Starting (and not stopping) resuscitation

One of the most difficult moments faced by anaesthetists and other healthcare staff is when to carry on attempts to resuscitate a person, and when those efforts should reasonably stop. This dilemma was the subject of a session at Euroanaesthesia.

In the first part of the session, Dr Jose Solsona, Director of the ICU Department and Chair of the Ethics Committee at Hospital del Mar, in Barcelona, outlined scenarios in which it is advised not to begin cardiopulmonary resuscitation (CPR) efforts, including in so called ‘living will’ situations. He discussed the poor survival figures for CPR: eight percent overall and 20 percent if done in-hospital (however 90 percent of CPR efforts take place outside hospital).

If the healthcare worker has witnessed the cardiac arrest, CPR should be started; however, if not, then it depends on whether there was a witness to say when the arrest occurred. Should this be more than 10 minutes ago, CPR should not be started. If no-one has witnessed the arrest or there is any doubt, CPR should be started. “CPR should also not be started if it presents a risk to the medical personnel,” adds Dr Solsona, giving the example of a cardiac arrest occurring in a swimming pool, and the attending doctor not being able to swim.

If the patient (for example in hospital) has made clear that they do not wish to be resuscitated by making a so-called ‘living will’, the clinician must be satisfied that a patient is capable of making their own decisions, and be able to communicate, understand, know the consequences, and be able to reason. The disparity between living wills and clinical decision was illustrated in a survey of physicians using six hypothetical scenarios.

Amongst the secenarios, an exceptional case described was in patients with depression, since they must be considered not competent to make such important decisions. Another example of a complicated situation given was of an AIDS patient who wishes not to be resuscitated in the latter part of their illness, but if an accident occurs sooner, should doctors overrule this, not knowing their life expectancy?

The presence of family or friends was also under question, as studies have shown that it could reduce anxiety in the patient, but their reactions may be unpredictable, especially where doctors regard CPR efforts in a patient as futile and stop, or don’t begin resuscitation.

Dr Janusz Andres, Chairman, Department of Anaesthesiology and Intensive Therapy at Jagiellonian University Hospital, Krakow, and President of the Polish Resuscitation Council noted two recently published cases of the prolonged and successful resuscitation; one documenting 96 minutes of pulselessness in the out-of-hospital cardiac arrest with a good neurological outcome, and the other a sudden unexpected cardiac arrest during anaesthesia, treated by almost one hour of successful resuscitation in the operating room.
“The extension of resuscitation efforts should be considered when the available monitoring indicates the reversibility of cardiac arrest, as well as in other cases that indicate life could be sustained,” said Dr Andres.

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