RESUMEN
We describe a request for CPR without chest compressions from a patient's daughter. Requests for partial codes raise numerous clinical concerns, including lack of evidence-based effectiveness, risk of medical error, and difficulty in communication. These in turn lead to ethical concerns, including a misapplication of respect for patient autonomy, violating the foundational principle of "first do no harm," and inconsistency with the tenets of shared decision-making. Many requests for partial codes are also based on a conflation of cardiopulmonary arrest and pre-arrest emergencies. We argue physicians have no ethical obligation to honor a request for a partial code and that doing so does not violate respect for patient autonomy. Requests for partial codes should be seen as a request for information about CPR and an invitation to conversation. We also report here the move our health system made to only offer evidence-based code status options and reject those with negligible likelihood for therapeutic benefit. This work included limiting options for code status to "Full Code" or "Do Not Attempt Resuscitation," creating an order set for non-arrest emergencies, and sample language to guide physicians in responding to requests for partial codes. To assist other hospitals or health systems considering this move, we provide the content of the order set for non-arrest emergencies and the sample language guide.
Asunto(s)
Reanimación Cardiopulmonar , Cuidados Críticos , Errores Médicos/prevención & control , Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/psicología , Códigos de Ética , Cuidados Críticos/ética , Cuidados Críticos/psicología , Cuidados Críticos/normas , Toma de Decisiones Conjunta , Humanos , Órdenes de ResucitaciónAsunto(s)
COVID-19/prevención & control , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Equipo de Protección Personal , Resucitación , Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/instrumentación , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/ética , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/legislación & jurisprudencia , Máscaras/ética , Máscaras/normas , Máscaras/provisión & distribución , Equipo de Protección Personal/ética , Equipo de Protección Personal/normas , Equipo de Protección Personal/provisión & distribución , Resucitación/ética , Resucitación/instrumentaciónRESUMEN
PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has raised a variety of ethical dilemmas for health care providers. Limited data are available on how a patient's concomitant cancer diagnosis affected ethical concerns raised during the early stages of the pandemic. METHODS: We performed a retrospective review of all COVID-related ethics consultations registered in a prospectively collected ethics database at a tertiary cancer center between March 14, 2020, and April 28, 2020. Primary and secondary ethical issues, as well as important contextual factors, were identified. RESULTS: Twenty-six clinical ethics consultations were performed on 24 patients with cancer (58.3% male; median age, 65.5 years). The most common primary ethical issues were code status (n = 11), obligation to provide nonbeneficial treatment (n = 3), patient autonomy (n = 3), resource allocation (n = 3), and delivery of care wherein the risk to staff might outweigh the potential benefit to the patient (n = 3). An additional nine consultations raised concerns about staff safety in the context of likely nonbeneficial treatment as a secondary issue. Unique contextual issues identified included concerns about public safety for patients requesting discharge against medical advice (n = 3) and difficulties around decision making, especially with regard to code status because of an inability to reach surrogates (n = 3). CONCLUSION: During the early pandemic, the care of patients with cancer and COVID-19 spurred a number of ethics consultations, which were largely focused on code status. Most cases also raised concerns about staff safety in the context of limited benefit to patients, a highly unusual scenario at our institution that may have been triggered by critical supply shortages.
