Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

Hilberman, Mark; Kutner, Jean S.; Parsons, Donald L; Murphy, Douglas B.

doi:10.1136/jme.23.6.361

Cited by 43 publications

(26 citation statements)

References 46 publications

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“…Blinderman et al suggest that when physicians offer resuscitation in a patient in a PVS, they are inadvertently offering a procedure that the health care team knows is ineffective at improving the state the patient is already in (19,20). The family clearly stated that the patient "would not wish to live this way" but also, in multiple meetings, state that they should not have to be the ones to make "these decisions" for their loved one because it means "choosing death."…”

Section: Withholding and Withdrawing Dialysis In Severely Neurologicamentioning

confidence: 99%

Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Skold¹,

Lesandrini

Gorbatkin

2014

Clinical Journal of the American Society of Nephrology

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SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...

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Section: Withholding and Withdrawing Dialysis In Severely Neurologicamentioning

confidence: 99%

Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Skold¹,

Lesandrini

Gorbatkin

2014

Clinical Journal of the American Society of Nephrology

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“…Attempting CPR carries high chances of failure and high risk of significant adverse effects and is often 'traumatic' end-of-life that occurs in a manner the patient and people close to the patient would not have wished. CPR is not an appropriate response to death that occurs as a result of advanced age or illness [1]. Resuscitation particularly in these circumstances violates a person's right to die with dignity.…”

Section: Introductionmentioning

confidence: 99%

Ethical Analysis of Medical Futility in Cardiopulmonary Resuscitation

RK¹

2014

J Clinic Res Bioeth

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Cardiopulmonary Resuscitation (CPR) is a life-saving intervention in emergency medical care practiced globally for the last more than seven decades. It cannot be a solution to prevent every death and there are risks associated with this intervention. This article focuses on the ethical dilemmas related to the decisions of medical futility in cardiopulmonary resuscitation particularly in emergency settings. There are guidelines for the decisions to start and stop CPR but are mostly based on technical grounds only. Technically possible interventions are not always medically reasonable and all four principles of biomedical ethics -viz. respect for autonomy, beneficence, nonmaleficence and justice are associated with the issues of medical futility in this process. Autonomy deals with the issues of the individual right for CPR as well as the other side of the coin do-not-resuscitate (DNR) including death with dignity. The 'advance directive' and the need for surrogate consent are further dimensions of autonomy. As a life saving measure, beneficence comes into play while non-maleficence argues against performing CPR when the outcomes are harmful or futile. Futile interventions have to be avoided for the justice so that the precious intensive care units are not occupied waiting for the end-of-life. Literatures were reviewed and analyzed in the context of medical futility in CPR and the ethical dimensions of the issues have been explored. Ethical approach assists in deciding the futility of cardiopulmonary resuscitation in a given situation where the shared decision is taken by the medical professionals and the surrogates of the patients.

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“…First, the clinicians regarded the obligation to respect parental autonomy as equal to, or more important than, the child's own best interests. Second, they failed to recognize that because the underlying condition could not be treated, resuscitation was not indicated [32]. One must consider multiple factors in assessing best interests, but the first is whether the intervention is medically therapeutic.…”

Section: Cases Of Pediatric Iatrogenesismentioning

confidence: 99%

Etiology and Manifestations of Iatrogenesis in Pediatrics

Teti¹,

Ennis-Durstine

Silber³

2017

AMA Journal of Ethics

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There is general agreement in the literature of what ought to occur following iatrogenic harm. Senior members of the team should disclose what occurred and how the problem will be remedied. Those involved should express heartfelt regrets and apologize sincerely. But in the pediatric setting, parents, as surrogates, can sometimes place clinicians on the horns of a dilemma: respect parental autonomy, which may involve continuing nonadvised therapy, or uphold the patient's best interests, which may indicate another course of care. In other cases, clinicians themselves may initiate or continue care without real benefit. The young patients who may be harmed as a result often cannot understand an explanation, an apology, or, when warranted, receive reparation; what duties are owed them? In this paper, we first discuss iatrogenesis writ large and then propose the formulation of this concept in this latter context, where harm occurs as a result of counterpoise between two or more ethical obligations, which we term counterpoise iatrogenesis. We then articulate its etiology and manifestation through two true cases. We conclude with a re-examination of the meaning and function of autonomy in pediatrics and the designation of secondary victims. IntroductionIatrogenesis, as we use the term here, refers to any patient harm resulting from treatment by a member of the medical team [1, 2] and is not limited to medical error [1,3]. Following iatrogenic harm, the clinicians involved, preferably senior members of the team, should inform the patient or family of what happened, how the problem will be remedied, and-particularly when lasting harm has occurred-what can be done for the patient [1,3]. Physicians should express regret and offer a sincere apology, which patients who have been harmed deserve [4,5].

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Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

Cited by 43 publications

References 46 publications

Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Ethical Analysis of Medical Futility in Cardiopulmonary Resuscitation

Etiology and Manifestations of Iatrogenesis in Pediatrics

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