The American Journal of Bioethics

Resuscitation Strategies in the United States: Realities of Hospital and Prehospital Treatment
Kenneth V. Iserson, McMurdo General Hospital, Antarctica
Despite claims to the contrary, differences in DNAR (do-notattempt-resuscitation) and CPR (cardiopulmonary resuscitation) implementation vary more by institution or medical care system within the United States and the United Kingdom than between the countries. New York State, often used as an example of automatically doing CPR in most circumstances (Bishop et al. 2010), actually represents the extreme outlier. In most of the United States, custom, law, and clinical practice have led to reasonable use of CPR, one of the ultimate resuscitation modalities (Iserson 2010). It is tragic to prolong a patients dying by providing inappropriate resuscitative measures. Even so, when discussing whether to initiate CPR, we must remember that if there is any doubt about whether a patient should be resuscitated, begin CPR. Life support can always be withdrawn if more information surfaces. Not initiating resuscitative procedures and discontinuing life-sustaining treatment are, under most circumstances, ethically equivalent, if sufcient information is available at the time these decisions are made (Iserson 2009). Two relatively common practices, already used by U.S. clinicians and bioethicists, mirror those that Bishop and colleagues (2010) suggest would ameliorate problems with DNAR orders and CPR: limitation-of-treatment orders, and time-limited trials of therapy. Limitation-of-treatment orders specify which resuscitation interventions (e.g., cardioversion, intubation, mechanical ventilation, or the administration of parenteral uids or nutrition, oxygen, antibiotics, blood products, sedation, antiarrhythmics, or vasopressors) clinicians may employ for a particular patient. (As an ethical matter, appropriate analgesia should never be withheld.) Generating this type of medical order also encourages in-depth discussion about prognosis and the usefulness of various interventions with patients or surrogates, and clearly transmits information about end-of-life treatments among treating clinicians (Iserson 2009). On occasion, problems arise when these orders are inconsistent with rational medical treatment. Some patients, for example, may choose to accept debrillation and chest compressions but not intubation and articial ventilation. Such conicts arise when clinicians have not fully briefed patients or surrogates on the nature of the proposed medical treatments. It is the attending physicians responsibility to ascertain that the order set is rational and that the patient or surrogate understands why it is being written as it is (Iserson 2009). Time-limited trials of therapy identify specic goals for treatment of uncertain efcacy. This transforms abstract futility discussions and their associated frustrations into empirical clinical tests. Patients or, more commonly, surrogate decision makers discuss and come to an agreement with the clinician about treatment goals, specic treatments, and the amount of time that the treatments will be tried until the goal must be reached. Often used in end-of-life care, especially in critical care units, time-limited treatment balances the need to try everythingincluding CPRwith an understanding that interventions must prove their usefulness to be continued. As was noted by the European Resuscitation Council, in situations in which the prognosis is uncertain, a trial of treatment should be considered while further information is gathered to help determine the likelihood of survival and the expected clinical course (European Resuscitation Council 2000). PREHOSPITAL/EMERGENCY DEPARTMENT CPR POLICIES Although dismissed as beyond the papers scope, the U.S. emergency medical systems (ambulance and emergency departments) have developed two patient-centered responses to CPR and DNAR that seem to best serve patients, the community, and professional integrity: (1) acknowledging differences between withholding and withdrawing treatment (especially CPR and related interventions) and (2) prehospital advance directives. These inpatient and prehospital strategies that are already widely used answer many of the concerns that the Bishop and colleagues (2010) article raises. Acknowledging Differences Between Withholding and Withdrawing Treatment Initiating CPR is, and should be, the default action in emergency medical careboth in emergency departments and in the prehospital (ambulance) system. Society has special expectations about the nature of emergency treatment. These expectations not only make withholding medical treatment much more problematic than later withdrawing unwanted or useless interventions, but also attach a morally signicant difference to the interventions.

