Part 3: Ethical Issues

    Key Words:
  • advance directive
  • DNAR
  • life support
  • organ donation
PDF Accessible Version


The goals of resuscitation are to:

  • preserve life;
  • restore health;
  • relieve suffering;
  • limit disability; and
  • respect individuals’ decisions, rights, and privacy.

Because cardiopulmonary resuscitation (CPR) efforts must be initiated immediately at the time of arrest, a rescuer may not know who the victim is, what that individual’s goals of care are, or if an advance directive exists. As a result, administration of CPR may be contrary to the individual’s desires or best interests.

Ethical Principles

Ethical, legal, and cultural factors influence decisions about resuscitation. Ideally, these decisions are guided by science, patient or surrogate preferences, local policies and legal requirements, and established ethical principles.

Principle of Respect for Autonomy

Respect for autonomy is an important social value in medical ethics and law.

Informed decisions require that individuals receive and understand accurate information about their condition and prognosis as well as the nature, risks, benefits, and alternatives of any proposed interventions.

The following 3-step process may assist healthcare providers in ensuring each patient understands and makes informed decisions:

  1. the patient receives and understands accurate information about his or her condition, prognosis, nature of any proposed interventions, alternatives, and risks and benefits;
  2. the patient is asked to paraphrase the information to give providers the opportunity to assess the patient’s understanding and correct any misimpressions; and
  3. the patient deliberates and chooses among alternatives and justifies his or her decisions.

When decision-making capacity is temporarily impaired by conditions such as active illness, treatment of these conditions may restore capacity.

When an individual’s preferences are unknown or uncertain, it is ethically appropriate to treat emergency conditions until further information is available.

Advance Directives, Living Wills, and Patient Self-Determination

More than a quarter of elderly patients require surrogate decision making at the end of life according to one recent study.

Advance directives, living wills, and executing a durable power of attorney for health care ensure that when the patient is unable to make decisions, the preferences that the individual established in advance can guide care. These decisions are associated with less aggressive medical care near death, earlier hospice referrals for palliation, better quality of life, and caregiver’s bereavement adjustment.

A healthcare advance directive

  • is a legal binding document that in the United States (US) is based on the 1990 Patient Self-Determination Act. It communicates the thoughts, wishes, or preferences for healthcare decisions that might need to be made during periods of incapacity. The Patient Self-Determination Act mandated that healthcare institutions should facilitate the completion of advance directives if patients desire them. Advance directives can be verbal or written and may be based on conversations, written directives, living wills, or durable power of attorney for health care. The legal validity of various forms of advance directives varies from jurisdiction to jurisdiction. Courts consider written advance directives to be more trustworthy than recollections of conversations.

A living will

  • may be referred to as a “medical directive” or “declaration” or “directive to physicians,” and it provides written direction to healthcare providers about the care that the individual approves should he or she become terminally ill and be unable to make decisions. A living will constitutes evidence of the individual’s wishes, and in most areas it can be legally enforced.

A durable power of attorney for health care

  • is a legal document that appoints an authorized person to make healthcare decisions (not limited to end-of-life decisions). Simply put, a living will affects the care received, and a durable power of attorney accounts for unforeseen circumstances. The decisions made through the durable power of attorney for healthcare may be in conflict with the living will or advance directive; at the time of the unforeseen circumstances they are considered to be valid expressions of the patient’s best interests.

A comprehensive healthcare advance directive

  • combines the living will and the durable power of attorney for health care into one legally binding document.

All types of advance directives should be reviewed regularly as a patient’s medical condition and desire for types of medical treatment may change over time.

The presence of an advance directive, a living will, or a durable power of attorney for health care can help ensure that patient preferences match the actual care received.

A Do Not Attempt Resuscitation (DNAR) order

  • is given by a licensed physician or alternative authority as per local regulation, and it must be signed and dated to be valid.
  • should explicitly describe the resuscitation interventions to be performed in the event of a life-threatening emergency.
  • in most cases, is preceded by a documented discussion with the patient, family, or surrogate decision maker addressing the patient’s wishes about resuscitation interventions. Some jurisdictions may require confirmation by a witness or a second treating physician.

In many settings, “Allow Natural Death” (AND) is becoming a preferred term to replace DNAR, to emphasize that the order is to allow natural consequences of a disease or injury, and to emphasize ongoing end-of-life care.

Surrogate Decision Makers

In the event of incapacity, an adult may require a surrogate decision maker to make medical decisions.

Surrogate decision makers should base their decisions on the individual’s previously expressed preferences, if known; otherwise, surrogates should make decisions based on their understanding of what constitutes the best interests of the individual. There are several types of surrogate decision-makers.

  • The person appointed by the durable power of attorney for health care is authorized to make medical decisions within the scope of authority granted by the document.
  • A court-appointed guardian given authority to make healthcare decisions becomes the authorized surrogate.
  • A close relative or friend can become a surrogate decision maker if there is no court-appointed or other authority.

Most jurisdictions have laws that designate the legally authorized surrogate decision maker for an incompetent patient who has not identified a decision maker through a durable power of attorney for health care.

Pediatric Decision Making

As a general rule, minors are considered incompetent to provide legally binding consent about their health care. Children under 14 years of age in Canada and under 18 years of age in the United States rarely possess the legal authority to consent to their health care except under specific legally defined situations (eg, emancipated minors; mature minors; minors who have specific health conditions, such as those with sexually transmitted diseases or in need of pregnancy-related care).

Parents or guardians are generally empowered to make healthcare decisions on the behalf of minors, and in most situations, parents are given wide latitude in terms of the decisions they make on behalf of their children.

Ethically, however, a child should be involved in decision making at a level appropriate for the child’s maturity. As older children develop the capacity to make decisions, it is ethically appropriate to include them in discussions about their care and the treatments using language and explanations suitable for the child’s level of maturity and cognitive function.

