RC (UK)O1

ETHICS AND LEGAL ASPECTS OF

RESUSCITATION

RC (UK)O2

ObjectivesTo understand:• The ethical and legal implications of the duty of

care in regard to resuscitation• The implications of ‘Do Not Attempt

Resuscitation’ orders and ‘Advanced Directives’• The involvement of relatives in witnessing

resuscitation attempts• The considerations involved in the decision to

stop a resuscitation attempt

RC (UK)O3

Failure to start resuscitation

• Failure to recognise cardiac arrest has occurred

• Rescuer inadequacy

• Real or perceived risk to rescuer from attempting resuscitation

RC (UK)O4

CPR should be commenced routinely unless:

• The patient’s condition indicates that successful resuscitation is unlikely to result in length or quality of life acceptable to the patient

• It is not in accord with the recorded, sustained wishes of a mentally competent patient

RC (UK)O5

The overall responsibility for the decision to perform

resuscitation rests with the senior clinician in charge of

the patient’s care.

RC (UK)O6

The appropriateness of resuscitation may be raised by:

• The patient• Relatives or close friends• General Practitioner• Medical staff• Nursing staff

RC (UK)O7

Do Not Attempt Resuscitation (DNAR) Policy

Regularly reviewed and recorded in:• Medical notes• Nursing notes

Where possible must include prior consent of patient, explanation and justification.

RC (UK)O8

DNAR Orders apply to resuscitation only

RC (UK)O9

Deciding when to stop

• Place

• People

• Time

RC (UK)O10

Prolonged resuscitation

Indicated in special circumstances:• Hypothermia• Near drowning• Drug overdose• Children

RC (UK)O11

Advance Directives

• Refusing CPR can be legally binding if certain safeguards are met and doctor is satisfied that request is genuine

• May be difficult in emergencies

• If in any doubt - Resuscitate

RC (UK)O12

Advanced Directives

Safeguards:

• Adult

• Patient mentally competent when decision made

• Circumstances foreseen

• Not under duress

• Patient aware of the implications

RC (UK)O13

Should relatives witness resuscitation?

• May help in bereavement process• Exclusion may be distressing• Must be accompanied by appropriate person• Team aware• Patient takes priority• Staff stress and training recognised

RC (UK)O14

Any Questions?

RC (UK)O15

Summary

• It is important to commence resuscitation promptly and effectively

• To know when such measures are contraindicated

• To know when resuscitation attempts should cease

RC (UK)O16

A colleague states that she doesn’t want to be resuscitated if she ever has a cardiac arrest. The next week she sustains a cardiac arrest in front of you.

–Do you start resuscitation?

You find out that she was diagnosed last week with cancer and is taking anti-depressants.

–Do you continue resuscitation?

Her partner arrives and asks you to reverse your decision

–What do you do?

RC (UK)O17

An 82 year old woman falls and sustains a fractured neck of femur. She lives in sheltered housing, is prone to forgetfulness, and has been unwell for the last 2 days.

A resuscitation decision needs to be made.

–Who should be involved with this decision?

–What makes a ‘DNAR’ order valid?

RC (UK)O18

It is 3 am and 54 year old Albert Jones is recovering from a routine hernia operation when he collapses, is unsuccessfully resuscitated, and dies.

–How do you contact the relatives who live an hour away?

–How do you receive them as they arrive on the ward?

–Who should discuss the collapse with them and how?

RC (UK)O19

In the A&E department, a 42 year old man is brought in by his wife suffering from a suspected MI. They are in the cubicle together when he collapses in VF

–What do you do with his wife?

–She wants to stay – what support do you offer her?

–Should relatives be present during resuscitation?

RC (UK)O20

A 48 year old man collapses in a public place as you are driving past.

–Would you stop to assist?

–Would you start resuscitation if needed?

–What is the legal and professional view in this situation?

The Ambulance Service arrive and, on monitoring, he is found to be asystolic and remains in this rhythm.

–When do you decide to stop?

RC (UK)O21

Your elderly next door neighbour has not been seen out today. You find him on the floor, collapsed, not breathing, but with a weak pulse.

There are a number of empty drug and brandy bottles around him.

Pinned to his chest is a note saying

“DO NOT RESUSCITATE”

–What do you do?