[Ethical aspects of resuscitation]. / Az újraélesztés etikai vonatkozásai.

The former typically paternalistic physician-patient relationship has changed gradually toward an autonomy based one in the second half of the 20th century. Patient's autonomy includes the right to refuse life-saving therapy in modern constitutional states. Hungarian law assures the right to refuse life-saving treatment as well. However to our knowledge no such therapy refusal has occurred since the law coming into force likely because of the rather strict regulations. Forgoing resuscitation is basically determined by two factors: autonomy of the patient, and medical futility. The alteration of the law's form can facilitate the lawful Do Not Resuscitate (DNR)orders for the sake of patient's autonomy. Qualitative futility is characterized by quality of life, which only the patient has the right to judge. Resuscitation protocols based on results of controlled studies can significantly improve both the success rate of resuscitations and the quality of life. Education plays a prominent role in this process as it was demonstrated in our prospective comparative study. According to author's study Hungarian DNR orders are paternalistic and patient autonomy plays a secondary role. It was also established that patient's autonomy significantly improved in the subgroup trained according to international standards. Hungarian results were compared to the results of a highly educated group in the second study. The results confirmed the presumption: the education of resuscitation according to international standards improves both the representation of patient's autonomy in DNR decisions, survival rate and quality of life.

Ethical considerations behind the limitation of cardiopulmonary resuscitation in Hungary--the role of education and training.

INTRODUCTION: Although the long term success of cardiopulmonary resuscitation (CPR) is still less than hoped for, its value cannot be questioned when carried out appropriately in selected cases. Resuscitation frequently brings only short-term success, and several patients suffer severe consequences also causing an economic, medical and ethical burden to society. The issue of limitation of resuscitation, including Do Not Attempt Resuscitation (DNAR) and the termination of resuscitation has been surveyed in many European countries using a structured questionnaire. In Hungary no such comprehensive study has been conducted yet. The goal of this investigation was to recognise the ethical factors limiting resuscitation in Hungary. METHODS: We contacted 72 doctors personally during 2003, who were working actively at an intensive care unit (ICU) and asked them to answer a structured questionnaire in strict anonymity. We investigated the role of different ethical issues in beginning and suspending resuscitation efforts in conjunction with medical experience, sex, ideology, and education using a five point visual analogue scale. The answers given were categorised to autonomy, futility, obtainable quality of life, resource utilization, and to "another" category detailed later on. The questionnaire and the plan of this investigation was approved by the Semmelweis Medical University's Ethical Committee (SE-TUKEB 109/2003). RESULTS: The decision not to attempt resuscitation was mostly dictated by the opinion of the head of department and the doctor in charge of the patient (3.53 +/- 1.30), and after this the presumed obtainable quality of life (3.13 +/- 1.40), objective futility (3.11 +/- 0.94), and patient autonomy (2.02 +/- 1.63). The other objective (0.57 +/- 1.59), and subjective (1.04 +/- 1.21) factors, as well as resource utilization (0.29 +/- 0.66) played a less important role. The decision to terminate resuscitation efforts was mostly dictated by the objective futility criteria (3.39 +/- 0.88), obtainable quality of life (3.31 +/- 1.50), subjective futility (3.19 +/- 1.47), and autonomy (1.57 +/- 1.67) to a smaller extent. Among the doctors who participated in an appropriate-an internationally accredited (ERC/RC(UK)/AHA)-Advanced Life Support (ALS) training-the frequency of the appearance of the principle of modern bioethics-such as autonomy-was significantly higher and the same tendency could be observed in those who completed their studies at the medical university in the last 5 years. CONCLUSIONS: The results underline the original presumption that the Hungarian resuscitation practice is at first influenced by professional (or "thought to be professional") standpoints. The quality of life, and patient autonomy plays an important role in the decision making about limitation of resuscitation efforts. Current CPR education emphasizes the importance of ethical considerations, and this could be observed clearly in the answers.

Determinant role of education in the ethical aspects of resuscitation: a German/Hungarian comparison.

UNLABELLED: Introduction, objectives: Bioethical principles concerning Do Not Attempt Resuscitation (DNAR) orders are connected significantly with education according to our previous investigation. In order to confirm the hypothesis, Hungarian results were compared with the data gained from a highly qualified homogeneous group of German doctors, showing similar cultural traditions. METHODS: The questionnaire investigated the factors influencing DNAR orders as functions of intensive medical experience, ideological view and professional education, using a 5-point visual analogue scale. Answers were assigned to categories of autonomy, futility, obtainable quality of life, resource utilization and a category of other factors detailed later. RESULTS: The DNAR decision and termination of resuscitation are to almost the same extent determined by futility (3.29+-0.75; 3.49+-0.71) and obtainable quality of life (3.13+-1.31; 3.47+-1.34). The opinion of head of department was also important (3.24+-1.35; 3.23+-1.36). Patient's autonomy played an important role (3.15+-0.85; 2.36+-1.48) in decision making. In comparison with the Hungarian results, the only significant difference was found in the field of patient's autonomy in both not starting (p<0.0002) and terminating resuscitation (p<0.02) in favour of German doctors respecting it. DISCUSSION: The results support the original hypothesis that consideration of modern bioethical principles, and especially the patient's autonomy are related to the level of the doctor's education. Comparing to Hungarian data there is only a minimal difference in other bioethical points, while the population of German doctors interviewed appreciated the patient's autonomy significantly higher. There should be greater discussion of ethical considerations in cardiopulmonary resuscitation education.