Current evidence supports early termination of ED resuscitative efforts in CPA patients who meet established criteria for physiologic futility. These criteria include the prehospital BLS rule, cardiac standstill on bedside echo, and/or an end-tidal CO2 <10–15 mm Hg after 20 minutes of standard ACLS. Several ED CPA studies have shown that cardiac standstill on ED echocardiography is 100 percent predictive of failure to leave the ED alive regardless of both downtime and initial presenting rhythm.6
Explore This IssueACEP Now: Vol 34 – No 04 – April 2015
End-of-life care is a complex task for emergency physicians and should include careful consideration of patients’ wishes, family input, scientific evidence regarding prognosis, and physician judgment. Several organizations have provided guidance for such complex decisions. Current ACEP policy states that “physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient.” This policy also states that emergency physicians’ judgments should be unbiased, based on available scientific evidence and societal and professional standards, and sensitive to differences of opinion regarding the value of medical intervention in various situations.7 The American Medical Association has also stated in policy that “physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients.”8
Equally important as deciding when to refuse a family member’s request for continued resuscitative efforts is how the family is approached about the decision. Shared decision making with clinicians, patients, and families can be a means of achieving consensus for the best approach to honor patients’ wishes. Clinicians should clearly explain their positions and invoke practice guidelines when appropriate. Furthermore, clinicians should identify and address why conflict exists when making these decisions in order to decrease possible feelings of abandonment and mistreatment.9
In the case presented, it would be ideal if the health care team and family understood and agreed with the decision to discontinue resuscitative efforts. However, it is ultimately up to the provider to make the best clinical decision with the information provided. In this case, it would be appropriate to cease further resuscitative efforts and to focus on family support, including communication and spiritual counseling if desired. The emergency physician should explain to the family that their loved one received the best and most appropriate care that modern medicine can provide.
The authors are serving on the ACEP Ethics Committee. Dr. Phillips is chief resident in the department of emergency medicine at George Washington University Medical Center in Washington, D.C. Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio. Dr. Jesus is assistant professor of emergency medicine at Christiana Care Health System in Newark, Delaware. Dr. Wang is resident physician at the Stanford/Kaiser Emergency Medicine in Palo Alto, California. Dr. Larkin is Lion Foundation professor and chair of emergency medicine at the University of Auckland in New Zealand.
- Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician’s obligation. N Engl J Med. 1986;315(21):1347-1351.
- Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5):493-497.
- Brett AS, McCullough LB. Addressing requests by patients for nonbeneficial interventions. JAMA. 2012;307(2):149-150.
- Sasson C, Rogers MA, Dahl J, et al. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63-81.
- Larkin GL, Carey SM, Allen E, et al. Recurrence risk for emergency department survivors of pulseless cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Ann Emerg Med. 2005;46:S17-S18.
- Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8:616-21.
- ACEP Policy Statement. Non-beneficial (“futile”) emergency medical interventions. American College of Emergency Physicians, Dallas, 1998, reaffirmed 2008. Available at: http://www.acep.org/Clinical—Practice-Management/Non-Beneficial-(-Futile-)-Emergency-Medical-Interventions/. Accessed Dec. 8, 2014.
- AMA Policy on End-of-Life Care. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/ethics-resource-center/end-of-life-care/ama-policy-end-of-life-care.page. Accessed Dec. 8, 2014.
- Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit treatment: a differential diagnosis. JAMA. 2000;283(7):909-914.