A proposal for selective resuscitation of adult cardiac arrest patients in a pandemic

Abstract

Allocation of limited resources in pandemics begs for ethical guidance. The issue of ventilator allocation in pandemics has been reviewed by many medical ethicists, but as localities activate crisis standards of care, and health care workers are infected from patient exposure, the decision to pursue cardiopulmonary resuscitation (CPR) must also be examined to better balance the increased risks to healthcare personnel with the very low resuscitation rates of patients infected with coronavirus disease 2019 (COVID‐19). A crisis standard of care that is equitable, transparent, and mindful of both human and physical resources will lessen the impact on society in this era of COVID‐19. This paper builds on previous work of ventilator allocation in pandemic crises to propose a literature‐based, justice‐informed ethical framework for selecting treatment options for CPR. The pandemic affects regions differently over time, so these suggested guidelines may require adaptation to local practice variations.

Impact of the COVID-19 pandemic on cardiac arrest systems of care

“…Family assent should be sought but is not specifically required to apply a unilateral DNR in the absence of agreement by the surrogate decision-maker [ 74 ▪▪ ]. Conversely, a selective approach has been proposed that would limit resuscitation to <6 min if ROSC is not achieved in cases of unwitnessed, asystolic, or recurrent arrest [ 78 ▪ ]. For other cardiac arrests, the authors endorse the use of the sequential organ failure assessment score to further guide resuscitative efforts [ 78 ▪ ].…”

“…Conversely, a selective approach has been proposed that would limit resuscitation to <6 min if ROSC is not achieved in cases of unwitnessed, asystolic, or recurrent arrest [78 ▪ ]. For other cardiac arrests, the authors endorse the use of the sequential organ failure assessment score to further guide resuscitative efforts [78 ▪ ].…”

State emergency medical services guidance and protocol changes in response to the COVID‐19 pandemic: A national investigation

“…It is important to note that some states use a regionalized approach to develop and disseminate guidance, complicating assessment of the scope and impact of state‐issued guidance. Although previous work has examined agency‐level operational changes and resources for the pandemic, 7 the impact of COVID‐19 on specific clinical situations, 8–10 guidance regarding crisis standards of care, 11 and the ethical distribution of scarce resuscitation resources, 12 this study offers a comprehensive national assessment of COVID‐19–initiated EMS protocol changes and guidance.…”

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

“…This surge led to a strain on available resources and unprecedented ethical questions around allocation of potentially limited resources. 1 , 2 The utility of resuscitation efforts for in-hospital cardiac arrest (IHCA) specifically was scrutinized 3 , 4 given the high resource utilization, concerns around exposing clinicians to COVID-19, and early studies demonstrating nearly universally poor outcomes of IHCA. 5 , 6 , 7 As a result, both palliative care specialists and ethics teams were increasingly called upon to assist with questions related to goals of care and code status determinations for patients with COVID-19.…”