Ethics and Law in Resuscitation

On November 17th and 18th 2001 a congress on “Ethics and Law in Resuscitation”
was held in Krakow (Poland). It was a joint scientific meeting of the European
Resuscitation Council and the Polish Resuscitation Council, which was launched
during the opening of the symposium. The scientific programme covered several
important ethical and legal aspects in resuscitation. Some of the outstanding
presentations of the congress are summarised below.

“Protection of human rights and dignity - is there a common European way?”

Yes, at least in principle, stated Kettler (Goettingen, Germany) in his lecture and
demonstrated that the Council of Europe has set a unique framework to protect
fundamental freedoms and human dignity. The Council’s most significant
achievement is the European Convention on Human Rights which has come into
force in 1953. It sets out the inalienable rights and freedoms of each individual and
obliges states to guarantee these rights to everyone within their jurisdiction.
Corresponding to this basic document, since 1999 the Parliamentary Assembly of the
Council of Europe is dealing with a paper called “Protection of the human rights and
dignity of the terminally ill and the dying”. Kettler cited the recommendation of the
Assembly that the Committee of Ministers encourages the member states of the
Council of Europe to recognise and protect a terminally ill or dying person’s right to
comprehensive palliative care. This includes appropriate palliative care, ambulant
hospice teams and networks, inter-professional co-ordinated teamwork, adequate
pain relief, development and implementation of quality standards, research and
training, and establishment of palliative medicine in public awareness. Respect and
protection of the d ignity requires to respect the right of self-determination and to
uphold the prohibition against intentionally taking the life of terminally ill or dying
persons. Kettler underlined that the general framework given by the Council of
Europe offers only a certain range of interpretation, leading to different views on the
level of national legal systems. In particular, the opinions on the value of self-
determination are differing fundamentally throughout Europe. Nevertheless, though
the common European way is rather broad and with several options for deviations, it
seems to lead into the right direction.
Every competent patient has the right to say “keep your hands off”, as Steen (Oslo,
Norway) pointed out in his lecture on “Patient self-determination and surrogate
decision-making”. The right to refuse treatment persists even if life -threatening
cardiac arrest occurs. However, certain requirements have to be met to qualify a
decision as competent: the patient must be fully informed, should understand the
information and the consequences of the options, should be free from external
pressures and consistent in his or her treatment choices. But patients are allowed to
change preferences, and people rapidly alter perception of quality of life and CPR
preferences with varying health condition. If competence is compromised, close
relatives or friends can become surrogate decision makers. Unlike living wills,
surrogate status applies to all situations with incompetence. Steen reported that the
legal situation of surrogates varies with country and with time. Surrogate decisions
should be based on previously expressed patient preferences, but in many instances
these are not known or not reflected by the surrogates. Advanced directives might
help to adjust the patient’s preferences, even in cardiac arrest when the situation
gives the physician an urge to act. Advance directives offer patients the opportunity
to express their thoughts and preferences for end-of-life care. Steen criticised that
many people do not wish to discuss advance directives or CPR. People rarely plan
for future illness, and therefore, physicians do not know how to act in the patient’s
best interest. With regard to withholding resuscitative efforts there is no or only little
correlation between patients’ preferences and physicians’ decision just by intuition.

