Ethical challenges in resuscitation
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A rapidly evolving resuscitation science provides more effective treatments to an aging population with multiple comorbidites. Concurrently, emergency care has become patient-centered. This review aims to describe challenges associated with the application of key principles of bioethics in resuscitation and post-resuscitation care; propose actions to address these challenges; and highlight the need for evidence-based ethics and consensus on ethical principles interpretation.
Following agreement on the article’s outline, subgroups of 2–3 authors provided narrative reviews of ethical issues concerning autonomy and honesty, beneficence/nonmaleficence and dignity, justice, specific practices/circumstances such as family presence during resuscitation, and emergency research. Proposals for addressing ethical challenges were also offered.
Respect for patient autonomy can be realized through honest provision of information, shared decision-making, and advance directives/care planning. Essential prerequisites comprise public and specific healthcare professionals’ education, appropriate regulatory provisions, and allocation of adequate resources. Regarding beneficence/nonmaleficence, resuscitation should benefit patients, while avoiding harm from futile interventions; pertinent practice should be based on neurological prognostication and patient/family-reported outcomes. Regarding dignity, aggressive life-sustaining treatments against patients preferences should be avoided. Contrary to the principle of justice, resuscitation quality may be affected by race/income status, age, ethnicity, comorbidity, and location (urban versus rural or country-specific/region-specific). Current evidence supports family presence during resuscitation. Regarding emergency research, autonomy should be respected without hindering scientific progress; furthermore, transparency of research conduct should be promoted and funding increased.
Major ethical challenges in resuscitation science need to be addressed through complex/resource-demanding interventions. Such actions require support by ongoing/future research.
KeywordsResuscitation Personal autonomy Beneficence Social justice
The authors are grateful to Prof. Antonio G. Spagnolo, Director of the Institute of Bioethics and Medical Humanities Università Cattolica del Sacro Cuore, Rome, Italy, for offering useful advice during manuscript preparation. The authors acknowledge the support of the European Resuscitation Council for the conduct of teleconferences.
Compliance with ethical standards
Conflicts of interest
Gavin Perkins has received research funding from the National Institute for Health Research to conduct studies in cardiac arrest; he holds volunteer roles within the Resuscitation Council (UK), European Resuscitation Council and International Liaison Committee on Resuscitation. Leo Bossaert holds volunteer roles within the European Resuscitation Council. Robert Greif holds a volunteer role within the European Resuscitation Council and International Liaison Committee on Resuscitation. No other author has a conflict of interest to disclose.
- 3.Bossaert LL, Perkins GD, Askitopoulou H, Raffay VI, Greif R, Haywood KL, Mentzelopoulos SD, Nolan JP, Van de Voorde P, Xanthos TT, Ethics of resuscitation and end-of-life decisions section Collaborators (2015) European resuscitation council guidelines for resuscitation 2015: section 11. The ethics of resuscitation and end-of-life decisions. Resuscitation 95:302–311. https://doi.org/10.1016/j.resuscitation.2015.07.033 CrossRefPubMedGoogle Scholar
- 4.Australian Resuscitation Council; New Zealand Resuscitation Council (2015) Section 10: guideline 10.5—legal and ethical issues related to resuscitation. Australian Resuscitation Council website. https://resus.org.au/guidelines/. Accessed 9 May 2018
