Cpr Ethics

7/25/2019 Cpr Ethics

1/51

Ethical Issues In

Cardiopulmonary

ResuscitationDr. DoHA RASHEEDY ALY

Lecturer of Geriatric Medicine

Department of Geriatric and

Gerontoloy

Ain Shams !ni"ersity#$% % #$


2/51


3/51

CPR has the same goals as other

medical interventions:to preser"e life.

restore health.

relie"e sufferin.

limit disa'ility.

(ne oal uni)ue to C*R is the re"ersal of clinical

death+ an outcome achie"ed in only a minority of

patients.


4/51

,he performance of C*R+ may conflict -ith

the patients o-n desires or may not 'e in his

'est interest.Decisions concernin C*R are complicated and

often must 'e made -ithin seconds 'y rescuers -ho

may not /no- the patient or /no- of the e0istence of

an ad"ance directi"e.

In some instances resuscitation may not 'e

the 'est use of limited medical resources.

Concern a'out costs associated -ith proloned

intensi"e care should not preclude emerency

resuscitati"e attempts in indi"idual patients.


5/51

Prognosis of CPRCPR has a grim prognosis at any age.

A 1$ year Meta analysis of almost #$+$$$ cases of in

hospital C*R re"ealed that patients youner than 2$

years of ae had a success rate of &3.# 4"ersus .5

4for patients older than 2$ years.2#.6 4 of post7C*R deaths -ere -ithin 2# hours and

&.3 4 of successfully resuscitated patients had a

permanent neuroloical impairment.

Schneider A. et al. In7hospital Cardiopulmonary Resuscitation8 a1$7year re"ie-. J Am Board Fam Pract. &66193:#;86&7&$&


6/51

In frail elderly and demented patients sur"i"al

follo-in C*R is dismal :$754; reardless of the

clinical settin and for patients in lon term carefacilities C*R sur"i"al is essentially $4.Gordon M. C*R in Lon ,erm Care8 Mythical Reality or an C+ Hoffman7>ilde S+ et al. Results of cardiopulmonary resuscitation. Arch Intern Med

&6619&?18&12$@?.

*atients -ho are hihly functional -ith fe-er chronic illnesses+

hospitalied for a cardiac etioloy+ and closely monitored 'efore thearrest are more li/ely to 'enefit from C*R. In these circumstances+

C*R can 'e "ery successful+ and elderly patients -ill 'enefit as much

as youner patients

,resch DD+ ,ha/ur RB. Cardiopulmonary resuscitation in the elderly. eneficial or an e0ercise in futility= Emer

Med Clin


7/51

>ritin a D


8/51

Ethical Principles


9/51

Ethical Principles

Healthcare professionals should consider ethical+ leal+ and cultural

factors -hen carin for those in need of C*R.

,hey should 'e uided 'y8

&. science.#. the indi"idual patient or surroate preferences.

1. local policy.

5. leal re)uirements.


10/51

Autonomy8

Riht of patient to accept or refuse treatment

eneficence8

Are -e pro"idin 'enefit to patient or are -e ust delayin death

and prolonin sufferin=


11/51

OUT OF HOSPT!" SETT#$S


12/51

Criteria for #ot Starting CPR in

O%t&of Hospital Cardiac !rrest&. Situations -here attempts to perform C*R -ould place the

rescuer at ris/ of serious inury.

#. ('"ious clinical sins of irre"ersi'le death :e+ rior mortis+

dependent li"idity+ decapitation+ transection+or decomposition;1. A "alid+ sined+ and dated D


13/51

Terminating Res%scitative

Efforts in !d%lt OHC!Rescuers -ho start LS should continue resuscitation until one of

the follo-in occurs8

&.Restoration of effecti"e+ spontaneous circulation

#. Care is transferred to a team pro"idin ad"anced life support

1.,he rescuer is una'le to continue 'ecause of e0haustion+ thepresence of danerous en"ironmental haards+ or 'ecausecontinuation of the resuscitati"e efforts places others in eopardy

5.Relia'le and "alid criteria of death


14/51

criteria for termination of

res%scitation

LS

ALS


15/51

'"S termination&of&res%scitation r%le for ad%lt OHC!.().

*orrison " + et al. Circ%lation (,-,-((:S//0&S/10

Copyriht J American Heart Association

'"S of&res%scitation r%le for ad%lt OHC!.().


16/51

!"S termination&of&res%scitation r%le for ad%lt OHC!.)).

*orrison " + et al. Circ%lation (,-,-((:S//0&S/10

Copyriht J American Heart Association

!"S of&res%scitation r%le for ad%lt OHC!.().