Asunto(s)
COVID-19 , Instituciones Oncológicas , Consultoría Ética/tendencias , Neoplasias , Órdenes de Resucitación/ética , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales , Reanimación Cardiopulmonar/ética , Niño , Toma de Decisiones , Comités de Ética Clínica , Femenino , Asignación de Recursos para la Atención de Salud/ética , Neoplasias Hematológicas , Humanos , Unidades de Cuidados Intensivos , Intubación Intratraqueal/ética , Neoplasias Renales , Neoplasias Pulmonares , Masculino , Inutilidad Médica , Competencia Mental , Persona de Mediana Edad , Mieloma Múltiple , Ciudad de Nueva York , Salud Laboral/ética , Habitaciones de Pacientes , Autonomía Personal , Apoderado , SARS-CoV-2 , Sarcoma , Adulto JovenRESUMEN
The unprecedented for modern medicine pandemic caused by the SARS-COV-2 virus ("coronavirus", Covid-19 disease) creates in turn new data on the management and survival of cardiac arrest victims, but mainly on the safety of CardioPulmonary Resuscitation (CPR) providers. The Covid-19 pandemic resulted in losses of thousands of lives, and many more people were hospitalized in simple or in intensive care unit beds, both globally and locally in Greece. More specifically, in victims of cardiac arrest, both in- and out- of hospital, the increased mortality and high contagiousness of the SARS-CoV-2 virus posed new questions, of both medical and moral nature/ to CPR providers. What we all know in resuscitation, that we cannot harm the victim and therefore do the most/best we can, is no longer the everyday reality. What we need to know and incorporate into decision-making in the resuscitation process is the distribution of limited human and material resources, the potentially very poor outcome of patients with Covid-19 and cardiac arrest, and especially that a potential infection of health professionals can lead in the lack of health professionals in the near future. This review tries to incorporate the added skills and precautions for CPR providers in terms of both in- and out- hospital CPR.
Asunto(s)
COVID-19 , Reanimación Cardiopulmonar , Paro Cardíaco , Salud Laboral , COVID-19/mortalidad , COVID-19/prevención & control , COVID-19/transmisión , Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/normas , Paro Cardíaco/terapia , Paro Cardíaco/virología , Humanos , Exposición Profesional/prevención & control , Salud Laboral/ética , Salud Laboral/normas , SARS-CoV-2RESUMEN
ABSTRACT Objective: To reflect about the do-not-resuscitation order at COVID-19 in Brazil, under bioethical focus and medical and nursing professional ethics. Method: Reflection study based on the principlist bioethics of Beauchamps and Childress and in professional ethics, problematizing actions, and decisions of non-resuscitation in the pandemic. Results: It is important to consider the patient's clinic, appropriation of treatment goals for people with comorbidities, elderly people, with less chance of surviving to resuscitation, or less quality of life, with the palliative care team, to avoid dysthanasia, use of scarce resources and greater exposure of professionals to contamination. Conclusion: COVID-19 increased the vulnerabilities of professionals and patients, impacting professional decisions and conduct more widely than important values such as the restriction of freedom. It propelled the population in general to rethink ethical and bioethical values regarding life and death, interfering in decisions about them, supported by human dignity.
RESUMEN Objetivo: Reflexionar sobre el orden de no reanimación en COVID-19 en Brasil, bajo enfoque bioético y ética profesional médica y de enfermería. Método: Estudio de reflexión basado en la bioética principialista de Beauchamps y Childress y ética profesional, acciones problemáticas y decisiones de no reanimación en la pandemia. Resultados: Considerar la clínica del paciente, con un esquema apropiado de los objetivos del tratamiento, especialmente en los ancianos y las personas con comorbilidades y contar con el apoyo del equipo de cuidados paliativos, para evitar la distanasia, así como el mal uso de los recursos y la exposición de los profesionales a la contaminación. Conclusión: COVID-19 aumentó las vulnerabilidades de profesionales y pacientes, impactando decisiones profesionales y conductas más amplias que valores importantes como la restricción de la libertad, pero especialmente haciendo que la población en general reconsidere los valores éticos y bioéticos con respecto a la vida y la muerte, interferir en las decisiones sobre ellos apoyadas por la dignidad humana.
RESUMO Objetivo: Refletir sobre ordem de não reanimação na COVID-19 no Brasil, sob foco bioético e da ética profissional médica e de enfermagem. Método: Estudo de reflexão embasado na bioética principialista de Beauchamps e Childress e na ética profissional, problematizando ações e decisões de não reanimação na pandemia. Resultados: Importa considerar a clínica do paciente, apropriação das metas dos tratamentos de pessoas com comorbidades, idosas, com menores chances de sobreviver à reanimação, ou menor qualidade de vida, junto à equipe de cuidados paliativos, para evitar distanásia, uso dos recursos escassos e maior exposição dos profissionais à contaminação. Conclusão: A COVID-19 ampliou as vulnerabilidades de profissionais e pacientes, impactando nas decisões e condutas profissionais mais amplamente do que nos valores importantes como a restrição da liberdade. Impulsionou a população em geral a repensar valores éticos e bioéticos referentes à vida e à morte, interferindo nas decisões sobre elas, respaldas na dignidade humana.