- 5.Mentzelopoulos SD, Bossaert L, Raffay V, Askitopoulou H, Perkins GD, Greif R, Haywood K, Van de Voorde P, Xanthos T (2016) A survey of key opinion leaders on ethical resuscitation practices in 31 European countries. Resuscitation 100:11–17. https://doi.org/10.1016/j.resuscitation.2015.12.010 CrossRefPubMedGoogle Scholar
- 6.Mancini ME, Diekema DS, Hoadley TA, Kadlec KD, Leveille MH, McGowan JE, Munkwitz MM, Panchal AR, Sayre MR, Sinz EH (2015) Part 3: ethical issues: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 132(18 Suppl 2):S383–S396. https://doi.org/10.1161/CIR.0000000000000254 CrossRefPubMedGoogle Scholar
- 9.Kon AA, Davidson JE, Morrison W, Danis M, White DB, American College of Critical Care Medicine; American Thoracic Society (2016) Shared decision making in ICUs: an American college of critical care medicine and american thoracic society policy statement. Crit Care Med 44:188–201. https://doi.org/10.1097/CCM.0000000000001396 CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Council of Europe (2014) Guide on the decision-making process regarding medical treatment in end-of-life situations. Bioethics.net website. http://www.bioethics.net/2014/05/council-of-europe-launches-guide-on-decision-making-process-regarding-medical-treatment-in-end-ofllife-situations/. Accessed 9 May 2018
- 11.Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C (2015) European resuscitation council and European society of intensive care medicine guidelines for post-resuscitation care 2015: section 5 of the European resuscitation council guidelines for resuscitation 2015. Resuscitation 95:202–222. https://doi.org/10.1016/j.resuscitation.2015.07.018 CrossRefPubMedGoogle Scholar
- 12.Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, Bossaert LL, Brett SJ, Chamberlain D, de Caen AR, Deakin CD, Finn JC, Gräsner JT, Hazinski MF, Iwami T, Koster RW, Lim SH, Ma MH, McNally BF, Morley PT, Morrison LJ, Monsieurs KG, Montgomery W, Nichol G, Okada K, Ong ME, Travers AH, Nolan JP, Collaborators Utstein (2015) Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American heart association emergency cardiovascular care committee and the council on cardiopulmonary, critical care, perioperative and resuscitation. Resuscitation 96:328–340. https://doi.org/10.1016/j.resuscitation.2014.11.002 CrossRefPubMedGoogle Scholar
- 13.Mentzelopoulos SD, Mantzanas M, van Belle G, Nichol G (2015) Evolution of European union legislation on emergency research. Resuscitation 91:84–91. https://doi.org/10.1016/j.resuscitation.2015.03.006 CrossRefPubMedGoogle Scholar
- 16.Gibbs AJO, Malyon AC, Fritz ZBM (2016) Themes and variations: an exploratory international investigation into resuscitation decision-making. Resuscitation 103:75–81. https://doi.org/10.1016/j.resuscitation.2016.01.020 CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Sprung CL, Truog RD, Curtis JR, Joynt GM, Baras M, Michalsen A, Briegel J, Kesecioglu J, Efferen L, De Robertis E, Bulpa P, Metnitz P, Patil N, Hawryluck L, Manthous C, Moreno R, Leonard S, Hill NS, Wennberg E, McDermid RC, Mikstacki A, Mularski RA, Hartog CS, Avidan A (2014) Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The consensus for worldwide end-of-life practice for patients in intensive care units (welpicus) study. Am J Respir Crit Care Med 190:855–866. https://doi.org/10.1164/rccm.201403-0593CC CrossRefPubMedGoogle Scholar
- 25.Wittink MN, Morales KH, Meoni LA, Ford DE, Wang NY, Klag MJ, Gallo JJ (2008) Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins precursors study. Arch Intern Med 168:2125–2130. https://doi.org/10.1001/archinte.168.19.2125 CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Puchalski CM, Zhong Z, Jacobs MM, Fox E, Lynn J, Harrold J, Galanos A, Phillips RS, Califf R, Teno JM (2000) Patients who want their family and physician to make resuscitation decisions for them: observations from support and help. Study to understand prognoses and preferences for outcomes and risks of treatment. hospitalized elderly longitudinal project. J Am Geriatr Soc 48(5 Suppl):S84–S90CrossRefPubMedGoogle Scholar
