European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1448 F.K. Lippert et al. / Resuscitation 81 (2010) 1445–1451written advance directives. 1 In some countries, the written advancedirective is considered to be legally binding; in others not.The issue of initiating life-prolonging treatment or continuingotherwise futile resuscitation attempts with the sole purposeof harvesting organs is debatable. 77,78 There is variation betweencountries and cultures about the ethics of this process; at present noconsensus exists. If considering prolonging CPR and other resuscitativemeasures to enable organ donation to take place mechanicalchest compressions may be valuable in these circumstances. 79,80DNAR ordersFamily presence during resuscitationA do-not-attempt resuscitation (DNAR) order (also describedmore recently as a DNACPR decision) is a binding legal documentthat states that resuscitation should not be attempted in theevent of cardiac or respiratory arrest; meaning that CPR shouldnot be performed. Other treatment should be continued, particularlypain relief and sedation, as required and indicated, if theyare considered to be contributing to the quality of life. If not,orders not to continue or initiate any such treatments should bespecified independently of DNAR orders. For many years, DNARorders in many countries were written by single doctors, oftenwithout consulting the patient, relatives or other health personnel,but there are now clear procedural requirements in manycountries. 65Although the ultimate responsibility and decision for DNARrests with the senior doctor in charge of the patient, it is wise for thisindividual to consult others before making the decision. Followingthe principle of patient autonomy it is wise, if possible, to ascertainthe patient’s wishes about a resuscitation attempt. This mustbe done in advance, when the patient is able to make an informedchoice. Opinions vary as to whether such discussions should occurroutinely for every hospital admission or only if the diagnosis ofa potentially life-threatening condition is made. In presenting thefacts to the patient, the doctor must be as certain as possible of thediagnosis and prognosis and may seek a second medical opinionin this matter. It is vital that the doctor should not allow personallife values to distort the discussion—in matters of acceptability ofa certain quality of life, the patient’s opinion should prevail. It isconsidered essential for the doctor to have discussions with closerelatives if at all possible. Whereas they may influence the doctor’sdecision, it should be made clear to them that the ultimate responsibilityand decision will be that of the doctor. It is neither fair norreasonable to place the burden of decision on the relative.According to the principle of autonomy, patients have the rightto refuse treatment; however, they do not have an automatic rightto demand a specific treatment—they cannot insist that resuscitationmust be attempted in any circumstance. A doctor is requiredonly to provide treatment that is likely to benefit the patient, andis not required to provide treatment that would be futile. However,it would be wise to seek a second opinion in making this decision,for fear that the doctor’s own personal values, or the question ofavailable resources, might influence his or her opinion. 66In adult cardiac arrest various studies have addressed the impactof advance directives and DNAR orders in directing appropriateresuscitation efforts. Most of these studies are old and oftencontradictory. 67–76 Standardised orders for limiting life-sustainingtreatments decrease the incidence of futile resuscitation attemptsand should ensure that adult patient wishes are honoured. Instructionsshould be specific, detailed, and transferable across healthcare settings, and easily understood. Processes, protocols, and systemsshould be developed that fit within local cultural normsand legal limitations to allow providers to honour patient wishesregarding resuscitation efforts.Organ procurementThe concept of a family member being present during the resuscitationprocess was introduced in the 1980s and has becomeaccepted practice in many countries. 81–86 Many relatives wouldlike to be present during resuscitation attempts and, of those whohave had this experience, over 90% would wish to do so again. Mostparents would wish to be with their child at this time. 82Relatives have considered several benefits from being permittedto be present during a resuscitation attempt, including comingto terms with the reality of death. However, this is a choice entirelyto be made by the relatives. Several measures are required toensure that the experience of the relative is the best under the circumstances.This includes allocating personnel to take care of therelatives. 87,88In the event of an out-of-hospital arrest, the relatives mayalready be present, and possibly performing basic life support (BLS).They should be offered the same choices and appreciation of theireffort as bystander offering BLS. With increasing experience of familypresence during resuscitation attempts, it is clear that problemsrarely arise. Fifteen years ago, most staff would not have countenancedthe presence of relatives during resuscitation, but there isan increasingly open attitude and appreciation of the autonomy ofboth patient and relatives. 