Asunto(s)
Humanos , Bioética , Reanimación Cardiopulmonar/ética , Cuidados Críticos , Ética en Enfermería , COVID-19 , Cuidados Paliativos/ética , Brasil , Ética MédicaRESUMEN
Obstinacy or therapeutic cruelty is a medical practice based on the application of extraordinary and disproportionate methods of life support in terminally ill or irrecoverable patients. It is not without risks and can cause physical, psychological and social damage, which is why this practice is not ethically acceptable. It violates the four principles of bioethics: non-maleficence, beneficence, justice and autonomy. The reasons that lead to therapeutic obstinacy are: 1) lack of a definitive diagnosis; 2) false expectation of improvement of the patient; 3) disagreement (between doctors and family or between doctors themselves) with respect the patient's situation; 4) difficulty in communicating with the patient and his/her family; 5) compliance with unrealistic or futile treatments; 6) cultural or spiritual barriers and 7) medical-legal aspects. Limitation of therapeutic effort (LTE) is a deliberate or thoughtful decision about the non-implementation or withdrawal of therapeutic measures that will not provide significant benefit to the patient. But, refusing a treatment, must not imply the artificial acceleration of the death process. Chile does not contemplate euthanasia or assisted suicide in its legislation. Criteria used to justify the limitation of the therapeutic effort are: 1) futility of the treatment (futility); 2) declared wishes of the patient; 3) quality of life and 4) economic cost. The Healthcare Ethics Committee of the Hospital de Urgencia Asistencia Pública has prepared a LET Clinical Guide, proposing a decision-making flow chart that takes in account the autonomy of the patient, the opinion of the medical team, patient and family. In case of disagreement, the Healthcare Ethics Committee's may be requested to issue a pronouncement.
La obstinación o ensañamiento terapéutico es una práctica médica basada en la aplicación de métodos extraordinarios y desproporcionados de soporte vital en enfermos terminales o irrecuperables. No está exenta de riesgos y puede producir daño físico, psicológico y social, motivo por el cual no es aceptable desde el punto de vista ético. Viola los cuatro principios de la bioética: no maleficencia, beneficencia, justicia y autonomía. Las razones que conducen a la obstinación terapéutica son: 1) la falta de un diagnóstico definitivo; 2) la falsa expectativa en el mejoramiento del paciente; 3) el desacuerdo (entre médicos y familia o entre los médicos mismos) con la situación del paciente; 4) la dificultad para comunicarse con el paciente y con la familia; 5) la conformidad con tratamientos poco realistas o fútiles; 6) barreras culturales o espirituales y 7) aspectos médico legales. La limitación del esfuerzo terapéutico (LET) es una decisión deliberada o meditada sobre la no implementación o la retirada de medidas terapéuticas que no aportarán un beneficio significativo al paciente. Pero, rechazar un tratamiento no puede implicar la aceleración artificial del proceso de la muerte. Chile no contempla en su legislación la eutanasia ni el suicidio asistido. Criterios utilizados para justificar o no, la limitación del esfuerzo terapéutico: 1) la inutilidad del tratamiento (futilidad); 2) los deseos expresos del paciente; 3) la calidad de vida y 4) el costo económico. El Comité de Ética Asistencial del Hospital de Urgencia Asistencia Pública, ha elaborado una Guía Clínica de LET. Propone un flujograma de toma de decisiones que considera la autonomía del paciente, la postura tanto del equipo médico, del paciente y su familia y en caso de no acuerdo, del comité de Ética Asistencial.