- 29.Vandervoort A, Houttekier D, Van den Block L, van der Steen JT, Vander Stichele R, Deliens L (2014) Advance care planning and physician orders in nursing home residents with dementia: a nationwide retrospective study among professional caregivers and relatives. J Pain Symptom Manage 47:245–256. https://doi.org/10.1016/j.jpainsymman.2013.03.009 CrossRefPubMedGoogle Scholar
- 30.[No authors listed] (2017) Guidelines for emergency physicians on the interpretation of physician orders for life-sustaining therapy (POLST). Ann Emerg Med. 7012212510.1016/j.annemergmed.2017.04.046Google Scholar
- 33.Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine: convention on human rights and biomedicine. Oviedo, 4.IV.1997. http://conventions.coe.int/Treaty/en/Treaties/Html/164.htm. Accessed 9 May 2018
- 34.Ebell MH, Jang W, Shen Y, Geocadin RG, Get With The Guidelines-Resuscitation Investigators (2013) Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation. JAMA Intern Med 173:1872–1878. https://doi.org/10.1001/jamainternmed.2013.10037 CrossRefPubMedGoogle Scholar
- 36.Griffith DM, Salisbury LG, Lee RJ, Lone N, Merriweather JL, Walsh TS, RECOVER Investigators (2018) Determinants of health-related quality of life after ICU: importance of patient demographics, previous comorbidity, and severity of illness. Crit Care Med 46:594–601. https://doi.org/10.1097/CCM.0000000000002952 CrossRefPubMedGoogle Scholar
- 37.Venkat A, Becker J (2014) The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit: case examples and review of state laws affecting withdrawing or withholding life-sustaining treatment. J Intensive Care Med 29:71–80. https://doi.org/10.1177/0885066611433551 CrossRefPubMedGoogle Scholar
- 40.Ernecoff NC, Curlin FA, Buddadhumaruk P, White DB (2015) Health care professionals responses to religious or spiritual statements by surrogate decision makers during goals-of-care discussions. JAMA Intern Med 175(10):1662–1669. https://doi.org/10.1001/jamainternmed.2015.4124 CrossRefPubMedGoogle Scholar
- 45.Gräsner JT, Lefering R, Koster RW, Masterson S, Böttiger BW, Herlitz J, Wnent J, Tjelmeland IB, Ortiz FR, Maurer H, Baubin M, Mols P, Hadžibegovíc I, Ioannides M, Škulec R, Wissenberg M, Salo A, Hubert H, Nikolaou NI, Lóczi G, Svavarsdóttir H, Semeraro F, Wright PJ, Clarens C, Pijls R, Cebula G, Correia VG, Cimpoesu D, Raffay V, Trenkler S, Markota A, Strömsöe A, Burkart R, Perkins GD, Bossaert LL, EuReCa ONE Collaborators (2016) EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 105:188–195. https://doi.org/10.1016/j.resuscitation.2016.06.004 CrossRefPubMedGoogle Scholar
- 46.Daya MR, Schmicker RH, Zive DM, Rea TD, Nichol G, Buick JE, Brooks S, Christenson J, MacPhee R, Craig A, Rittenberger JC, Davis DP, May S, Wigginton J, Wang H, Resuscitation Outcomes Consortium Investigators (2015) Out-of-hospital cardiac arrest survival improving over time: results from the resuscitation outcomes consortium (ROC). Resuscitation. 91:108–115. https://doi.org/10.1016/j.resuscitation.2015.02.003 CrossRefPubMedPubMedCentralGoogle Scholar
- 47.Beck B, Bray J, Cameron P, Smith K, Walker T, Grantham H, Hein C, Thorrowgood M, Smith A, Inoue M, Smith T, Dicker B, Swain A, Bosley E, Pemberton K, McKay M, Johnston-Leek M, Perkins GD, Nichol G, Finn J, Aus-ROC Steering Committee (2018) Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: results from the Aus-ROC Epistry. Resuscitation 126:49–57. https://doi.org/10.1016/j.resuscitation.2018.02.029 CrossRefPubMedGoogle Scholar
- 48.Pichler G, Fazekas F (2016) Cardiopulmonary arrest is the most frequent cause of the unresponsive wakefulness syndrome: a prospective population-based cohort study in Austria. Resuscitation 103:94–98. https://doi.org/10.1016/j.resuscitation.2016.02.023 CrossRefPubMedGoogle Scholar
