Ethics and cardiopulmonary resuscitation


Introduction

Ethics is considered a philosophical discipline that deals with the study of morality, morally
relevant behavior and its norms. Furthermore, the principles that guide a person's actions in
situations where there is a choice based on free will are examined. Human activity is evaluated in
terms of good and evil (1).

A specific area is medical ethics. It examines the morale and attitude of healthcare professionals
towards the patient.

One of the ethical dilemmas concerns cardiopulmonary resuscitation. In particular, the rescue
service's outgoing crews deal with these issues regularly in contact with the critically ill and
his family.


Ethical principles

The basic ethical principles include:

Non-maleficiency - the principle of harm. If the doctor is not able to treat him properly, he
should not hurt. Damage to the patient includes poor diagnosis, incorrect treatment and therapy,
poorly performed surgery. In the Czech environment, depersonalization of a patient is often
considered damage to the patient, when the patient is considered an object or thing. It is correct
to note that the patient's injury is usually not intentional but due to staff negligence.

Benefication - the goal of the principle is to do good to the patient. The basis of the modern
approach is an individualized ad hoc approach to each patient's situation. A question related to
the topic of the work arises - is it better to preserve the patient's life against his will, or to
respect his autonomy?

Autonomy - the essence of the principle is that the doctor and the patient are partners. Together,
they ideally agree on the next steps. A possible alternative to the principle is the paternalistic
approach of the physician. It is approached in situations where the patient does not accept another
approach.

Justice - the principle of justice in a simplified form deals with the necessary respect for the
environment, which may be affected by my illness, eg during infections. It is up to the doctor to
explain this rule, or it is possible to use existing legislation. Part of the principle is the
so-called right to health care, if the company (state) declares it by law (2, 3, 4).




History of ethics

Medical ethics comes from ancient civilizations. Mentions are in ancient documents, or eg the
Hippocratic Oath. The documents focused mainly on the characteristics of health care providers and
the relationship between doctors and patients. In modern times, ethics is strictly assessed about
cases of ignoring ethics and patients' rights, especially in the last century (5).


Cardiopulmonary resuscitation

Cardiopulmonary resuscitation is a set of consecutive actions that lead to the immediate resumption
of oxygenated blood flow through the brain in the event of a failure of basic vital functions.

We distinguish two types of emergency resuscitation. Basic and advanced. Basic resuscitation is a
simple procedure without the need for additional specialized aids and is performed by witnesses of
the incident. Extended emergency resuscitation is then reserved for professional resuscitation
teams with specialized equipment (6).


The first "European" guidelines were issued in 1992 to unify resuscitation efforts. The main
principle of issuing these uniform procedures is to ensure adequate care for all patients in
civilized countries. Guidelines are based on evidence-based practice. The individual links describe
in detail the procedures in the individual age categories and are regularly updated. The
recommended procedures also include chapters referring to medical ethics in connection with
emergency resuscitation (6).


Ethics in emergency resuscitation

The guidelines issued by the European Resuscitation Council refer to ethical guidelines for use in
end-of-life decision-making by children and adults on the following points:


Patient preferences and treatment decisions

- Using a joint decision - doctor + patient to plan future treatment. This increases the agreement
between the treatment provided and the patient's expectations.

- Actively plan future care for all patients who are at real risk of cardiac arrest and subsequent
low quality of life after successful emergency resuscitation.

- Support the planning of further care at the request of the patient.

- actively record the future care plan through electronic records and registers.

- specify individual steps in care plans, eg securing the airways. The goal is to reduce
misunderstandings and prevent unwanted failure to provide treatment where indicated.

- Cardiopulmonary resuscitation should not be provided by healthcare professionals if they deem it
in vain.


Improving communication

- Healthcare professionals should be trained in communication and be able to communicate adequately
with the patient when communicating bad news.

- It is necessary to provide information about the patient's poor prognosis and health truthfully
and honestly.

- It is advisable to involve family members in the discussion on the plan of further care.

- the possibility of recording interview records for retrospective review and analysis is
recommended.


Deciding when to start and when to stop cardiopulmonary resuscitation

Withholding and Withdrawing CPR

- Cardiopulmonary resuscitation should be considered a conditional treatment by the public and
healthcare professionals.

