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ACEP Now: Vol 34 – No 04 – April 2015

Image Credit: © SHUTTERSTOCK.COM

The Case

A frantic call comes in on the box: “CPR in progress—three minutes out!” Emergency medical services (EMS) abruptly rolls in with a 41-year-old female schoolteacher who became unresponsive at work. The school personnel provided immediate bystander CPR, and EMS arrived on scene five minutes after the patient lost pulses. EMS continued CPR but had neither established IV access nor given any medications. You immediately dichotomize her prognostic profile. You note that she is young and had a witnessed arrest, immediate CPR, and a potentially reversible cause of cardiac arrest. In the back of your mind, however, you are also assessing the negative prognostic variables: resuscitative efforts have been under way for at least 15 minutes with no IV access, no code medications were given, and she was not intubated in the field.

In the emergency department, you establish access, intubate, and attempt defibrillation for what appears to be ventricular fibrillation. Attempted resuscitation continues with multiple rounds of advance cardiovascular life support (ACLS) medications. By the fourth shock, 30 minutes after the arrest, her pupils are fixed and dilated. The patient’s family arrives and is obviously distraught, urging you to save her life. The pressure of knowing her prognosis, the urgency of her family’s pleas to continue resuscitative efforts, and a sense of professional failure now weigh on your mind as you approach the decision to terminate resuscitation. Your team turns to you expectantly, waiting for direction.

Discussion

A particularly challenging situation occurs when the family of a patient in cardiac arrest desires protracted attempts to save a loved one. Although clinicians may be tempted to honor family member requests in order to avoid confrontation or save time, interventions should only be considered when there exists at least a possibility of medical benefit for the patient.¹ Respect for patient autonomy and family wishes is sometimes used to justify providing nonbeneficial resuscitative treatment. Such action, however, ignores family member bias and the limitations of surrogate decision making, and it also violates clinicians’ dual professional responsibility to protect both patients’ health interests and scarce health care resources.^2,3

Despite the development of CPR more than half a century ago, the prognosis for patients with cardiopulmonary arrest (CPA) remains grim. The prehospital survival rate to neurologically intact hospital discharge for victims of out-of-hospital cardiac arrests is approximately 3 percent, and rates of survival in ED patients who arrest are in the range of 20 percent.⁴ For patients who arrest in the field, studies from prehospital systems in many countries have validated a basic life support (BLS) rule for termination. This rule highlights three criteria that characterize physiologic futility with a 99.8 percent predictive value: 1) EMS did not witness the arrest, 2) no shock was delivered prior to transport, and 3) there was a failure to obtain return of spontaneous circulation (ROSC) prior to transport. Similar studies evaluating ED arrest patients reveal that recurrent arrests are less likely to result in ROSC and, ultimately, survival to hospital discharge.⁵

Current evidence supports early termination of ED resuscitative efforts in CPA patients who meet established criteria for physiologic futility. These criteria include the prehospital BLS rule, cardiac standstill on bedside echo, and/or an end-tidal CO2 <10–15 mm Hg after 20 minutes of standard ACLS. Several ED CPA studies have shown that cardiac standstill on ED echocardiography is 100 percent predictive of failure to leave the ED alive regardless of both downtime and initial presenting rhythm.⁶

End-of-life care is a complex task for emergency physicians and should include careful consideration of patients’ wishes, family input, scientific evidence regarding prognosis, and physician judgment. Several organizations have provided guidance for such complex decisions. Current ACEP policy states that “physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient.” This policy also states that emergency physicians’ judgments should be unbiased, based on available scientific evidence and societal and professional standards, and sensitive to differences of opinion regarding the value of medical intervention in various situations.⁷ The American Medical Association has also stated in policy that “physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients.”⁸

Equally important as deciding when to refuse a family member’s request for continued resuscitative efforts is how the family is approached about the decision. Shared decision making with clinicians, patients, and families can be a means of achieving consensus for the best approach to honor patients’ wishes. Clinicians should clearly explain their positions and invoke practice guidelines when appropriate. Furthermore, clinicians should identify and address why conflict exists when making these decisions in order to decrease possible feelings of abandonment and mistreatment.⁹

In the case presented, it would be ideal if the health care team and family understood and agreed with the decision to discontinue resuscitative efforts. However, it is ultimately up to the provider to make the best clinical decision with the information provided. In this case, it would be appropriate to cease further resuscitative efforts and to focus on family support, including communication and spiritual counseling if desired. The emergency physician should explain to the family that their loved one received the best and most appropriate care that modern medicine can provide.

The authors are serving on the ACEP Ethics Committee. Dr. Phillips is chief resident in the department of emergency medicine at George Washington University Medical Center in Washington, D.C. Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio. Dr. Jesus is assistant professor of emergency medicine at Christiana Care Health System in Newark, Delaware. Dr. Wang is resident physician at the Stanford/Kaiser Emergency Medicine in Palo Alto, California. Dr. Larkin is Lion Foundation professor and chair of emergency medicine at the University of Auckland in New Zealand.

References

1. Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician’s obligation. N Engl J Med. 1986;315(21):1347-1351.
2. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5):493-497.
3. Brett AS, McCullough LB. Addressing requests by patients for nonbeneficial interventions. JAMA. 2012;307(2):149-150.
4. Sasson C, Rogers MA, Dahl J, et al. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63-81.
5. Larkin GL, Carey SM, Allen E, et al. Recurrence risk for emergency department survivors of pulseless cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Ann Emerg Med. 2005;46:S17-S18.
6. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8:616-21.
7. ACEP Policy Statement. Non-beneficial (“futile”) emergency medical interventions. American College of Emergency Physicians, Dallas, 1998, reaffirmed 2008. Available at: http://www.acep.org/Clinical—Practice-Management/Non-Beneficial-(-Futile-)-Emergency-Medical-Interventions/. Accessed Dec. 8, 2014.
8. AMA Policy on End-of-Life Care. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/ethics-resource-center/end-of-life-care/ama-policy-end-of-life-care.page. Accessed Dec. 8, 2014.
9. Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit treatment: a differential diagnosis. JAMA. 2000;283(7):909-914.