The Cambridge textbook of bioethics

464P. D. Levin and C. L. Sprung

willing to undergo ICU care to achieve as little as one month of post-ICU survival (Danis et al., 1988).

Triage decisions are also influenced by factors unrelated to the patient and their illness. The simplest example of these administrative factors is bed availability. If no ICU bed is available, then the patient cannot be admitted to ICU regardless of their medical problems or prognosis. There may, however, be more complexity to administrative issues, as patients examined by a physician (rather than referred by phone) and patients examined by junior rather than senior physicians are refused ICU admission more frequently, as are patients from medical units and those referred at night (Garrouste-Org et al., 2005).

How then should decisions be made about how to use the scarce resource of ICU beds? The professional societies have published guidelines to help to direct triage decisions for ICU care. The Task Force of the American College of Critical Care Medicine and the Society of Critical Care Medicine (1999) emphasized benefit as a priority, while the American Thoracic Society(1997) suggested that patients should be admitted on a first come first served basis, provided there is an expected minimal benefit to ICU admission. Unfortunately, as described above, medical benefit, is not well assessed by physicians while benefit, as determined by patients and their family, is not measurable. In an attempt to improve medical benefit assessments, scoring systems have been suggested. The APACHE and SAPS systems are inappropriate for this task as they are dependent on data accumulated during the first 24 hours of ICU care, which are not available at the time of triage. Recently, a large multicenter trial including more than 7000 patients referred for ICU care has been completed, aiming to provide a triage scoring system to assist in ICU admission and discharge decision making. The preliminary results will be published shortly in abstract form (C. L. Sprung, personal communication).

In conclusion, at present no clear evidence-based guidelines are available to assist the physician in deciding which patients should be admitted to

the ICU when bed supply is limited. While many medical and administrative factors have been identified that influence the triage process, most of these factors, unfortunately, have been identified in a negative context – meaning perhaps that they represent biases rather than valid independent criteria. For more on issues related to resource allocation and triage, see Ch. 33.

End of life care

For many patients dying in the ICU, there comes a point where further medical intervention will not result in a cure but rather will either leave the patient chronically ICU dependent or prolong the dying process. Beyond this point, while medical interventions may have physiological effects, they will not alter the final outcome, and they are considered by many (but not all) to be non-beneficial. Defining the point beyond which further therapy is non-beneficial is, however, by no means straightforward, as the decision has physiological, functional, psychological, and ethical elements. For example, for some patients or families, while the heart is beating, the patient is alive, even if there is extensive damage to other organs or even if the patient is defined as brain dead. For such patients or their families, the no-benefit point may only be reached after prolonged resuscitation. In contrast, for a patient who believes that life has no meaning without functional independence, quality of life determines the no-benefit point and that point might be reached soon after a head injury, despite the fact that a full physical recovery, albeit with reduced mental ability, can be achieved. In any event, there comes a point where therapeutic interventions change to interventions designed to manage the end of life.

Similar to other hospital areas, the objectives of end of life care in the ICU are to prevent suffering and to ensure death with dignity. However, in contrast to other hospital areas, ICU interventions (such as ventilation, inotropes, and dialysis) are able to maintain or support organ function for long periods of time. Consequently, while on an

oncology ward, it might be sufficient to refrain from life-support interventions while nature takes its course, in the ICU environment, measures that are sustaining life might already be in place. These measures, while not contributing to the patient’s recovery, can delay death. Once the no-benefit point has been reached, consideration must be given to the management of life-supporting interventions.

In the ICU, end of life care exists as a continuum beginning with full care and ending with euthanasia. While different categories can be recognized on the continuum, and are described below, the borders between them are often blurred. It should be noted, however, that in most jurisdictions euthanasia is illegal.

The first limitation often applied is the do-not- resuscitate (DNR) order (or the do-not-attempt- resuscitation order). Such an order may have been determined in advance in a ‘‘living will,’’ or may be applied on ICU admission or at any stage during ICU care. While the patient is stable and does not require active intervention to prolong life, the care that a patient with a DNR order receives may be identical to that of any other patient. A DNR order represents a specific type of decision to ‘‘withhold’’ therapy. Withholding therapy means not beginning a therapy that might be required to prolong life. Such a decision might include not starting inotropes despite a decrease in blood pressure, or not beginning dialysis for acute renal failure.

Further along the spectrum of end of life care is withdrawal. Withdrawal means the cessation of a therapy required to prolong life. An example is the cessation of mechanical ventilation, or extubation of a patient despite the prediction that the patient will not be able to sustain spontaneous ventilation and is, therefore, almost certain to die.