- Criteria for not starting or ending cardiopulmonary resuscitation must be included in accordance
with legislation and cultural practices.

- Clear and measurable criteria must be established for not initiating or terminating emergency
resuscitation. A specific factor is a previously expressed wish. The recommended procedures define
criteria that are not a separate reason for not starting or ending emergency resuscitation.

- each case of non-initiation or termination must be recorded in the medical records. these cases
should be reviewed retrospectively.

- A specific group of patients are indicated for transport during continuous resuscitation to the
hospital.

- The Guidelines make it clear that health professionals should not be involved in so-called "play"
resuscitation. E.g. poor emergency resuscitation, resuscitation for social reasons.

- In times of pandemic, it is necessary to consider the use of specific resources with regard to
their availability. The quality of life of a patient with successful emergency resuscitation must
be considered. Evaluation criteria must not be general, such as the patient's age.


Family presence during resuscitation


The resuscitation team should consider the presence of the family during an ongoing emergency
resuscitation if the family expresses an interest. At the same time, it is necessary to set aside
one member of the resuscitation team, who will be available to the watching family. Healthcare
professionals must be trained to communicate with family members during emergency resuscitation.


Patient outcomes and ethical considerations


Healthcare systems should evaluate the emergency resuscitation performed and take steps to reduce
system variability. Emergency resuscitation research should have a clearly defined data set (7.8).
The quality of emergency resuscitation is monitored on a long-term basis. The Czech Republic was
part of an extensive study evaluating the results of emergency resuscitation. The results achieved
by the rescue services in the Czech Republic are very positive and in many criteria exceed the
expected values ​​(9).


Previously expressed wishes and Do not resuscitate (DNR)


Do not resuscitate is indicated by the attending physician based on an evaluation of quality of
life and expected treatment outcomes. If intensive care is not promising or the patient's expected
quality of life is very low, a decision is made in consultation not to initiate emergency
resuscitation in the event of a failure of vital functions. As mentioned above, all treatment
should be effective. Recently, the COVID19 pandemic may have a higher incidence of DNR indications
due to insufficient hospital capacity (10).


The previously stated wish is relatively new in the Czech legal context. In the Health Services Act
no. 372/2011 Sb. it states that "the patient may, in the event that he or she finds himself or
herself in a state in which he or she is unable to express consent or disagreement with the
provision of health services and the way in which they are provided, give his or her prior
consent". At the same time, it is forbidden to discontinue such treatment if it leads to the death
of the patient, unless a previously stated wish has been known and substantiated and treatment has
already begun. It is possible to make a previously expressed wish even before the performance
itself. This will be done before the witnesses, the entry in the medical records and the witnesses
will sign the declaration.



Hollywood resuscitation

Unofficial name for resuscitation, which is provided by professional teams. This resuscitation is
ineffective, playful and feigned. Why do resuscitation teams do it? The main reason is reassuring
the family that everyone is trying to save human life. Another reason may be the effort to avoid
confrontation of the family and surroundings, that the effort to resuscitation is not enough.
Communication and communication of annoying messages are also a problem (9). Does mock
resuscitation happen today? Yes, it's happening. It was yesterday, it is today and it will be
tomorrow. Although this is contrary to the rules set out above and against ethics, the elimination
of this theater is unlikely. Data is missing, nobody brags about it.

From the second point of view, if we imagine a situation where a layman provides quality emergency
resuscitation in an effort to save a human life, the rescue crew arrives and says immediately that
it does not make sense. Result? Absolute demotivation for the lay savior. He tried, the
professionals wouldn't even try. Isn't it better to play resuscitation for a while?


Conclusion

Ethics and medical ethics are very extensive scientific disciplines. Their development has been
going on for thousands of years and is still not over. The essay deals only with the marginal part
of ethics - ethics in cardiopulmonary resuscitation. The rules are based on Guidleines, which are
regularly updated and expanded. Nevertheless, there are debatable chapters that can be considered
unethical from one point of view, and at the same time motivational for the surroundings.


References

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Petr Matouch, M20871