17/51

# HOSPT!" SETT#$S


18/51

Criteria for #ot Starting CPR in

!d%lt HC!e- criteria can accurately predict the futility ofcontinued resuscitation. In liht of this uncertainty+

all adult patients -ho suffer cardiac arrest in the

hospital settin should ha"e resuscitati"e attempts

initiatedunless the patient has a "alid D


19/51

A D


20/51

Contraindications

,he only a'solute contraindication to C*R is a do7not7resuscitate:D


21/51

2ithholding and 2ithdra3ing CPR 4Termination of Res%scitative

Efforts5 Related To n&Hospital Cardiac !rrest*hysicians decision is 'ased on consideration of

many factors8

&.-itnessed "ersus un-itnessed arrest+

#.time to C*R+

1.initial arrest rhythm+

5.time to defi'rillation+?.comor'id disease

3.prearrest state

2.there is R(SC at some point durin the resuscitati"e efforts.


22/51

2hen is CPR not of 6enefit7 Bno-lede of the pro'a'ility of success -ith C*R could 'e used to

determine its futility.!ni"ersity of >ashinton School of Medicine

C*R has 'een sho-n to 'e ha"e a $4 pro'a'ility of success in the

follo-in clinical circumstances8

Septic shoc/

Acute stro/e

Metastatic cancer

Se"ere pneumonia

In other clinical situations+ sur"i"al from C*R is e0tremely limited8

Hypotension :#4 sur"i"al;

Renal failure :14;

AIDS :#4;

Home'ound lifestyle :54;

Ae reater than 2$ :54 sur"i"al to dischare from hospital;

Cli i l F t Th t Ch P di ti


23/51

Clinical Feat%res That Change Predictive

!cc%racy

Youn ae

,o0ins or electrolyte a'normalities

*rofound hypothermia

Dru o"erdose


24/51

CPR # 8E*E#T!


25/51

OHC!

,he impact of dementia on sur"i"al after cardiac arrest -as

in"estiated 'y Dull et al. ,hese authors considered C*R in the

presence of dementia Fun-anted'ecause of poor sur"i"alrates. only 14 of the residents sur"i"ed to hospital dischare.

In other studies+ the dischare rate of nursin home residents

from the hospital after cardiac arrest raned from $ to 1.54 .


26/51

HC!

E"en in a hospital+ C*R is three times less li/ely to 'e

successful in patients -ith dementia than in patients -ho are

coniti"ely intact+ and the success rate is almost as lo- as in

metastatic cancer :E'ell MH+ ec/er LA+ arry HC+ Haen M. Sur"i"al after in7hospital cardiopulmonary resuscitation. A meta7analysis. Gen Int Med &669

&1:8$?7&3.

Aeis another factor that decreases the success rate of C*R.


27/51

!ccording to Red Cross

all patients in cardiac arrest should recei"e resuscitationunless8

:&; the patient has a "alid Do


28/51

SUCCESS R!TES OF CPR

i iti l i h it l C*R


29/51

Karious studies ha"e found that initial in7hospital C*R success

rates rane from &3. to 554.

Lon7term sur"i"al :dischare from hospital; rates

rane from 1.& to &3.?4.

roo/s+ S.C. et al. :#$&$;. (ut7of7hospital cardiac arrest fre)uency and sur"i"al8 E"idence for

temporal "aria'ility. Resuscitation+ &:#; &2?7&&.

Myrianthefs+ *. et al. :#$$1;. Efficacy of C*R in a eneral+ adult IC!. Resuscitation+ ?2:&; 5175.

2ithd l f lif t i thi ll


30/51

2ithdra3al of life s%pport is ethically

permissi6le %nder these circ%mstances

A recent meta7analysis of 11 studies of outcome of ano0ic7ischemic

coma documented the follo-in 1 factors to 'e associated -ith poor

outcome8&.a'sence of pupillary response to liht on the third day.

#.a'sence of motor response to pain 'y the third day.

1.'ilateral a'sence of cortical response to median somatosensory

e"o/ed potentials -ith the first -ee/


31/51

'rain stem death !Bs Department of Health Code of *ractice o"ernin use of

that procedure for the dianosis of death8 ,here should 'e no dou't that the patients condition @ deeply

comatose+ unresponsi"e and re)uirin artificial "entilation @ is due to

irre"ersi'le 'rain damae of /no-n aetioloy.

,here should 'e no e"idence that this state is due to depressantdrus.

*rimary hypothermia as the cause of unconsciousness must ha"e

'een e0cluded.

*otentially re"ersi'le circulatory+ meta'olic and endocrine distur'ances

must ha"e 'een e0cluded.

*otentially re"ersi'le causes of apnoea:dependence on the "entilator;+

such as muscle rela0antsand cer"ical cord inury+ must 'e e0cluded.

the definiti"e criteria are8
http://en.wikipedia.org/wiki/Aetiologyhttp://en.wikipedia.org/wiki/Depressanthttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Apnoeahttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Apnoeahttp://en.wikipedia.org/wiki/Hypothermiahttp://en.wikipedia.org/wiki/Depressanthttp://en.wikipedia.org/wiki/Aetiology


32/51

the definiti"e criteria are8

i0ed pupils -hich do not respond to sharp chanes in the intensity of

incident liht.