Finally, the most ‘‘aggressive’’ form of end of life care includes steps taken to shorten the dying process, or active euthanasia. In this circumstance, interventions (such as the administration of drugs) are performed with the specific intent of causing death. The administration of opiates at very high dosage together with muscle relaxants to a spontaneously breathing patient might be an example.

It has been claimed there is no ethical difference between withholding and withdrawing therapy (American Thoracic Society, 1991; American Medical Association, 2006; UK General Medical Council, 2006); as both may ultimately result in the patient’s demise. Despite this, there is a clear recognition that in practice these two options are not the same. For example, the UK General Medical Council has stated (2006): ‘‘it may be emotionally more difficult . . . to withdraw a treatment . . . than to decide not to provide a treatment in the first place.’’ Physician questionnaires have also revealed that 66% of physicians and nurses do not see withholding and withdrawing as equivalent in Europe (Vincent, 1999), while 26% of North American physicians felt more disturbed by withdrawing therapy than withholding (Society of Critical Care Medicine Ethics Committee, 1992). The outcomes of these decisions are also different. A DNR order placed in a living will may be followed by many years of good life. However, a recent study of the events surrounding end of life decisions for 4248 patients in European ICUs (Sprung et al., 2003), showed that 89% of patients for whom therapy was withheld died, compared with 99% of patients for whom therapy was withdrawn, with a median time to death being 14 hours following withholding and four hours following withdrawal of therapy. The difference between withholding and withdrawing therapy has also been noted in a new law intended to regulate end of life care in Israel. This law accepts and permits cessation of intermittent therapies in terminally ill patients but does not allow withdrawal of continuous therapies (Eidelman et al., 1998).

Decisions regarding the type of end of life care appropriate for a specific patient do not seem to be objective. For example, using questionnaire responses from 1361 Canadian physicians and nurses to 12 case vignettes (Cook et al., 1995), in only one example tested was there greater than 50% agreement regarding the limitation strategy to be employed. Further, in an observational study of 5910 ICU deaths in North America (Prendergast et al., 1998), the proportion of deaths preceded by withdrawal of therapy ranged from 0 to 79% across

466P. D. Levin and C. L. Sprung

different centers, with a range of 0 to 67% for withholding therapy. In Europe, similar variability has been described, with 47% of ICU deaths in northern Europe being preceded by withdrawal compared with 18% of deaths in southern Europe (Sprung et al., 2003).

The most relevant factor determining the end of life strategy employed by clinicians and patients seems to be cultural. For example, more religious physicians tend to be more conservative in their end of life practices (38% of ‘‘religious’’ physicians felt uncomfortable withdrawing care as opposed to 21% of non-religious physicians [Vincent, 1999]), as are physicians who are in non-academic practice (Society of Critical Care Medicine Ethics Committee, 1994) or who are older (Alemayehu et al., 1991). Ethnic differences may be equally important. Limitation of life support seems to be less common in Japan and Hong Kong, for example (Ip et al., 1998; Nakata et al., 1998; Sirio et al., 2002; Yaguchi et al., 2005), while even within the USA, different ethnic subgroups view end of life care very differently (Blackhall et al., 1999).

Given that many patients are treated in multicultural urban societies, it can be expected that significant differences in approach to end of life care will be found between patients and healthcare providers. Therefore, the question arises as to who should decide on the most appropriate end of life care for a given patient. In the USA, autonomy is the preeminent value in decision making; however, 95% of ICU patients may lack decision-making capacity at the time end of life decisions have to be made, and only 20% will have previously expressed their views (Cohen et al., 2005). Consensus seems to exist that the patient’s natural proxy is their family and in the USA, family involvement in end of life decision making is the rule, with 93–100% family involvement (Smedira et al., 1990; Prendergast and Luce 1997; Cohen et al., 2005). In Europe, family involvement in end of life decision making is variable, ranging from 84% involvement in northern European countries to 47% in southern European countries. It must be noted, however, that family involvement may not mean a sharing of

decision making, as 88% of families in Europe were told of the end of life policy being enacted, while only 38% were asked for their views (with some discussions including both telling and asking) (Cohen et al., 2005).