In his lecture on “Stress overload by CPR providers in emergency medicine

practice ” Jakubaszko (Wroclaw, Poland) pointed out that in last few years a lot of
evidence has accumulated dealing with stress and traumatic stress experiences in
emergency medicine practice. Every year, one hundred thousand rescuers in Poland
face the danger of death or physical injury in the line of their duty. Those people who
experience severe or long-lasting stress often have symptoms and problems
emerging afterwards.
Stress is a generic term that refers to the temporary adaptation process that is
accompanied by mental and physical symptoms. Sources of stress in emergency
medical practice may include long hours of enduring work with little recognition,
having to respond instantly, making life-and-death decisions, fearing serious errors,
dealing with dying people and grieving survivors, and last but not least great
responsibility for lives of survivors.
Most rescuers experience normal stress reactions to such strains for several days or
weeks, which may include emotional reactions of fear, guilt, grief, anger, irritation,
helplessness, feeling numb or having diminishe d interests and pleasure; cognitive
reactions of confusion, disorientation, shortened attention span, and difficulty
concentrating; physical reactions of fatigue, tension, insomnia, edginess, and being
easily startled or becoming overly alert.
But those rescuers – police and fire fighters, emergency medical technicians, and
physicians – who may find themselves suddenly in danger are overcome with
feelings of fear, helplessness and guilt. In most instances these are normal reactions
to abnormal situations but as many as one in three rescuers may feel unable to
regain control of their lives and experience severe symptoms, what in turn may lead
to lasting PTSD, anxiety, or depression. Some common traumatic experiences
include multiple casualty incident, serious injury or death of a child, injury or death of
a co-worker, providing emergency care to a relative, abuse and neglect of infants and
children, severe traumatic injury and amputation, intense media tension to an
accident.
Particular symptoms may begin soon after the traumatic experience. The main
symptoms are re-experiencing of the trauma and avoidance of trauma reminders
(extreme attempts to avoid disturbing memories), accompanied by dissociative
reactions (feeling completely unreal or outside, like in a dream), extreme emotional
numbing, severe anxiety (paralysing worry, compulsions or obsessions). Together
with physiological this may result in a problem called posttraumatic stress disorder.
Re-experiencing means that the rescuers continue to have some mental, emotional,
and physical experiences that occurred just after the traumatic events or soon after.
They are thinking about the trauma, seeing the horrific images, feeling agitated and
having sensations like those occurring during the event. The results of such exposure
may lead to complex symptomatology in fo rm of behavioural and adjustment
disorder, or more severe, of posttraumatic stress reaction.
How serious the symptoms and problems are afterwards depends on many things
including a person’s life experiences before the trauma, a person’s own ability to
cope with stress, and what kind of help or support a person gets from family, friends,
or professional mental health assistance.
It is most essential to recognise and relive stress reactions. Managing of stress may
include attending a debriefing. It helps the rescuer to talk about feelings as they
arise. Additionally, it gives the needed recognition and appreciation for a job well
done. Chronic and unrelieved stress may lead to a burnout syndrome, a state of
exhaustion of physical or emotional strength decreasing the professional
effectiveness. It may be considered as a final stage in a breakdown in adaptation that
results from the long-term stress, and includes the development of dysfunctional
attitudes and behaviours towards patients, the job, and the organisation.

Medical staff should be prepared for ethical dilemmas related to resuscitation.

Compromised patient’s competence, no informed consent, the refusal of medical
interventions, or surrogate decision making are common in emergency situations.
The staff should know how to think quickly through ethical conflicts. Therefore, there
has to be an education in bioethics. In their lecture on “Training in ethical and legal
matters – what has been done, what should be done ?”, Bahr and Mohr
(Goettingen, Germany) presented a brief analysis of the actual situation in Europe.
Their survey was based on a questionnaire which had been sent around via e-mail to
the members of ERC’s executive committee, and colleagues from seven different
countries replied. In four of the seven countries the topic “ethical and legal matters” is
included in the curriculum for medical students, in two not, and one colleague did not
know. The topic is mostly included at an advanced stage, third to fifth year of the
curriculum. In one country students deal with the topic even each year. Besides
general aspects the training includes subjects such as informed consent, limitations
of medical intervention, DNR-decisions, and family participation. Involved in teaching
are mostly physicians from various specialities, occasionally experts in medical ethics
and philosophers. Legal matters also are included in the curriculum for medical
students in four out of the seven countries, in two not, one did not know, and again
mostly at an advanced stage. The training subjects were reported from two countries.
They include questions like certification of death, identification of causes of death,
insurance matters, euthanasia, and abortion. The uniform answer to the question
whether the topic “ethical and legal” matters” is included in the curriculum for young
doctors has been “no”. However, alternative activities were reported: Voluntary
postgraduate mastership courses (in two countries), case discussions during ward
rounds, or activities during ERC courses and congresses. The experts participating in
this short survey rated the topic “ethical and legal matters” as rather important in the
context of continuous medical education, and six out of seven felt that there is a need
for improving the training. Based on the results of their questionnaire, Bahr and Mohr
gave some suggestions how to extend the educational process. Mentors amongst
elder doctors would be favourable, as well as written guidelines on specific topics, for
instance the ethical aspects of CPR. Closed discussions should take place, focussing
on common clinical problems. Scenarios should be used to develop decision-making
capability and to show that ethical knowledge is useful in daily practice. Since ethical
competence in emergency medicine remains a c ommitment to lifelong and
continuous education, the topic “ethical and legal matters” should be included in the
curriculum of all specialities as mandatory.

The historical development of resuscitation policies in the context of philosophical,

legal, ethic al aspects and the current necessity of standardisation of resuscitation
policies in Poland according to the new International Guidelines 2000 was presented
by Andres (Krakow, Poland). He suggested that the definition of life from the medical
and legal point of view may need more precise description and diagnosis of death
might be difficult in acute resuscitation scenarios. Problems of the „level” of life after
resuscitation and „dissociated” character of death were mentioned in his lecture. We
often are doing everything to stop the dying process (dysthanasia), but when
everything possible has been already done, do we need to use extraordinary means
or let the patient die (ortothanasia).

