In this edition of the Journal of Emergency Medicine, Marco and Schears report on a survey of 41% of the National Association of Emergency Medical Technicians regarding their attitudes and opinions regarding the initiation and termination of resuscitation efforts for patients in cardiac arrest (1). The survey represents the opinions of 1446 Emergency Medical Technicians (EMT) and, thus, is significant in representing attitudes of out-of-hospital care providers. The researchers found that almost 90% of EMTs would withhold resuscitation efforts in the presence of an official state-approved advance directive. The survey probes the issue of what the EMTs would do in conditions that they consider futile (defined as very low likelihood of success). Fourteen percent of EMTs stated that they would always or often withhold resuscitative efforts in situations in which they consider treatment futile and no advance directive is available. An additional 21% stated they sometimes withhold resuscitative efforts in this situation. In a sub-analysis, the researchers found that providers with more than 10 years experience were more likely to withhold resuscitation attempts than EMTs with less experience (1).
The data from this interesting study touch on key ethical as well as clinical issues, including judgments about medical futility for patients in cardiac arrest. What is medical futility? Who should determine it in the clinical situation? In the setting of cardiac arrest, guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care have been developed through the American Heart Association consensus process (2). An action is considered futile if it serves no useful purpose. Futility, in any specific condition, must be assessed with respect to a purpose or goal 2, 3. For example, antibiotics can be said to be futile with regard to treatment of a viral upper respiratory infection. Physicians are under no obligation to provide futile treatments even if the patient requests them. Some authors distinguish between quantitative and qualitative futility judgments 3, 4. Quantitative futility addresses the scientific data from multiple good studies in the medical literature. How likely is it that the patient in cardiac arrest will survive? Qualitative futility focuses on the goals of treatment and issues such as quality of life are important considerations. For example, if a patient can be resuscitated from cardiac arrest but has a very low chance of long-term survival because of underlying medical conditions, should the resuscitation be considered futile? Healthcare providers must be precise about the goals and purpose for which futility is being considered.
Who should make the decision regarding what is the most appropriate goal and whether the treatment is futile? Should this be a decision made at the bedside for individual patients in cardiac arrest? Is the treatment futile if it is only 20% effective, 5% effective, 1% effective? Are there different threshold levels for deciding the effectiveness of the treatment depending on the condition involved and alternatives? For example, for someone in cardiac arrest, the treatment that is effective in 2% of patients may be reasonable, whereas a treatment of 2% may not be reasonable for initiating a chemotherapy treatment for patients with cancer. What is the patient’s role in making this decision? What is the role of the patient’s family? the patient’s primary care provider? the emergency healthcare provider?
In most cases, the decision whether to embark upon a course of treatment such as chemotherapy or antibiotics is jointly made by the patient and the treating physician. Factors such as the patient’s quality of life, treatment alternatives and the effectiveness of the treatment to reach the goal that the patient desires are key elements. There is often time to consult with other physicians as well as family members before the decision is finalized. The patient in cardiac arrest is fundamentally different than patients in other clinical settings in which futility is a concern. If the patient has a valid advance directive, emergency healthcare providers should follow the advance directive unless there is some reason to suspect the patient would change the decision under the specific clinical circumstance. The research survey confirms this practice with about 90% of EMTs stating that they would follow advance directives.
If the patient does not have advance directives, how should one decide whether the attempted resuscitation of patient in cardiac arrest is futile? It is our belief that this decision should not be made at the bedside by emergency healthcare providers. There is often little reliable data about the patient’s underlying medical conditions, the patient’s and the family’s wishes and values, and the ultimate prognosis of the patient for resuscitation from cardiac arrest. We feel that this decision is best made by a societal consensus process, which takes into account social as well as individual values and the best scientific information regarding the prognosis to achieve the stated medical goals. Leaving this decision to individual healthcare providers at the bedside opens the decision to biases of healthcare providers and incomplete information, which can significantly influence a decision not to resuscitate patients in cardiac arrest.
This contention is more than theoretical if we review the literature on resuscitation from cardiac arrest. Some studies contended that older persons have such a poor prognosis for resuscitation from cardiac arrest, they should not be given the option of attempted resuscitation. Murphy et al. found that the long-term survival for older patients was only 1% and questioned the need to provide resuscitation to this population (5). These studies had serious flaws in their methodology. It is only when further studies were done that it was demonstrated that it was not age per se, but probably underlying disease states that rendered the poor prognosis. Longstreth et al. found a survival rate of 10% for older patients in cardiac arrest, which was only slightly below the survival rate for younger patients (6). Other studies have implied that patients with metastatic cancer may have a very poor prognosis and questioned whether such patients should be offered resuscitation (7). Further studies, however, show that 10% of patients with cancer survived to hospital discharge and 4% survived for a year (8).
Guidelines have been developed through the consensus process of the American Heart Association. It is known that several variables affect prognosis, including co-morbid diseases, etiology of the arrest; circumstances of the arrest including witnessed vs. unwitnessed, initial rhythm, time to CPR, defibrillation and advanced cardiac life support (ACLS). However, no clear criteria or combination of criteria have been demonstrated to accurately predict futility of resuscitation efforts. Therefore, it is recommended that all patients in cardiac arrest receive immediate resuscitation unless the following conditions apply: 1) the patient has a valid advance directive indicating a preference for no resuscitation, 2) the patient has signs of irreversible death (rigor mortis, decapitation or dependent lividity) or 3) in circumstances where no physiologic benefits can be expected because the vital functions are deteriorated despite maximal therapy for such conditions, conditions such as progressive septic or cardiogenic shock (2). These patients are usually in hospital intensive care units and rarely would be encountered by EMTs.
The decision to terminate resuscitative efforts is a medical decision that should be made by the base station physician. EMTs are not independent practitioners and operate under the licensure of the base station physician or medical director by protocols. The decision to terminate resuscitation efforts follows a determination that the patient has been unresponsive to advance cardiac life support treatment (2). The decision must be made in light of the prognostic factors as well as response to resuscitative measures such as defibrillation and drugs. The decision on whether to terminate the resuscitation in the out-of-hospital setting or transport the patient to the emergency department is a clinical one that the physician in charge of resuscitation must make. In many EMS systems, terminating resuscitation in the out-of-hospital environment is acceptable once it is deemed that the patient has been given an adequate trial of advanced cardiac life support. The system must be set up such that important issues that are usually addressed in the hospital may be performed in the community. This includes notifying and talking to the family and appropriate care of the body.
The survey performed by Marco and Schears gives us insight into a problem of education of EMTs. Futility of resuscitation for a patient in cardiac arrest is not a decision the EMT should be making at the bedside. We recommend that EMTs and emergency physicians follow the consensus guidelines for cardiac resuscitation and only limit care in the specific situations outlined above. Further, local EMS systems and authorities should have clear guidelines for when not to start CPR and ACLS. These guidelines would include a valid advance directive indicating no resuscitation or signs of irreversible death (rigor mortis, decapitation or dependent lividity). We would caution EMTs about making decisions that do not fit these consensus guidelines and may involve subjective determinations of the prognosis for successful resuscitation. The survey points to the need for education about the meaning and significance of futility in cardiac arrest and strong medical direction to assure that all patients receive appropriate resuscitation from cardiac arrest.
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