Year 2000 Guidelines Analysis

Ethical Aspects of CPR and ECC

This report is based on final published changes reported in 
Circulation Supplement for August 22, 2000. All readers are 
encouraged to read the findings for themselves-this review is not 
meant to be comprehensive nor should it substitute for a
provider's own inquiry into these subjects, issues and 
recommendations. This material in Circulation represents a process 
of intensive review and consensus begun well over 18 months ago. 
A "roll out" is scheduled for September 21-24 in San Diego where 
this information will be further explained and how it will be 
incorporated in guielines will be presented. This, then represents 
the content that the San Diego conference will be based upon..

Chris Perrin, ACUTE CARE, INC. Director of Education

SEE ALSO: PBLS (Pediatric Basic Life Support)
PALS (Pediatric Advanced Life Support),
Adult BLS (Basic Life Support),
Post-Resuscitation, Acute Coronary Syndromes and CVA,
and ACLS (Advanced Cardiac Life Support)

Ethical Aspects of CPR and ECC

"CPR and ECC have the same goals as other medical interventions: to preserve life, restore health, relieve suffering, and limit disability."

Patient autonomy emphasized.

Advance Directives-cannot be used to withhold life-saving treatment unless:

• A surrogate has given authorization;
• Patient has a terminal condition certified by two physicians, or
• Patient is in a persistent vegetative state certified by two physicians (one of whom has expertise in assessing brain function)

Living wills constitute clear wishes and should be enforceable, in most circumstances.

Realize that patients change their mind frequently-sometimes within months of an initial decision--one study found that those who opted for DNAR status were more likely to change that status than those who did not opt for it.

Criteria for not starting CPR-

• Valid DNAR order
• Signs of irreversible death
• No physiological benefit can be expected (maximum therapy for "progressive septic or cardiogenic shock" has been reached and vital functions continue to deteriorate)

Withhold delivery resuscitation if

• Confirmed gestation less than 23 weeks; or
• Birthweight less than 400 grams;
• Anencephaly;
• Confirmed trisomy 13 or 18.

Recommendation: CPR can be discontinued if no return of spontaneous pulse during BLS and ACLS (and no mitigating circumstances such as hypothermia, age, toxins, overdose)

• After 30 minutes of interventions for adults;
• 15 minutes for newborns.

For BLS providers, continue unless---

• pulse/breathing return;
• care assumed by higher level of provider;
• reliable signs of irreversible death;
• rescuer exhaustion, compelling environmental hazards or unreasonable life/death risk to others
• presentation of valid DNAR order

Inhospital DNAR orders are generally not transferable to out-of-hospital situations. Family presence during resuscitation attempts in-hospital is premised on social worker or nurse stationed with family (explain, comfort, clarify) and having sophisticated rehearsal/role plays prior to working real situations.

Other ethical issues mentioned: withdrawal of life support, notifying survivors, organ and tissue donation, research/training on the newly dead…

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