There are never enough means to finance everything that is feasible and desirable.
In his lecture on “Cost implications of resuscitation” Bahr (Goettingen, Germany)
pointed out that concerning health care systems the limited financial resources in our
societies have a special dimension, since health is one of the greatest goods.
Therefore, talking about cost implications of resuscitation needs to talk about cost
implications of the entire health care system. If there is not enough money for
everything, then we have to talk about allocation and rationalisation. Rationalisation
is neither good nor bad. The objective is that there is enough for other – potential –
patients as well who also have the right of being treated appropriately. From an
ethical point of view rationalisation in a health care system is permitted and –
furthermore – necessary, having in mind the principle of justice.
Rationalisation may be direct. This means that there are effects on the concrete
case. The contrast is an indirect rationalisation, aiming at the statistical or potential
patient. Of course actual duties always are more important than potential duties, and
it would be ethically not acceptable to withhold any actual obligation only to keep the
chances for a potential one. From an ethical point of view we have to state that
rationalisation may never be carried out on an actual patient.
Rationalisation is called strong when it is impossible to purchase compensating
health goods, whereas a weak rationalisation includes the possibility for individuals to
buy health care goods for compensating the effects. Rationalisation is called open if it
has been made transparent by broad social processes and, thus, can be accepted
more easily. Covered rationalisation is intransparent and cutbacks have not been
discussed.
The distress belonging to the decision-making process in rationalisation can only be
coped with in a human way if the decision is shifted to the planning level, far away
from the concrete patient. So the decision does not affect an individual patient but
only the probability for all members of society to die earlier because a specific
therapy is not available. It is not inconsequent to reject an investment as long as only
statistical lives are affected; probabilities have a price. An individual human life has
no price, and in case of danger each individual life has to be saved. Bahr
demonstrated the potential consequences of rationalisation by an example related to
resuscitation: If you are resuscitating a concrete patient you have to bring into play
every means you have in trying to save this patient’s life. But if the next day you are
asked by your government whether a certain amount of money should be spent for
buying new devices, that it would be justified to say no in favour of for example a
prevention programme.

Ethical and legal aspects of resus citation are also in the centre of Christian`s
reflection. In the last paper of the symposium on „Religious Aspects of
Resuscitation” Fr. Muszala from the Institute of Bioethics at the Papal Academy of
Theology in Krakow presented the problem from the point of view of Catholic ethics.
The Christians, according to God’s order „Thou shalt not kill” have always taken great
care of human life, especially in the state of danger and dying (e.g. in the parable
about Good Samaritan). Also today the Catholic Church pronounces „the Gospel of
Life” and appeals to respect, defend and serve the life. In the matter of resuscitation
there are some important texts contained in the declarations (Iura et bona, 1980, and
Dichiarazione circa il Prolungamento,1985) containing fundamental theses of
Catholic bioethics referring to the subject. Everyone has the duty to take care of his
own health and take the treatment. Those who look after the sick should use
„proportional” means, i.e. the ones that are widely used, give hope for success and
are not followed with non-proportional costs that would give little chance for success,
and are applied in the just way. A physician is not obliged to use extraordinary and
non-proportional means; in such cases he should adjust to the will of the sick. In the
last part the speaker noticed the significant role of the spiritual father who cares of a
patient’s soul just as much as physicians care of his body. The final goal of human
being is to enter the heavenly kingdom, and a physician is not obliged to save the
patient’s life „at any price”; a person leaving this world has the right to live his death
in such a way as he wishes, surrounded by his relatives and spiritual father.

At the Krakow meeting a rather new but very much live experience how to attract an
audience to the sometimes rather abstract issue of ethics were three so called
“What-If-Sessions”. The chairmen Baskett (Bristol), Bossaert (Antwerp) and Mohr
(Goettingen) had prepared some histories and presented in a step by step fashion
cases from the resuscitative and intensive care scene. The audience was taken
through the different scenarios and was asked at various points what they would do.
The participants had the opportunity to express and to discuss different suggestions
how to proceed. The questions put to the audience led to spontaneous answers and
to an enthusiastic and sometimes controversial discussion. The topics covered in the
“What-if-sessions” were to start or not to start, to stop or not to stop CPR, futility
factors in DNAR, Jehovah’s witnesses, under age consent for operation, under age
organ donation, withholding or withdrawing treatment, and palliative care on the ICU.
The format of the interactive “What-If-Session” was a very positive experience and
seems to be worthwhile to be continued during future meetings.

All of us who joined the congress in Krakow had the feeling that the meeting was a
great success. It marked the start of the Polish Resuscitation Council, and the
discussions on ethics were very interesting and stimulating. Some of the scientific
material might be included in the ERC 2002 congress in Firence.
Authors:
Mohr M1 , Bahr J1, Kettler D 1, Andres J 2
1
Dep. of Anaesthesiology, Intensive Care and Emergency Medicine
University Hospital of Goettingen
2
Dep. of Anaesthesiology and Intensive Care Medicine
University Hospital of Krakow