Address correspondence to Kenneth V. Iserson. E-mail: kvi@u.arizona.edu

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Reviving the Conversation Around CPR/DNR

The primary exceptions to initiating CPR for patients without documentation to the contrary are when the body exhibits rigor mortis, livor mortis, or injuries incompatible with life (e.g., decapitation) or it is burned beyond recognition (Iserson 2001). In emergency medicine, a morally signicant difference rightfully persists between withholding and withdrawing medical treatment. This is because, in emergency medicine, clinicians often lack the information about the patients identity, medical condition, and wishes needed to make an informed decision about withholding treatment (Iserson 1996). Prehospital Advance Directives Many of the deaths that occur outside hospitals or chronic care facilities in the United States are not only expected but also welcomed as relief from terminal disease. However, patients who lack decision-making capacity cannot communicate to emergency medical services system and emergency department personnel their wish not to be the recipient of advanced life support procedures (Tolle et al. 1998). CPR decisions are often made in seconds by rescuers who may not know the patient or whether an advance directive exists.Prehospital (and emergency department) personnel may not be able to determine whether resuscitation should be initiated or continued. As a result, administration of CPR may sometimes conict with a patients desires or best interests. Prehospital advance directives (PHAD) offer patients an opportunity to clarify that situation. Developed and rst enacted into law in the early 1990s, PHADs allow terminally ill patients to simply describe their wish not to be resuscitated to any prehospital personnel that may (inadvertently or by protocol) be sent to their bedside. PHAD laws need not be complex, either in their language or in their implementation requirements. Some of these laws and the accompanying forms are simple enough to be easily interpreted by both providers and patients. Used successfully for nearly two decades, these laws strike a balance between the needs of the citizens and the unfounded fears of lawyers wary of any potential liability for the state or the emergency medical services system (Iserson 1993).

However, bystanders and EMS personnel should adhere only to standard, EMS system-approved forms. No one in the prehospital setting should attempt to interpret unique, lawyer or personally written, or other non-standard advance directives (Iserson 2010; Iserson 1993; Bossaert 1998). In sum, clinicians in both the United States and the United Kingdom now employ multiple strategies to avoid using CPR and other resuscitation strategies indiscriminately, which they understand will, in some cases, not achieve the patients goals of therapy and only prolong the dying process. REFERENCES
Bishop, J. P., K. B. Brothers, J. E. Perry, and A. Ahmad. 2010. Reviving the conversation around CPR/DNR. American Journal of Bioethics 10(1): 6167. Bossaert, L. 21998. European Resuscitation Council guidelines for resuscitation. In The ethics of resuscitation in clinical practice, 206217. Amsterdam, Netherlands: Elsevier. European Resuscitation Council. 2000. Pt 2: Ethical aspects of CPR and ECC. Resuscitation 46: 1727. Iserson, K. V. 1996. Withholding and withdrawing medical treatment: An emergency medicine perspective. Annals of Emergency Medicine 28(1): 5155. Iserson, K. V. 1993. A simplied prehospital advance directive law: Arizonas approach. Annals of Emergency Medicine 22(11): 1703 1710. Iserson, K. V. 2001. Death to dust: What happens to dead bodies?, 2nd ed. Tucson, AZ: Galen Press. Iserson, K. V. 2009. Ethics in emergency cardiovascular care. In The textbook of emergency cardiovascular care and CPR, ed. J. M. Field, 567585. Philadelphia, PA: Lippincott Williams and Wilkins. Iserson, K. V. 2010. Bioethics. In Rosens emergency medicine: Concepts and clinical practice, 7th ed., ed. J. A. Marx, R. S. Hockberger, R. M. Walls, et al., 25542568. Philadelphia, PA: Mosby Elsevier. Tolle, S. W., V. P. Tilden VP, C. A. Nelson CA, et al. 1998. A prospective study of the efcacy of the physician order form for lifesustaining treatment. Journal of the American Geriatrics Society. 46: 10971102.

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