Asunto(s)
Humanos , Inutilidad Médica/ética , Cuidados Críticos/ética , Relaciones Médico-Paciente/ética , Relaciones Profesional-Familia/ética , Procedimientos Quirúrgicos Operativos/ética , Eutanasia , Reanimación Cardiopulmonar/ética , Privación de Tratamiento , Autonomía Personal , Toma de Decisiones , Prioridad del PacienteRESUMEN
Healthcare providers have disparate views of family presence during cardiopulmonary resuscitation; however, the attitudes of physicians have not been investigated systematically. This study investigates the patterns and determinants of physicians' attitudes to FP during cardiopulmonary resuscitation in Saudi Arabia. A cross-sectional design was applied, where a sample of 1000 physicians was surveyed using a structured questionnaire. The study was conducted in the southern region of Saudi Arabia for over 11 months (February 2014-December 2014). The collected data was analyzed using the Pearson chi-square test. Spearman's correlation analysis and chi-square test of independence were used for the analysis of physicians' characteristics with their willingness to allow FP. 80% of physicians opposed FP during cardiopulmonary resuscitation. The majority of them believed that FP could lead to decreased bedside space, staff distraction, performance anxiety, interference with patient care, and breach of privacy. They also highlight FP to result in difficulty concerning stopping a futile cardiopulmonary resuscitation, psychological trauma to family members, professional stress among staff, and malpractice litigations. 77.9% mostly disagreed that FP could be useful in allaying family anxiety about the condition of the patient or removing their doubts about the care provided, improving family support and participation in patient care, or enhancing staff professionalism. Various concerns exist for FP during adult cardiopulmonary resuscitation, which must be catered when planning for FP execution.
Asunto(s)
Actitud del Personal de Salud , Reanimación Cardiopulmonar/psicología , Familia/psicología , Ansiedad de Desempeño/psicología , Médicos/psicología , Adulto , Reanimación Cardiopulmonar/ética , Estudios Transversales , Femenino , Paro Cardíaco/terapia , Humanos , Masculino , Persona de Mediana Edad , Privacidad/psicología , Arabia Saudita , Encuestas y CuestionariosRESUMEN
The pandemic caused by COVID19 is associated with an increase in the number of cases of cardiorespiratory arrest, which has resulted in ethical concerns regarding the enforceability of cardiopulmonary resuscitation, as well as the conditions to carry it out. The risk of aerosol transmission and the clinical uncertainties about the efficacy, the potential sequelae, and the circumstances that could justify limiting this procedure during the pandemic have multiplied the ethical doubts on how to proceed in these cases. Based on ethical and legal grounds, this paper offers a practical guide on how to proceed in the clinical setting in cases of cardiopulmonary arrest during the pandemic. The criteria of justice, benefit, no harm, respect for autonomy, precaution, integrity, and transparency are asserted in an organized and practical framework for decision-making regarding cardiopulmonary resuscitation.
La pandemia de COVID-19 se ha asociado con un incremento en el número de casos de paro cardiorrespiratorio y con ello han aumentado las inquietudes éticas en torno a la exigencia de la reanimación cardiopulmonar, así como sobre las condiciones para realizarla. El riesgo de contagio por aerosoles y las incertidumbres clínicas sobre la eficacia, las potenciales secuelas y las circunstancias que podrían justificar la limitación del procedimiento durante la pandemia, han multiplicado las dudas éticas sobre cómo proceder en estos casos. Con base en fundamentos éticos y jurídicos, en el presente artículo se ofrece una guía práctica sobre cómo proceder en los casos de paro cardiopulmonar en el contexto de la pandemia. Los criterios de justicia, beneficio, no daño, respeto a la autonomía, precaución, integridad y transparencia, se presentan de forma organizada y práctica para la adopción de decisiones en materia de reanimación cardiopulmonar.