Further, even when involved in the end of life decision-making process, family members do not accurately represent the wishes of their loved ones, with agreement concerning end of life care preferences between the patient and their family members ranging from 50 to 88% (Seckler et al., 1991; Sonnenblick et al., 1993; Marbella et al., 1998). Also, even when known, only 46% of children are willing to abide by their parents wishes (Sonnenblick et al., 1993). Finally, despite the espoused importance of patient autonomy in North America, 23% of 879 US physicians had withdrawn therapy without the patient or their family’s consent, 12% without their knowledge, and 3% despite their objections (Asch et al., 1995). It seems, therefore, that although autonomy is a sought-after value, it is both hard to determine and difficult to respect.

Perhaps because of the vast differences in approach to end of life care expressed by different cultural groups, or the inherent difficulties in dealing with death, conflict between families and the ICU staff at the end of life is not uncommon. In one study, 44% of all conflicts between the ICU team and family members originated in differences of opinion regarding end of life care (Studdert et al., 2003). Resolution of these conflicts can usually be achieved with sensitive negotiation; however, when these measures fail, external arbiters may have to be considered. These might include an ethics consultant (Fletcher and Siegler, 1996) (a third party not involved in the ICU care of the specific patients, and indeed not necessarily a physician), an ethics committee, or the courts (Gostin, 1997).

For more on issues related to end of life issues, see Section II.

The cases

The situation described at the beginning of this chapter illustrates a number of points. Firstly, a

triage decision has to be made regarding Patient F. Does he have an indication for ICU admission, or is he too well or too sick? The patient does have an indication for ICU admission (traumatic head injury); however, his chances of surviving to hospital discharge may be reduced by his limited functional capacity (the patient is wheel-chair bound). In addition, the history of dementia may indicate a low post-ICU quality of life. To be meaningful, however, this diagnosis needs to be fully explored with family members and the family physician. In our experience emergency room diagnoses of dementia range from mild benign senile forgetfulness to full blown organomental syndrome. In our institution, this patient would certainly be accepted to the ICU at least for a trial of therapy.

As no beds are currently available, the next decision required relates to how to provide a bed. One option would be to transfer or withdraw ventilation from Patient E. Is this decision ethical? Should Patient F, whose chances of survival are also poor, act as a lever to limit the therapy given to Patient E? Or should a first-come-first-served approach be taken, and Patient F left in the emergency room?

Patient E is deteriorating and unlikely to recover; however, his family, for cultural reasons, rejects the possibility of withdrawal of therapy. In practice, in family meetings our main objective would be to avoid conflict. We would state that the patient is dying and that no therapy will stop this process. The family, however, is requesting that dialysis be performed, raising the question to what extent patients and their families can determine patient care when it is contradictory to physician recommendations. We would maintain that dialysis could potentially cause more harm than good in this hemodynamically unstable patient, and that as such we should not take steps that may cause harm. We would then attempt to negotiate with the family agreement to transfer the patient to the regular floor. If this failed, we have the fortunate prerogative of admitting ICU patients to the

anesthetic recovery room, and this is what we would do.

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A 25-year-old male is brought to the emergency department by medics at midnight on Saturday night after being assaulted outside a downtown bar. The medics report that he was hit on the head and unconscious for a few minutes. When they arrived at the scene, the patient was confused but talking. He has a 4-inch laceration in his left parietal scalp and alcohol on his breath. When the patient arrives in the emergency department, he is slurring his speech and reports drinking several beers at the bar before being assaulted. He refuses any diagnostic tests or therapeutic interventions. He does not let the nurse start an intravenous line or draw blood, nor let the physician examine his laceration or do an adequate neurological examination. He demands to leave. He says he has been assaulted before and will be OK. He becomes increasing abusive to the staff and repeats his demands to leave.

The paramedics are called to a skilled nursing facility for an 80-year-old woman who is in cardiac arrest. The patient was last seen four hours previously by a healthcare aide and later found in her room unresponsive. When the medics arrive, the patient is unresponsive with no pulse or blood pressure. They call their base station asking to declare the patient dead. They say that it is futile to resuscitate elderly patients in nursing homs because such patients never survive. In addition, since she has been down a long time she will have severe neurological dysfunction. The patient has no advance directive. She has been in the nursing facility for three weeks for rehabilitation after a hip replacement.

What is emergency and trauma ethics?

Ethical dilemmas are common in the emergency medical care system. In this chapter, we will discuss

how the emergency department is different than other environments in medicine. These differences create unique ethical issues that are dealt with on a daily basis by emergency healthcare professionals (Iserson et al., 1995; Sanders, 1995; Adams et al., 1998; Larkin for the SAEM Ethics Committee, 1999; American College of Emergency Physicians, 2004; Girod and Beckman, 2005). Patients presenting to an emergency department (ED) are inherently different from those in primary care or specialty practices. Some of the differences include the following considerations, which may influence ethical decision making in emergency and trauma medicine.

