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 is the
subject of a session at Euroanaesthesia, the annual congress of the
European Society of Anaesthesiology (ESA).
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,
Barcelona, Spain, will outline scenarios in which it is advised not to
begin cardiopulmonary resuscitation (CPR) efforts, including in so
called 'living will' situations. He will discuss the poor survival
figures for CPR: 8% overall and 20% if done in-hospital (however 90% of
CPR efforts take place outside hospital).
If the healthcare worker has themselves witnessed the cardiac
arrest, then CPR should be started; however, if not, then whether or not
to start 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, then
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.
Physicians decided differently from the patient's directives in 70%
of cases (according to data published by The Archives of Internal
Medicine) "An exception may be made in patients with depression, since
such patients must be considered not competent to make important
decisions, like whether to be revived by CPR," says Solsona. He will
also outline an example case where it could be difficult to interpret a
clear living will. He will describe a patient with AIDS who is
hospitalised after a serious road accident. While administering CPR, the
staff discover a living will asking not to administer CPR. "But how are
the staff to know if the person meant this just for the final part of
their AIDS illness? They may have been prepared for death in the near
future, but if an unexpected accident brings that day forward, would the
person want to be revived, so that they can, for example, say goodbye
to relatives and friends? The person could go on to live for years, as
we don't know their life expectancy in this situation."
He will also discuss the use of a proxy: where the patient nominates
a close relative or friend to represent their views if they are unable
to do so themselves. "Preliminary results from my own hospital suggest
that only half of patients wish to nominate a proxy," says Solsana.
"This could possibly be because the person thinks death is very close,
and does not want to talk about it."
Dr Solsona will also state that, even in the presence of family of
the patient, anaesthetists or other medical staff in a public hospital
system are under no obligation to begin or continue what are reasonably
regarded by the doctors as futile CPR efforts. And despite evidence from
a recent New England Journal of Medicine Paper that family members
witnessing CPR efforts meant those family members suffered less anxiety
and depression, and did not interfere in medical efforts, Dr Solsona
will argue that their presence introduces an unknown variable that
medical staff should not be exposed to while treating the patient (since
some could react very badly and cause stress and anxiety to the medical
"While no patient whose death is preventable should die, the vast
majority of resuscitation attempts fail and the patient subsequently
dies," says co-presenter Dr Janusz Andres of Jagiellonian
University, Krakow, Poland, Chairman, Department of Anaesthesiology and
Intensive Therapy at Jagiellonian University Hospital, Krakow, and
President of the Polish Resuscitation Council.
Resuscitation guidelines indicate that after 20 minutes of
ineffective resuscitation, the resuscitation team leader, most often an
anaesthetist, has to decide whether to stop resuscitation, taking into
account several potentially reversible causes of cardiac arrest. "Good
neurological outcome is the main goal and the success of resuscitation,"
says Dr Andres. "Immediate, uninterrupted chest compressions and early
defibrillation in cardiac arrest if indicated are main requirements of
success in every case."
It is obligatory in every resuscitation attempt – in out- and in-hospital scenarios - to monitor the quality and efficacy of the ongoing resuscitation. The measuring of the levels of carbon dioxide exhaled by the patient (the method called "continuous capnography") during resuscitation indicates presence of pulmonary blood flow during resuscitation and might predict the probability of ROSC (Return of Spontaneous Circulation). Direct arterial systolic and diastolic pressures (arterial relaxation pressure) are of unique values for the monitoring of resuscitation quality. If a central venous line is available, coronary perfusion pressure (difference between aortic pressure and right atrium pressure) can be calculated. Central venous and arterial blood saturations as well as an arterial blood gas analysis and echocardiography could also be used in periods of prolonged resuscitation, especially in the hospital. Dr Andres will discuss two recently published cases of the prolonged and successful resuscitation. The first one documents (Mayo Clin Proc. 2011;86:544) the longest duration (96 minutes) of pulselessness in the out-of-hospital cardiac arrest with a good neurological outcome. The second case deals with sudden unexpected cardiac arrest during anaesthesia (Can J Anesth 2012;59:578) treated by almost one hour of successful resuscitation in the operating room in the conditions when the decision to terminate resuscitation was being discussed.
"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," says Dr Andres. "These include extraordinary situations when we plan to use extracorporeal circulation, the presence of persistent ventricular fibrillation during resuscitation, temporary return of spontaneous circulation, young age of the patient, and evidence of organ perfusion."
He calls for anaesthesia-related advanced life support guidelines to
be issued in support of existing resuscitation guidelines (Eur J
"So far the vast majority of resuscitation efforts have to be
limited and then stopped. These include irreversible causes of cardiac
arrest like in severe trauma, long lasting asystole (flat lining of the
heart's electrical activity despite ongoing advanced life support); the
time before resuscitation beginning being too long to have a reasonable
chance of succeeding, or poor functional pre-arrest status of the
patient like in end-stage cardiac failure," concludes Dr Andres.