Asunto(s)
Betacoronavirus , Reanimación Cardiopulmonar/ética , Infecciones por Coronavirus/complicaciones , Paro Cardíaco/terapia , Pandemias , Neumonía Viral/complicaciones , Guías de Práctica Clínica como Asunto , Directivas Anticipadas , Aerosoles , Microbiología del Aire , COVID-19 , Reanimación Cardiopulmonar/métodos , Toma de Decisiones Clínicas , Colombia/epidemiología , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Paro Cardíaco/etiología , Humanos , Control de Infecciones/métodos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Inutilidad Médica , Exposición Profesional , Pandemias/prevención & control , Autonomía Personal , Equipo de Protección Personal , Neumonía Viral/epidemiología , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , SARS-CoV-2 , Justicia SocialRESUMEN
OBJECTIVE: Our study aims to provide a paradigm when it is ethical to perform cardiopulmonary resuscitation (CPR) on patients during the COVID-19 pandemic. SUMMARY BACKGROUND DATA: Hospitals around the nation are enacting systems to limit CPR in caring for COVID+ patients for a variety of legitimate reasons and based on concepts of medical futility and allocation of scarce resources. No ethical framework, however, has been proposed as a standard to guide care in this crucial matter. METHODS: Our analysis begins with definitions of ethically relevant terms. We then cycle an illustrative clinical vignette through the mathematically permissible possibilities to account for all conceivable scenarios. Scenarios with ethical tension are examined. RESULTS: Patients have the negative right to refuse care including CPR, but they do not have the positive right to demand it. Our detailed ethical analysis and recommendations support CPR if and only if 1) CPR is judged medically beneficial, and in line with the patient's and values and goals, 2) allocations or scarce resources follow a just and transparent triage system, and 3) providers are protected from contracting the disease. CONCLUSIONS: CPR is an intervention like any other, with attendant risks and benefits and with responsibility for the utilization of limited resources. Our ethical analysis advocates for a systematic approach to codes that respects the important ethical considerations in caring for the critically ill and facilitates patient-centered, evidence-based, and fair treatment to all.
Asunto(s)
Discusiones Bioéticas , COVID-19/terapia , Reanimación Cardiopulmonar/ética , SARS-CoV-2 , Códigos de Ética , Humanos , Guías de Práctica Clínica como Asunto , Terminología como AsuntoAsunto(s)
Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/normas , Pandemias/ética , Betacoronavirus , COVID-19 , Infecciones por Coronavirus , Personal de Salud , Recursos en Salud/provisión & distribución , Humanos , Exposición Profesional , Neumonía Viral , Órdenes de Resucitación , SARS-CoV-2Asunto(s)
Cardiología/educación , Reanimación Cardiopulmonar , Infecciones por Coronavirus/prevención & control , Enfermedades Profesionales/prevención & control , Pandemias/prevención & control , Personal de Hospital/psicología , Neumonía Viral/prevención & control , Directivas Anticipadas , Aerosoles , Actitud del Personal de Salud , Líquidos Corporales/virología , COVID-19 , Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/métodos , Oscilación de la Pared Torácica , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/psicología , Infecciones por Coronavirus/transmisión , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Intubación Intratraqueal/efectos adversos , Enfermedades Profesionales/psicología , Exposición Profesional , Habitaciones de Pacientes , Neumonía Viral/complicaciones , Neumonía Viral/psicología , Neumonía Viral/transmisión , Equipos de Seguridad/provisión & distribución , Órdenes de Resucitación , RiesgoRESUMEN
OBJECTIVES: Success of in-hospital resuscitation decreases with age; however, national data show that 11.3% of patients over 80 years survive to discharge. There are few published qualitative data about the quality of life for these patients postsuccessful resuscitation. We aimed to investigate postresuscitation quality of life in patients over the age of 80 through a series of case studies. METHODS: All patients over the age of 80 years, who received cardiopulmonary resuscitation (CPR) at our district general hospital in 2015-2016, were included. Success of resuscitation, survival at day 1 and to discharge were recorded. For patients who survived to 1 day and beyond, case reports were written to create individual patient stories. RESULTS: 47 patients over the age of 80 years received CPR at Musgrove Park Hospital over a 2-year period. Five (10.6%) survived to discharge. Of those surviving to discharge, two had substantial functional decline, requiring discharge to nursing homes having previously been independent. Of the five families/patients who commented on their experience, only one expressed a positive view. When discussed, the majority of patients/families opted for a Do Not Attempt CPR. CONCLUSION: Our results have shown that there is a risk of substantial functional decline associated with successful CPR in those patients over the age of 80 years. The majority of patients and relatives contacted after successful resuscitation expressed a negative view of the experience. Our study highlights the importance of having early informed discussions with patients and families about CPR in order to avoid detrimental outcomes and ensure patient wishes are correctly represented.