1.Patients come to the ED with an actual or perceived acute medical or surgical emergency. A fundamental principle of emergency medicine is primarily to assess patients for serious diseases with threats to life or limb. When serious diseases are ruled out, the patient is assessed for common diseases. This focus on life-threatening conditions means that time pressures are key to completing diagnostic tests to rule out lifethreatening conditions (Sanders, 1995; American College of Emergency Physicians, 2004).

2.Patients seeking care in the ED do not choose their doctor. In clinic practice, the patients usually choose their doctor and develop a rapport and trust relationship over many years. Physicians in clinic practices have the time to get to know the patient and understand his/her values. Without knowing the patient and their lifestyle and values, it is much more difficult for emergency physicians to address ethical dilemmas (Sanders, 1995).

470A. B. Sanders

3.Many patients seen in EDs with trauma or acute medical conditions have altered mental status. Alcohol, drugs, head trauma, pain, psychiatric conditions, and anxiety over the acute change in health status are common among such patients and can influence decision making and informed consent (Sanders, 1995; American College of Emergency Physicians, 2004). Sometimes these conditions are suspected but unknown at the time of treatment.

4.Diagnostic and therapeutic decisions must be made quickly for patients in ED, often with incomplete data. In a clinic or inpatient hospital environment, physicians can take time to consult with experts, search the literature, and discuss options before specific decisions are made. In contrast, the patient who presents to the ED with an acute myocardial infarction, a dislocated shoulder, or a ruptured spleen presents with an emergency condition that must be promptly addressed (Sanders, 1995).

5.The ED is an open and less controlled environment compared with clinics. Police, paramedics (often from the local fire department), and others are often present. This leads to potential issues with confidential information. There can also be potential ethical conflicts regarding obligations to patients and responsibilities to society. The inebriated patient involved in a motor vehicle crash and the patient who presents with a drug overdose are examples of patients that present potential conflicts of interest. Should the ED report these patients to the police or confidentially treat their medical conditions? Emergency healthcare providers often balance obligations to the patients with obligations to society (Sanders, 1995; Knopp and Satterlee, 1999; American College of Emergency Physicians, 2004).

6.The emergency medical care system is an essential part of emergency and trauma medicine. Medics and emergency medical technicians operate under the license and orders of the emergency physician. They face potential ethical dilemmas with conflicting responsibilities to patients, base station physicians, law

enforcement agencies, employers, and society. Medics often face angry, hostile patients, many of whom are under the influence of alcohol or drugs or have psychiatric conditions. They balance respect for patient autonomy with trying to deliver optimal care for patients in the community (Sanders, 1995; American College of Emergency Physicians, 2004).

Why is emergency and trauma ethics important?

Ethics

Many of the traditional ethical dilemmas exempt emergency conditions. For example, fundamental ethical considerations such as informed consent, confidentiality, and patient autonomy may not apply for patients having emergency conditions. The patient who suffers multisystem trauma, who is unconscious, or who is in cardiac arrest is immediately treated with standard medical or surgical treatment including surgery and other invasive treatments. Standards of confidentiality may not be met as emergency healthcare professionals may request medical records from other hospitals without informed consent of the patient (Knopp and Satterlee, 1999). If many traditional ethical considerations do not apply to emergency conditions, do they apply when there is a potential for an emergency condition? This can only be determined after a thorough ED work-up.

Law

It is important that emergency healthcare professionals be aware of legal precedents that affect the practice of emergency medicine. In the USA, for example, the Emergency Medicine Treatment and Labor Act (EMTALA) is a federal law that requires that each patient presenting to an ED receives a screening examination and be medically stabilized. Prior to the EMTALA law, hospital emergency departments could refuse to care for

patients who did not have the ability to pay and were referring them to government hospitals, with resultant delays in care. This was termed ‘‘patient dumping.’’ Since the EMTALA laws were enacted in 1986 and updated in 1994 and 2003, patients must be stabilized and an accepting physician contacted before patients are transferred to another hospital for specialized care not available at the initial hospital (Capron, 1995; Derse, 1999).

Some traditional legal precedents such as the need for informed consent and confidentiality have exceptions when a patient presents in a true emergency condition. Under this exception, the patient must be unconscious or incapacitated with no immediate family available, time is critical for diagnostic or therapeutic procedures, and a reasonable person would consent to the procedure or request for medical information (Derse, 1999).

Policy

Ethics in emergency and trauma medicine is thus more complex than ethical issues in a primary care setting. The special circumstances and nuances of emergency medical care is addressed in the subspecialty Codes of Ethics developed for emergency physicians (Larkin, 1999; American College of Emergency Physicians, 2004). This emphasizes the unique duties of emergency physicians, including the ‘‘social role and responsibility to act as healthcare providers of last resort for patients who have no other ready access to healthcare.’’ The basic principles of the emergency physician– patient relationship includes beneficence, respect for patient autonomy, fairness, respect for privacy, and non-maleficence. Informed consent by patients is important provided they have decisionmaking capacity.

How should I approach emergency and trauma ethics in practice?

It is important to understand that ethical issues are common in the ED. Each patient encounter is

unique and clinicians cannot follow definitive rules for all cases.

In emergency medicine and trauma care, evaluating decision-making capacity is the key element of informed consent. The patient may be suspected to have taken alcohol, drugs, or have unknown medical conditions that affect their decisionmaking capacity. Their clinical picture, as well as mental status, may fluctuate in the same ED visit. Even more confusing is the fact that decisionmaking capacity is decision specific and depends on the consequences of the decision. An inebriated patient with a laceration may be released if they refuse sutures, with the consequences of a scar or wound infection. However, the same inebriated patient may be restrained and forced to stay in the ED after a serious motor vehicle crash if they refuse medical care. The consequences of refusing trauma care after a motor vehicle crash can be immediate death (Iserson et al., 1995; Derse, 1999).

Although emergency healthcare providers respect and value patient autonomy, exceptions to informed consent also exist. Patients in true life-and-death situations must be treated appropriately even if there is no time to obtain informed consent. Implied consent is assumed, as a reasonable person would want standard medical treatment to save his/her life. A trauma patient who is acutely bleeding from his/her ruptured spleen is promptly taken to the operating room. The unconscious patient with a drug overdose is treated as an emergency regardless of consent. In addition, patients who do not have decision-making capacity are treated with standard medical care until their capacity to make decisions is restored. The most common example is the inebriated patient, who sobers up in the ED and is then able to make rational decisions about healthcare. Finally, there may be public health and societal benefits that overrides an individual’s consent to treatment. For example, a patient with an infectious disease such as tuberculosis may not have a choice about treatment options (Iserson et al., 1995; Palmer and Iserson, 1997; Moskop, 1999; Naess et al., 2001; American College of Emergency Physicians, 2004).

472 A. B. Sanders

Emergency healthcare professionals operate under the assumption that patients want full resuscitation for medical or traumatic emergencies (Moskop, 1999; Marco and Larkin, 2000; Naess et al., 2001; American Heart Association, 2005). The clinical teaching is to ‘‘err on the side of life.’’ Patients facing lifeor limb-threatening conditions receive full resuscitation efforts with the following exceptions:

(i) the patient has a valid advance directive saying they do not want resuscitation, and (ii) resuscitation attempts would be futile (American Heart Association, 2005).

Cardiopulmonary resuscitation (CPR) is one of the few procedures that is begun unless a limitation of medical care order is in effect. The default CPR order is appropriate since cardiac arrest is the ultimate medical emergency where a delay of even minutes drastically reduces the chances for successful resuscitation. Patients with valid advance directives will have these honored by emergency and prehospital care professionals. Many communities have a standardized prehospital do-not- resuscitate (DNR) form that the medics will look for when they find a patient in cardiac arrest. It is important that primary care physicians be aware of the community standards for DNR (Marco, 1999; Sanders, 1999; Marco and Larkin, 2000; American Heart Association, 2005). Patients with terminal diseases who do not have DNR forms available will have resuscitation procedures instituted when they call for medics. From an ethical standpoint, there is no issue in stopping resuscitation efforts if valid information is presented that the patient or their surrogate decision maker does not want resuscitation. It must be pointed out, however, that medics are trained to resuscitate, to ‘‘err on the side of life,’’ unless there is a valid DNR form. It is also important to remember that not all advance directives ask to limit care. Some advance directives ask that everything be done to save a person’s life.

If a resuscitation attempt is considered futile, emergency healthcare professionals are under no obligation to provide it. There is controversy about exactly what the circumstances are when resuscitation attempts should be considered futile.

A number of factors influence the prognosis for patients in cardiac arrest. These include patient factors such as comorbid diseases and etiology of the arrest, and systems factors such as down time before CPR, time to defibrillation, and initial rhythm (American Heart Association, 2005). None of these factors is, in itself, predictive of medical futility. Some factors can also be subjected to bias of the individual treating physician. Therefore, emergency healthcare providers should follow standard guidelines for when to withhold resuscitation efforts. Guidelines are developed and updated by the International Resuscitation Liaison Council on Resuscitation and local resuscitation councils. The American Heart Association (2005) gives the following criteria for withholding CPR efforts.

(a)The patient has a valid Do Not Attempt Resuscitation (DNAR) order

(b)The patient has signs of irreversible death (e.g., rigor mortis, decapitation, or dependent lividity)

(c)No physiological benefit can be expected

because vital functions have deteriorated despite maximal therapy (e.g., progressive septic or cardiogenic shock).

Physicians can stop resuscitation efforts when the patient is unresponsive to advanced cardiac lifesupport efforts. This is a clinical decision the emergency physician makes based on known prognostic factors such as time in arrest, setting, response to treatment, comorbid diseases, etc. The vast majority of patients who survive an out-of- hospital arrest will have return of spontaneous circulation with the treatment of paramedics. There is no advantage in transporting a patient in cardiac arrest to a hospital as long as the emergency medical services system has a protocol for pronouncing a patient dead (American Heart Association, 2005).

The cases

The first case illustrates that emergency healthcare providers try to respect the patient’s autonomy and

in this case, the patient requested not to be treated. However, in order to respect the patient’s request, he must have the decision-making capacity to understand the consequences of his decision. In this case, there are a number of factors that may impair his judgement. Firstly, the patient admits to drinking several beers. His breath smells of alcohol and he is slurring his speech. Could the alcohol be clouding his judgement to refuse treatment? If he were sober, would he still refuse medical care? Secondly, the extent of his trauma is unknown. He was hit on the head, has a laceration, and was reported to be unconscious for a few minutes. Is his decision about refusing medical care influenced by his recent head trauma? Are there other unknown medical conditions involved? Did the patient also ingest drugs, such as cocaine or amphetamines, which also may affect his judgement? The patient is refusing diagnostic tests and there is no immediate way to sort out these factors. The patient does not cooperate with a formal mental status examination. The emergency physician must make an immediate decision and there is not time to get consultations. If the patient is getting aggressive, then he must either be restrained or allowed to leave. Because the consequences to the patient for a bad decision are significant, including a cerebral bleed that can cause death, the emergency physician decides the patient does not have adequate decision-making capacity and restrains him until diagnostic tests are complete and his alcohol wears off.

The second case, an 80-year-old woman in a skilled nursing facility who suffers a cardiac arrest, raises the question of the futility of resuscitation efforts. Patients who suffer cardiac arrest are assumed to want resuscitation (implied consent) unless they clearly indicate otherwise through a DNR order presented to the medics. The absence of such an order in the nursing home indicates that the patient wishes everything be done to save her life. However, healthcare professionals are under no obligation to provide care that does not have

proven benefit even if the patient requests such care. In the experience of the medics, it is rare for older patients in a nursing home to resuscitate from cardiac arrest, especially if they have been down a long time. Do we respect the patient’s autonomy or withhold resuscitation on the basis of futility? The medical literature on the success of cardiac arrest shows that there are poor prognostic factors such as down time before CPR and comorbid diseases. In this case, we actually do not know what the true down time to CPR was. It could have been as long as four hours or as short as one minute prior to being found unconscious. We are also uncertain of the patient’s comorbid diseases. For instance, many nursing home patients are severely disabled. However, the patient in this case was temporarily in the nursing home to help with rehabilitation. There is also no way to determine a neurological outcome until 48–72 hours after the arrest. Emergency healthcare professionals should always err on the side of life. There are published international guidelines for when to withhold resuscitation efforts. The patient does not have a DNR, clear signs of death (rigor mortis or dependent lividity), and there is no indication of deteriorating physiological functions. Therefore, the emergency physician orders the medics to immediately begin CPR and advanced cardiac life support protocols.

REFERENCES

Adams, J., Schmidt, T., Sanders, A., Larkin, G. L., and Knopp, R. (1998). Professionalism in emergency medicine. Acad Emerg Med 5: 1193–9.

American College of Emergency Physicians (2004). Code of ethics for emergency medicine. Ann Emerg Med 43: 686–94.

American Heart Association (2005). Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, Part II: ethical issues. Circulation 112: 6–11.

Capron, A. M. (1995). Legal setting of emergency medicine. In Ethics in Emergency Medicine, 2nd edn, ed.