- 49.Andrew E, Mercier E, Nehme Z, Bernard S, Smith K (2018) Long-term functional recovery and health-related quality of life of elderly out-of-hospital cardiac arrest survivors. Resuscitation 126:118–124. https://doi.org/10.1016/j.resuscitation.2018.03.017 CrossRefPubMedGoogle Scholar
- 50.Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS, American Heart Association Get with the Guidelines-Resuscitation Investigators (2012) Trends in survival after in-hospital cardiac arrest. N Engl J Med 367:1912–1920. https://doi.org/10.1056/NEJMoa1109148 CrossRefPubMedPubMedCentralGoogle Scholar
- 51.Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS, American Heart Association’s Get With the Guidelines-Resuscitation Investigators (2014) Hospital variation in survival after in-hospital cardiac arrest. J Am Heart Assoc 3:e000400. https://doi.org/10.1161/JAHA.113.000400 CrossRefPubMedPubMedCentralGoogle Scholar
- 53.Sandroni C, Cariou A, Cavallaro F, Cronberg T, Friberg H, Hoedemaekers C, Horn J, Nolan JP, Rossetti AO, Soar J (2014) Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European resuscitation council and the european society of intensive care medicine. Intensive Care Med 40:1816–1831. https://doi.org/10.1007/s00134-014-3470-x CrossRefPubMedPubMedCentralGoogle Scholar
- 54.Sandroni C, Nolan JP (2015) Neuroprognostication after cardiac arrest in Europe: new timings and standards. Resuscitation 90:A4–A5. https://doi.org/10.1016/j.resuscitation.2015.02.020 CrossRefPubMedGoogle Scholar
- 56.Lilja G, Nielsen N, Bro-Jeppesen J, Dunford H, Friberg H, Hofgren C, Horn J, Insorsi A, Kjaergaard J, Nilsson F, Pelosi P, Winters T, Wise MP, Cronberg T (2018) Return to work and participation in society after out-of-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes 11(1):e003566. https://doi.org/10.1161/CIRCOUTCOMES.117.003566 CrossRefPubMedGoogle Scholar
- 57.Calvert M, Kyte D, Mercieca-Bebber R, Slade A, Chan AW, King MT, Hunn A, Bottomley A, Regnault A, Chan AW, Ells C, O’Connor D, Revicki D, Patrick D, Altman D, Basch E, Velikova G, Price G, Draper H, Blazeby J, Scott J, Coast J, Norquist J, Brown J, Haywood K, Johnson LL, Campbell L, Frank L, von Hildebrand M, Brundage M, Palmer M, Kluetz P, Stephens R, Golub RM, Mitchell S, Groves T, The SPIRIT-PRO group (2018) Guidelines for inclusion of patient-reported outcomes in clinical trial protocols: the SPIRIT-PRO extension. JAMA 319:483–494. https://doi.org/10.1001/jama.2017.21903 CrossRefPubMedGoogle Scholar
- 61.Berdowski J, Berg RA, Tijssen JG, Koster RW (2010) Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 81:1479–1487. https://doi.org/10.1016/j.resuscitation.2010.08.006 CrossRefPubMedGoogle Scholar
- 62.Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I, Resuscitation outcomes consortium investigators (2008) Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 300:1423–1431. https://doi.org/10.1001/jama.300.12.1423 CrossRefPubMedPubMedCentralGoogle Scholar
- 64.Lamhaut L, Hutin A, Puymirat E, Jouan J, Raphalen JH, Jouffroy R, Jaffry M, Dagron C, An K, Dumas F, Marijon E, Bougouin W, Tourtier JP, Baud F, Jouven X, Danchin N, Spaulding C, Carli P (2017) A pre-hospital extracorporeal cardio pulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis. Resuscitation 117:109–117. https://doi.org/10.1016/j.resuscitation.2017.04.014 CrossRefPubMedGoogle Scholar
- 68.Nelson MJ, Deiorio NM, Schmidt TA, Zive DM, Griffiths D, Newgard CD (2013) Why persons choose to opt out of an exception from informed consent cardiac arrest trial. Resuscitation 84:825–830. https://doi.org/10.1016/j.resuscitation.2013.01.030 CrossRefPubMedPubMedCentralGoogle Scholar
- 69.Jansen TC, Bakker J, Kompanje EJ (2010) Inability to obtain deferred consent due to early death in emergency research: effect on validity of clinical trial results. Intensive Care Med 36:1962–1965. https://doi.org/10.1007/s00134-010-1988-0.PMID:20689926/ CrossRefPubMedPubMedCentralGoogle Scholar