1 Cultural and social variations still exist,and must be understood and appreciated with sensitivity.Research in resuscitation and informed consentThere is an essential need to improve the quality of resuscitationand thereby the long-term outcome. To achieve this, researchand randomised clinical trials are crucial, not only to introducenew and better interventions, but also to abandon the use of inefficientand costly procedures and medications, whether old ornew. As the ILCOR 2010 consensus on CPR and ECC Science clearlyreveals many current practises are based upon tradition and not onscience. 89,90There are important ethical issues relating to undertaking randomisedclinical trials for patients in cardiac arrest who cannotgive informed consent to participate in research studies. Progressin improving the dismal rates of successful resuscitation will onlycome through the advancement of science through clinical studies.The utilitarian concept in ethics looks to the greatest goodfor the greatest number of people. This must be balanced withrespect for patient autonomy, according to which patients shouldnot be enrolled in research studies without their informed consent.Over the past decade, legal directives have been introducedinto the USA and the European Union 91,92 that place significantbarriers to research on patients during resuscitation withoutinformed consent from the patient or immediate relative. 93 Thereare data showing that such regulations deter research progress inresuscitation. 94 It can be argued that these directives may in themselvesconflict with the fundamental human right to good medicaltreatment as set down in the Helsinki Declaration. 13 The US authoritieshave, to a very limited extent, sought to introduce methodsof exemption, 95 but these are still associated with problems andalmost insurmountable difficulties. 94,96,97www.elsuapdetodos.comResearch and training on the recently deadResearch on the recently dead encounters similar restrictionsunless previous permission is granted as part of an advance direc-
18 de 0ctubre de 2010 www.elsuapdetodos.comF.K. Lippert et al. / Resuscitation 81 (2010) 1445–1451 1449tive by the patient, or permission can be given immediately by therelative. The management of resuscitation can be taught using scenarioswith manikins and simulators or animal models, but trainingin certain skills required during resuscitation is difficult. Thereforethe question arises as to whether it is ethically and morally appropriateto undertake training and practice on the living or the dead.There is a wide diversity of opinion on this matter. 98,99 Many, particularlythose in the Islamic nations, find the concept of any skillstraining and practice on the recently dead completely unacceptablebecause of an innate respect for the deceased. Others willaccept the practice of non-invasive procedures that do not leavea mark; and some accept that any procedure may be learned onthe dead body with the justification that the learning of skills isparamount for the well being of future patients. One option is torequest informed consent for the procedure from the relative ofthe deceased. It is advised that healthcare professionals learn localand hospital policies regarding this issue and follow the establishedpolicy.SummarySudden unexpected cardiac arrest is a global challenge. Somedeaths are preventable and some arrests can be treated successfullyand result in a very good long-term outcome. However, mostresuscitation attempts are futile and death is inevitable. End-of-lifedecision is an important part of resuscitation.Scientific evidence does not provide much guidance for endof-life-decisions.Nevertheless, because of the importance of thesubject, the ERC has produced this guidance on this importantand difficult topic for healthcare providers. End-of-life decisionsare complex and may be influenced by individual, internationaland local cultural, legal, traditional, religious, social and economicfactors. Solutions should be tailored accordingly. Sometimes thedecisions can be made in advance, but often these difficult decisionshave to be made in an emergency and based upon limited information.Therefore it is important that healthcare providers understandthe principles involved, the challenges and the need for researchin resuscitation. End-of-life decisions and ethical considerationsshould be reflected in advance through education, discussions anddebriefings for health care professionals to further strengthen individualethical competence.AcknowledgementThis section is dedicated in honour of the late Peter J.F. Baskett,who was the previous and original author of these guidelines onethics 100 .References1. Baskett PJ, Lim A. The varying ethical attitudes towards resuscitation in Europe.Resuscitation 2004;62:267–73.2. da Costa DE, Ghazal H, Al Khusaiby S. Do not resuscitate orders and ethicaldecisions in a neonatal intensive care unit in a Muslim community. Arch DisChild Fetal Neonatal Ed 2002;86:F115–9.3. Richter J, Eisemann M, Zgonnikova E. Doctors’ authoritarianism in end-of-lifetreatment decisions. A comparison between Russia, Sweden and Germany. JMed Ethics 2001;27:186–91.4. De Leeuw R, Cuttini M, Nadai M, et al. Treatment choices for extremely preterminfants: an international perspective. J Pediatr 2000;137:608–16.5. Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensivecare units: the ethicus study. JAMA 2003;290:790–7.6. Ho NK. Decision-making: initiation and withdrawing life support in theasphyxiated infants in developing countries. Singapore Med J 2001;42:402–5.7. Cuttini M, Nadai M, Kaminski M, et al. End-of-life decisions in neonatal intensivecare: physicians’ self-reported practices in seven European countries.Lancet 2000;355:2112–8.8. Konishi E. Nurses’ attitudes towards developing a do not resuscitate policy inJapan. Nursing Ethics 1998;5:218–27.9. Muller JH, Desmond B. Ethical dilemmas in a cross-cultural context. A Chineseexample. West J Med 1992;157:323–7.10. Edgren E. The ethics of resuscitation, differences between Europe and theUSA—Europe should not adopt American guidelines without debate. Resuscitation1992;23:85–90.11. Bülow H-H, Sprung C, Reinhart K, et al. The world’s major religions’ pointsof viewon end-of-life decisions in the intensive care unit. Intens Care Med2008;34:423–30.12. Beauchamp TL, Childress J. Principles of biomedical ethics. 6th ed. Oxford:Oxford University Press; 2008.13. Association WM.Declaration of Helsinki Ethical principles for medical researchinvolving human subjects adopted by the 18th WMA General AssemblyHelsinki, Finland, June 1964 and amended at the 29th, 35th, 41st, 48th, 52nd,55th and 59th WMA Assemblies. Helsinki: World Medical Association; 1964.14. Shuster M, Billi JE, Bossaert L, et al. International consensus on cardiopulmonaryresuscitation and emergency cardiovascular care sciencewith treatment recommendations. Part 4: Conflict of interest managementbefore, during, and after the 2010 International ConsensusConference on Cardiopulmonary Resuscitation and Emergency CardiovascularCare Science With Treatment Recommendations. Resuscitation 2010;doi:10.1016/j.resuscitation.2010.08.024, in press.15. Sans S, Kesteloot H, Kromhout D. The burden of cardiovascular diseasesmortality in Europe. Task Force of the European Society of Cardiology onCardiovascular Mortality and Morbidity Statistics in Europe. Eur Heart J1997;18:1231–48.16. Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-ofhospitalcardiac arrest in Europe. Resuscitation 2005;67:75–80.17. Nichol G, Aufderheide TP, Eigel B, et al. Regional systems of care for outof-hospitalcardiac arrest: a policy statement from the American HeartAssociation. Circulation 2010;121:709–29.18. Organisation WH. World Health Report 2002; 2002.19. Organisation WH. Global status report on road safety 2009.20. Organisation WH. WHO World Health Statistics 2009 and 2010; 2009.21. Black RE, Cousens S, Johnson HL, et al. Global, regional, and national causes ofchild mortality in 2008: a systematic analysis. Lancet 2010;375:1969–87.22. Layon AJ, Modell JH. Drowning: update 2009. Anesthesiology 2009;110:1390–401.23. Moulaert VRMP, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairmentsin survivors of out-of-hospital cardiac arrest: a systematic review. Resuscitation2009;80:297–305.24. Holler NG, Mantoni T, Nielsen SL, Lippert F, Rasmussen LS. Long-term survivalafter out-of-hospital cardiac arrest. Resuscitation 2007;75:23–8.25. van Alem AP, de Vos R, Schmand B, Koster RW. Cognitive impairment in survivorsof out-of-hospital cardiac arrest. Am Heart J 2004;148:416–21.26. Bunch TJ, White RD, Gersh BJ, et al. Long-term outcomes of out-of-hospitalcardiac arrest after successful early defibrillation. N Engl J Med 2003;348:2626–33.27. Nichol G, Stiell IG, Hebert P, Wells GA, Vandemheen K, Laupacis A. What is thequality of life for survivors of cardiac arrest? A prospective study. Acad EmergMed 1999;6:95–102.28. Stiell I, Nichol G, Wells G, et al. Health-related quality of life is better for cardiacarrest survivors who received citizen cardiopulmonary resuscitation. Circulation2003;108:1939–44.29. Granja C, Cabral G, Pinto AT, Costa-Pereira A. Quality of life 6-months aftercardiac arrest. Resuscitation 2002;55:37–44.30. Lettieri C, Savonitto S, De Servi S, et al. Emergency percutaneous coronary interventionin patients with ST-elevation myocardial infarction complicated byout-of-hospital cardiac arrest: early and medium-term outcome. Am Heart J2009;157:569–75, e1.31. Tiainen M, Poutiainen E, Kovala T, Takkunen O, Happola O, Roine RO. Cognitiveand neurophysiological outcome of cardiac arrest survivors treated withtherapeutic hypothermia. Stroke 2007;38:2303–8.32. Graf J, Muhlhoff C, Doig GS, et al. Health care costs, long-term survival, andquality of life following intensive care unit admission after cardiac arrest. CritCare 2008;12:R92.33. Horsted TI, Rasmussen LS, Meyhoff CS, Nielsen SL. Long-term prognosis afterout-of-hospital cardiac arrest. Resuscitation 2007;72:214–8.34. Saner H, Borner Rodriguez E, Kummer-Bangerter A, Schuppel R, von Planta M.Quality of life in long-term survivors of out-of-hospital cardiac arrest. Resuscitation2002;53:7–13.35. O’Reilly SM, Grubb NR, O’Carroll RE. In-hospital cardiac arrest leads to chronicmemory impairment. Resuscitation 2003;58:73–9.36. Lundgren-Nilsson A, Rosen H, Hofgren C, Sunnerhagen KS. The first year aftersuccessful cardiac resuscitation: function, activity, participation and quality oflife. Resuscitation 2005;66:285–9.37. Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiatedcardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation2007;116:2900–7.38. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adultsin the hospital: a report of 14720 cardiac arrests from the National Registry ofCardiopulmonary Resuscitation. Resuscitation 2003;58:297–308.39. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelinesfor Resuscitation 2010. Section 4. Adult Advanced Life Support. Resuscitation2010;81:1305–52.www.elsuapdetodos.com
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