Asunto(s)
Reanimación Cardiopulmonar , Estado Funcional , Paro Cardíaco/terapia , Calidad de Vida , Órdenes de Resucitación , Sobrevivientes , Anciano de 80 o más Años , Reanimación Cardiopulmonar/ética , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/psicología , Femenino , Hospitalización , Humanos , Masculino , Evaluación de Necesidades , Alta del Paciente , Órdenes de Resucitación/ética , Órdenes de Resucitación/psicología , Medición de Riesgo , Sobrevivientes/psicología , Sobrevivientes/estadística & datos numéricosRESUMEN
Most professional guidelines advocate family presence during resuscitation (FPDR). Many clinicians, however, are still reluctant to implement this recommendation. In this article I present the most comprehensive case for FPDR to date. I review the little that has been written about the ethics of FPDR, as well as the available empirical evidence. More importantly, I present and defend three arguments for FPDR: adherence to professional guidelines, benefit to patients and relatives, and patients' autonomy. I conclude with suggestions for future research.
Asunto(s)
Reanimación Cardiopulmonar/ética , Cuidados Críticos/ética , Familia , Relaciones Profesional-Familia/ética , Actitud del Personal de Salud , Reanimación Cardiopulmonar/psicología , Cuidados Críticos/psicología , Familia/psicología , Humanos , Guías de Práctica Clínica como AsuntoRESUMEN
Ethics consultants can apply a narrative ethics approach to address ethical challenges that arise in critical situations. This approach recognizes how those involved in the narrative make sense of, keep faith with, and try on new identities and new understanding of their stories. This case study explores the ways in which the stories of patient, provider, and clinical ethics consultant intersect, and considers how the organic nature of the narrative ethics approach allows ethics consultants to navigate the stories of multiple stakeholders as they grapple with complex health care decisions. This essay also suggests that clinical ethics consultants applying the lens of narrative ethics have an obligation to approach consultations with courage, professional humility, intellectual curiosity, and an appreciation for the narratives of as many of the stakeholders as possible (including one's own).
Asunto(s)
Relaciones Médico-Paciente/ética , Reanimación Cardiopulmonar/ética , Eticistas , Consultoría Ética , Femenino , Paro Cardíaco/terapia , Humanos , Narración , Defensa del Paciente/ética , Alta del Paciente , Adulto JovenRESUMEN
This personal narrative examines what physicians owe patients in ways that might be just as novel as any new technology for cardiopulmonary resuscitation (CPR). The narrative uses the actual words of Linda (not her real name), a woman who had to lead CPR on her mother. Rather than concentrating only on CPR, the narrative also discusses what happens-and does not happen-before and after an out-of-hospital cardiac arrest. Linda's story suggests possible ways to take better care of terminally and chronically ill patients at home: by listening in different ways to patients and families.
Asunto(s)
Reanimación Cardiopulmonar/ética , Toma de Decisiones/ética , Familia/psicología , Anciano Frágil/psicología , Paro Cardíaco Extrahospitalario/psicología , Prioridad del Paciente/psicología , Adulto , Planificación Anticipada de Atención/ética , Anciano , Servicios Médicos de Urgencia , Femenino , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Encuestas y Cuestionarios , Reino Unido/epidemiologíaRESUMEN
Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and on substituted interest judgments. Patients' known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR.
Asunto(s)
Reanimación Cardiopulmonar , Consentimiento Informado , Órdenes de Resucitación , Reanimación Cardiopulmonar/ética , Toma de Decisiones , Ética Médica , Humanos , Órdenes de Resucitación/éticaRESUMEN
Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges.
Asunto(s)
Reanimación Cardiopulmonar/ética , Familia/psicología , Órdenes de Resucitación/ética , Privación de Tratamiento/ética , Reanimación Cardiopulmonar/psicología , Toma de Decisiones Conjunta , Disentimientos y Disputas , Consultoría Ética , HumanosRESUMEN
PURPOSE: To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students. METHODS: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. RESULTS: Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. DISCUSSION: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.