Ethical Considerations for Mechanical Support.

Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation. Careful deliberation of ethical principles and potential dilemmas should be made when considering the use of extracorporeal life support in advanced cardiopulmonary failure.

When Teachable Moments Become Ethically Problematic.

There is frequently tension in medical education between teaching moments that provide skills and knowledge for medical trainees, and instrumentalizing patients for the purpose of teaching. In this commentary, I question the ethical acceptability of the practice of providing cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) to dying patients who would be unlikely to survive resuscitation, as a teaching opportunity for medical trainees. This practice violates the principle of informed consent, as the patient agreed to resuscitation for the purpose of potentially prolonging life rather than to futile resuscitation as a teaching opportunity. Justifying futile resuscitation in order to practice normalizes deceptive and nonconsensual teaching cases in medical training. Condoning these behaviors as ethically acceptable trains physicians to believe that core ethical principles are relative and fluid to suit one's purpose. I argue that these practices are antithetical to the principles espoused by both medical ethics and physician professionalism.

Actualización en la reanimación intrahospitalaria / Update on in hospital resuscitation

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Ethical and legal perspective of implantable cardioverter defibrillator deactivation or implantable cardioverter defibrillator generator replacement in the elderly.

PURPOSE OF REVIEW: Implantable cardioverter defibrillator (ICD) implantation has become a common and standard treatment for primary and secondary prevention of sudden cardiac death in patients with poor left ventricular ejection fraction across the world. Circumstances, of course, change after the initial implant as patients age. This raises legal and ethical questions about deactivating or not replacing ICD generators when the likelihood of meaningful benefit has diminished. RECENT FINDINGS: Health professionals are reluctant to discuss the end-of-life planning with patients who have ICDs. Older patients are more likely to have multiple comorbidities that worsen or accumulate further after initial implantation and attenuate the survival benefit of ICDs. Joint guidelines suggest physicians educate patients during the initial consent process about the possibility of deactivating ICDs after implantation if their individual situation changes to the point of futility. SUMMARY: ICD deactivation and nonreplacement are unavoidable issues that require clarity for meaningful and ethical implementation. This is an ongoing process.

Ética de las decisiones en resucitación cardiopulmonar / Ethics of the cardiopulmonary resuscitation decisions

La Resucitación Cardiopulmonar (RCP) se debe aplicar si está indicada, omitirse si no está o no ha sido previamente aceptada por el paciente y suspenderse si es inefectiva. Si la RCP se previera fútil, se registrará una Orden de No Intentar la Resucitación, que deberá ser conocida por los profesionales sanitarios que atienden al enfermo. Es aceptable limitar el soporte vital a los supervivientes con encefalopatía anóxica, si se descarta la posibilidad de que evolucionen a muerte encefálica. Tras la RCP se debe informar y apoyar a la familia del paciente, y revisar el procedimiento realizado para mejorarlo. Previa limitación del soporte vital se podría plantear cierto tipo de donación de órganos a corazón parado. Adquirir competencia en RCP precisa practicar con simuladores y, en ocasiones, sobre cadáveres recientes, siempre con permiso. La investigación sobre RCP es imprescindible, respetando leyes y normas éticas de excelencia (AU)

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks (AU)

Reviving the conversation around CPR/DNR.

This paper examines the historical rise of both cardiopulmonary resuscitation (CPR) and the do-not-resuscitate (DNR) order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR.