Abstract

Challenging issues confront emergency physicians routinely when performing cardiopulmonary resuscitation. Ethical issues surrounding resuscitation may include issues of futility, withholding or withdrawing interventions, advance directives, family presence, practising procedures on the newly dead, palliative care, and communication.Ethical Aspects of Resuscitation in Nursing.

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Principles of bioethics can be valuable in assessing and debating ethical dilemmas. In many cases where curative care is not possible or is not desired, the goal of medical care at the end of life is to provide comfort to the patient and family, rather than initiating technological interventions that are unlikely to benefit the patient.Ethical Aspects of Resuscitation in Nursing.

Challenging issues confront emergency physicians routinely when performing cardiopulmonary resuscitation (CPR). Principles of bioethics can be valuable in assessing and debating ethical dilemmas. Some of the important issues and dilemmas commonly encountered in emergency medicine are discussed. In many cases where curative care is not possible or is not desired, the goal of medical care at the end of life is to provide comfort to the patient and family, rather than initiating technological interventions that are unlikely to benefit the patient.Ethical Aspects of Resuscitation in Nursing.

PRINCIPLES OF MEDICAL ETHICS

Ethics has been defined as the way of understanding and examining the moral life, and as a theory or a system of moral values. Codes of medical ethics have been established by organisations or individuals as standards of moral and ethical medical care. The Hippocratic Oath is considered one of the oldest codes of medical ethics. In recent years, the American Medical Association (AMA) Code of Ethics (earliest version from 1847), The American College of Emergency Physicians (ACEP) Code of Ethics (1997), and The Society for Academic Emergency Medicine Code of Conduct (1999) have been established to provide guidance to physicians in application of ethical principles to clinical practice. Most ethical codes address common elements, such as beneficence (doing good), non-maleficence (doing no harm), respect for patient autonomy, confidentiality, honesty, distributive justice, and respect for the law. Ethical dilemmas often arise in clinical practice when there is a real or perceived conflict between two ethical principles or values. Ethical dilemmas are resolved by several approaches, which may include elements such as physician judgment, additional information gathering, meetings with health care professionals, patients, and families, and consultants, such as ethics, risk management, or social work consultants. Although the involvement of the institutional ethics committee or the judicial system is helpful in many clinical settings, decisions at the end of life often do not permit the time necessary for such consultations.Ethical Aspects of Resuscitation in Nursing.

RESUSCITATION

At the end of life, attempts at CPR are commonly performed. In many cases, this is appropriate and has a reasonable likelihood of improving outcome. However, in many other cases where the patient is near the end of life, resuscitation attempts are unlikely to benefit the patient, and may not be in accordance with the values and treatment goals of the patient and family. Understanding the literature regarding resuscitation, outcomes, factors relating to outcomes, and alternatives, are essential to medical decision making regarding resuscitation.Ethical Aspects of Resuscitation in Nursing.

There are numerous ethical issues related to resuscitation. Decisions must be made rapidly, and decisions are often based on information available to the emergency physician, which may be incomplete or erroneous. When making decisions in the resuscitation arena, many factors must be considered, including potential benefits of resuscitation (restoring life to the patient, a sense of closure and resolution of guilt for the survivors) and potential risks (financial and resource investments, resuscitation to a suboptimal quality of life, etc).Ethical Aspects of Resuscitation in Nursing.

Making decisions about end of life in acute care is intricate, involving hard decisions, such as whether to initiate cardiopulmonary resuscitation (CPR) or whether to discontinue or initiate life support in the event of a cardiac arrest.  Do not resuscitate decisions are commonly made in healthcare but they can be a source of legal challenge and ethical concern. The paper analyzes do not resuscitate as an ethical issue related to the end of life issues.Ethical Aspects of Resuscitation in Nursing.

A description of a specific scenario

Mrs. is a 35- year- old woman with multiple myeloma who started to experience acute pain in her lower abdomen. At noon, Mr. M’s husband took her to the ED for diagnosis and treatment. Mrs. M was diagnosed with acute appendicitis.  Mrs. M. stated that CPR should not be initiated in case he suffers a respiratory or cardiac arrest.  When Mrs. M’s chart was brought to the ED, it did not contain a DNR order and Mrs. M was adamant she should not be resuscitated. Mrs. M’s husband insisted that Mrs. A was critically ill but had two small children and they needed to be with her during his remaining time on earth and thus the doctors should ignore her verbal order.  The ethical dilemma is: If Mrs. M’s heart stops beating or she stops breathing, should CPR be initiated?

Stakeholders who should be involved in the decision-making process

The stakeholders who should e involved in the decision-making process include the surgeon, patient, family, primary team, an anesthesiologist. Ideally, a discussion should first be held between health care providers, followed by a meeting with the patient/family and team, and also any supportive personnel like a chaplain. According to Ciric et al. (2017), individuals have moral and legal rights to be engaged in making decisions regarding them and the question of not initiating CPR must be discussed with the patient. Even though relatives do not have a legal right to decide, it is important to include them in the decision.Ethical Aspects of Resuscitation in Nursing.

Analysis of the decision, the Alternatives and Consequences/Option A versus Option B for what should be done

CPR should be initiated for an individual experiencing pulmonary or cardiac arrest if there are no specific contradictions, like the presence of a Do Not Resuscitate (DNR) order.  If there is no DNR order, not taking resuscitation measures is subjected to judicial and ethical discretion. If there is proof that there is a chance of a patient surviving, failure to initiate CPR can lead to a suit for a criminal offense. As such, health institutions are obliged to offer all the essential equipment to perform CPR (Ciric et al., 2017).Ethical Aspects of Resuscitation in Nursing.

If a DNR order is present, nurses and other health professionals are not legally empowered to perform CPR even when they are aware that the case is medically futile. According to Kharis (2016), for critically ill patients,  CPR might work only partially or might not function, leaving the brain of the patient damaged or in a worse medical condition. In such events, some patients prefer receiving medical care without invasive efforts.   Fritz (2017) emphasizes that CPR is an invasive medical procedure that is not intended to be provided to individuals who have an irreversible condition.  Do not resuscitate decisions offer a scheme of communicating when a patient should be given CPR, either because it has minimal chance of success or because the patients do not want it. They are crucial schemes for safeguarding patients from harm.Ethical Aspects of Resuscitation in Nursing.

Action as a Resolution of the dilemma

I would resolve the dilemma by reaching a consensus with the patient and her family about the care and treatment that would be beneficial to the patient.  I would provide the patient and her family detailed information about the drawbacks, and benefits of CPR.  Although the patient has the autonomy to make the decision not to be resuscitated, I would explain its implications and attempt to emphasize its outcomes. If the patient understands the implications of withholding CPR, I would require her to sign the DNR order even if it is against the will of her relatives.Ethical Aspects of Resuscitation in Nursing.

Conclusion

Do not resuscitate decisions are commonly made in healthcare but they can be a source of ethical cancer. Do not resuscitate decisions offer a scheme of communicating when a patient should be given CPR, either because it has minimal chance of success or because the patients do not want it.Ethical Aspects of Resuscitation in Nursing.