be
attempted in any
circumstances”
- European Resuscitation
Council

17. “It is wise for a doctor to
seek a second opinion in
making a momentous
decision to with-hold
resuscitation for fear of the
doctor’s own personal
values, or the questions of
available resources might
influence his/her decision.”
- European Resuscitation
Council

18. Doctor’s Personal Factors
Influencing Resuscitation Decision
“Most doctors will err on the side of
intervention in children for emotional reasons,
even though the overall prognosis is often
worse in children than in adults.”
- European Resuscitation Council

19. DO NOT ATTEMPT RESUSCITATION
(DNAR) ORDER
DNAR order means just that - in the event of
cardiopulmonary arrest, CPR should not be
attempted at all.
Other treatment should be continued; e.g.
pain relief, sedation on required basis in
terminal illnesses.

20. Criteria For NOT to Start
CPR for In-Hospital Setting
# 3 No
physiologic
al benefit
expected
(futility)
#2 Patient with signs of
irreversible death (rigor
#1 Patient
mortis, decapitation,
decomposition, dependent with DNAR
order
lividity)

22. “If something is worth
doing, it is worth doing it
well”
“If the resuscitation process is worth
doing, it is worth doing it well”
Treat the resuscitation process seriously.
Respect the solemn moment for the patient and
relatives
Do not laugh or joke when resuscitation is
going on
“not merely about drawing the
curtain.....”

23. Criteria To STOP CPR
For In-Hospital Setting
#1
Patients
with DNAR
Order
In general, resuscitation should be
continued as long as VF persists.
And resuscitation should be
terminated when ongoing asystole for
#2 On
more than 20 minutes in the absence
of a reversible cause, and with all Grounds of
measures of BLS and ACLS in place Extra panel
futility*

24. Criteria For NOT Starting CPR
In Out-of-Hospital Setting
Paramedics are trained to start CPR at the very
first instance upon a victim in cardiac arrest with
the exception of:
1. A person with obvious clinical signs of
irreversible death (e.g. rigor mortis, dependent
lividity, decapitation, decomposition)
2. A person with clear DNAR order
3. Attempts to perform CPR would place the
rescuer at risk of danger/physical injuries

25. Criteria To STOP CPR In Out-
of-Hospital Setting
1. Restoration of effective, spontaneous
circulation and ventilation
2. Care is transferred to a more senior-level
emergency medical professional
3. The rescuer is unable to continue because of
exhaustion
4. Reliable criteria indicating irreversible death
5. A valid DNAR order is presented

26. Withdrawing Life Support
1. Not usually done in A&E department
2. Often in intensive care units for clinical
brain death patients
3. Patient in deep coma for >24 hrs, after
ruling out potentially reversible causes
4. Done by two specialists (usually
anesthesiologists, neurologists,
neurosurgeons) on two assessments (6hrs
apart)
5. Detailed criteria can be found in MMC Brain
death Guidelines

27. If you or your team have made
the decision to withdraw a life
support system in emergency
department, you should also
be responsible to document
and sign your decisions and to
answer any doubts from the
family. Do not push the job to
another team.

28. SURROGATE DECISION MAKERS
(IN ORDER OF PRIORITY)
1. Spouse
2. Adult child
3. Parent
4. Any relative
5. Person nominated as the person caring for the
incapacitated patient
6. Specialized care professionals
Must act in best interest of patient

29. Conclusion
Decision making in cardiopulmonary resuscitation
can be very complex due to the diversity of the
cases
It may have to be made in matters of seconds!
If in doubt, always err on for the patient’s benefit
Always treat the patient with dignity and respect
If you do not want this to be done to your own
family member, you do not want it to be done on
your patient