33/51


34/51

Patient in deep apnoeic coma


35/51


36/51


37/51


38/51


39/51

45 !".

+ +


40/51

# $ %&'()*#+ ,-. /+

0

1 2

3.

!"#$% )'& +*"( /0).-, 1#234 6,5)

7(8!9+:,";< =9(,";>? A3(@ BC1DC


41/51


42/51

H#,(( 2#% , "( I6 1), , JK %

2

34

"

J? C10 L

,

M

.

,"N

OPM16,";

@/#/Q#.(/4 '(RSA4 O%2 TU,V5V S,6W #N >E ,)' "X A4 O"V

@ )"9#ZY6+ (>75RNG >T,#1,)#")]? F!A\@ 2)"9#ZY TU,V5V !G"#)]G?

/0 /9#.^ @$.A4 O13H1)' M"/0 R]#N ,NS1 Y"9#Z(2 TU,V5V #N 75"X1K"X5F;".( >< 4 )#" _A4 O_M% %` L(#_% ,3 5 Y )"9#Z 2 TU , V5V !a"\A > D! %` F;'(2"! /4 E#

@DS9#$

( 4


43/51

( 0 560 7&4';:+ ,38. 9#*(

(BhK% ,9(aJP"2D4 /4 MiR(> RS%

> , )' A 4 4 10.? # P[D3U F; (/J(N

%Z W#3 L)' >& !? A4

jhK% DkNj l 4 "hK DkN % FN!O %6j10hK"N MM# DkN

E(0 W.KP[D3ENK#_A4 O/UL6E

(0

)

N

; E (m#

a

J#

2

k0

F "(3BL ? /0 >. .3 1, P!1> /J(N

L)' M0 C1Z#_0 /J:#_.KL >< 2_B) N;aJ#,D3 *"", D# /4

@"n#&% C,N"X

R* U

* 4 L


44/51

) R*# , 6"?" P[D3U E*? ,A4 O "Y L6 "nD 5n*? o [3 F "(KN p( R*? > 1R .K 1 1, P!1 aJ# ] G?

nT 0n e P l 6#+ 2 4 TU!q!F0 P[D3U)'@

>U P13 C10H l 6#+ 4 hKL6

l5$ 5N B nT 0n e rZQ !? ,G, EG!1


45/51

P[D3 , 4/ 36N '( >


46/51

( >-N , "X 1 P L O,N L6 4 M" LG #0 ]G z"6N ^ 1 38 ^ 1 50 L6 C? B2X

D< {QN C10 , 6> C10 2(XR( ff H$U P[D3U ?.(#ff Bpff( ff_!

@ P[D3C",*_N

? R ,"X1 1 P S


47/51

; ( > 04,"8+ :9!=0

> W.KP[D3F"(3 ENK#_A4 \AhKO/U"6,@ Do F"(3 D"4 M0

0 , 6"?" P[D3U R , ?* K< h\ O, "Y

P!1 aJ# ]G#p( ) R*#" n(? Do

n0

e P

+

6#

R

.K

1

,

1

6, !FP[D3 @ hK"jnT/

4 ,3

6N

.K

>

@D'

,N.?!M 5_F(K8;( z6N

t P13 ,J1}~} O#!J0 !1S yf

R3[0 1"N 2 Q(>.(P1"0"k#? t by)/ ? D0M#= _UN B4 y=t

b(lmn? N 9( /; ( O


49/51

.D(G ? DJ0 l D750 % Lk0 O);/)-N >N9>T.\ALY@ 1? #L5$ P? P= N D#JK!1#D#J"_ ),DNQ % 750T l"n6% Q#J(

L5$ PP1De@ NEFR_R< DEQP[

N

9(

[email protected] LY\p"QDC)9= n"T R% 6/0 n?3 %/0 !1M2 %"l 6/0 11QlZN

@:LN 6#%G E"8,NS4 \N 19P(#.(,"? J );/)N >N96%

@ ,("_ ^ 1 o[ 38 N 2' N F )N ,NS4 p:, M), PQG RY()' , 0 C? ="X0!M %4#JaP"/4 =GP"v"&\ (D:"J"0 c#C kD*

N' ;6 6% RY1Q? 4 DJ/"P@>. @IMJ 6

+

L


50/51

IC 0= / + &0 J&K L: M ID' '"? N "

/0 2 Q ,NG 6, "X > ? 2 TU #)1

/0 \A >1(# (< @,DNQ( T l"n6%>& LY( R"_ / @LK( ,"9ZQ D?$L5$ P N D#J? 75 ) , C1 >T_ 8 N'A /0 2JN\!*"(&-*Z#H0 P!M9p!#N P!M92#,"(I6,(1,JK

2~{ Q,N f#eET


51/51

,HA

Date post:	27-Feb-2018
Category:	Documents
Upload:	doha-ebed
View:	213 times
Download:	0 times

Cpr Ethics

Documents