Principle of Futility

Patients or families may ask for care that is highly unlikely to improve health outcomes. Healthcare providers, however, are not obliged to provide such care when there is scientific and social consensus that the treatment is ineffective. If the purpose of a medical treatment cannot be achieved, the treatment can be considered futile.

An objective criterion for medical futility was defined in 1990 for interventions and drug therapy as imparting a <1% chance of survival. Although this criterion may be controversial, it remains a basis for current futility research. An obvious example of an inappropriate or futile intervention is providing CPR for a patient who has suffered irreversible death.

Conditions such as irreversible brain damage or brain death cannot be reliably assessed or predicted at the time of cardiac arrest. Withholding resuscitation and the discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent.

In situations where the prognosis is uncertain, a trial of treatment may be initiated while further information is gathered to help determine the likelihood of survival, the patient’s preferences, and the expected clinical course. (Class IIb, LOE C) (2010 Part 3)

Out-of-Hospital Cardiac Arrest (OHCA)

Withholding CPR for Out-of-Hospital Cardiac Arrest

Criteria for Not Starting CPR

While the general rule is to provide emergency treatment to a victim of cardiac arrest, there are a few exceptions where withholding CPR would be considered appropriate:

  • situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril (eg, exposure to fire or toxins).
  • obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, decomposition).
  • a valid advance directive, a Physician Orders for Life- Sustaining Treatment (POLST) form ( indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order.

DNAR Orders in OHCA

Out-of-hospital DNAR protocols must be clearly written and easily implemented for all involved (all members of the healthcare team, patients, family members, and loved ones). DNAR documentation can take many forms (eg, written bedside orders, wallet identification cards, identification bracelets, or predefined paper documents approved by the local emergency medical services [EMS] authority). The ideal out-of-hospital DNAR documentation is portable and can be carried on the person, such as a POLST form.

Delayed or token efforts such as so-called “slow-codes” (knowingly providing ineffective resuscitative efforts) are inappropriate. This practice compromises the ethical integrity of healthcare providers, uses deception to create a false impression, and may undermine the provider-patient relationship. The practice of “pseudo resuscitation” was self-reported by paramedics to occur in 27% of cardiac arrests in a community where a prehospital DNAR and termination-of-resuscitation protocols were not in place.

Some EMS systems have extended the DNAR protocol to include verbal DNAR requests from family members as grounds to withhold therapy. Under such protocols, paramedics may withhold resuscitation for patients in cardiac arrest with a history of a terminal illness, who were under the care of a physician, and when at the time of the cardiac arrest the family requested that resuscitation not be attempted. This is an important first step in expanding the clinical decision rule pertaining to when to start resuscitation in OHCA, however there is insufficient evidence to support this approach without further validation.

Advance Directives in OHCA

Advance directives do not have to include a DNAR order, and a DNAR order is valid without an advance directive. While laws vary across jurisdictions, in general, EMS professionals should initiate CPR and advanced life support if there is

  • reasonable doubt about the validity of a DNAR order,
  • concern that the victim may have had a change of mind, or
  • a question about whether the patient intended the advance directive to be applied under the conditions for which EMS has been called, or
  • difficulty obtaining clear information about the victim’s wishes by EMS professionals

The DNAR order should be shown to EMS responders as soon as they arrive on the scene.

If, after resuscitation begins, relatives or other medical personnel arrive and confirm that the victim clearly expressed a wish that resuscitation not be attempted, CPR or other life-support measures may be discontinued by following local directives or protocols. Such protocols may include real-time consultation with medical direction.

Clinical Decision Rules for Terminating Resuscitation Efforts in Neonatal, Pediatric, or Adult OHCA

In the absence of clinical decision rules for the neonate, infant, child, or adult victim of out-of-hospital cardiac arrest (OHCA), CPR and advanced life support protocols are used by responsible prehospital providers in consultation with medical direction in real-time or as the victim is transported to the most appropriate facility per local directives.

The impact of the availability of advanced hospital-based interventions, including extracorporeal membrane oxygenation (ECMO) during refractory CPR and the use of targeted temperature management (TTM), is now being considered in some EMS systems as justification for continuing resuscitation and transport. For additional information, see Cardiac Arrest Centers in Part 4.

Clinical Decision Rules for Terminating Resuscitation Efforts in Neonatal or Pediatric OHCA

No predictors of neonatal or pediatric (infant or child) out-of-hospital resuscitation success or failure have been established. No validated clinical decision rules have been derived and evaluated.

In the absence of clinical decision rules for the neonatal or pediatric victim of OHCA, the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction, or transport the victim to the most appropriate facility per local directives.

Clinical Decision Rules for Terminating Resuscitation Efforts in Adult OHCA
Basic Life Support Out-of-Hospital System

Rescuers who start Basic Life Support (BLS) should continue resuscitation until one of the following occurs:

  • restoration of effective, spontaneous circulation
  • care is transferred to a team providing advanced life support
  • the rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met.

One set of reliable and valid criteria for termination of resuscitation reported by researchers in Ontario, Canada is termed the “BLS termination of resuscitation rule” (see Figure 1). It requires that all 3 of the following criteria be present to consider terminating BLS resuscitation attempts for adult victims of out-of-hospital cardiac arrest:

  1. arrest was not witnessed by EMS provider or first responder;
  2. no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and
  3. no AED shocks were delivered.

Figure 1: BLS Termination of Resuscitation Rule for Adult OHCA
This is a preview, select a link below to view this image in a variety of formats, including a full text description.

In Ontario, Canada the BLS termination of resuscitation rule had a positive predictive value of 99.5% and reduced the rate of hospital transport to 37% of cardiac arrests without compromising the care of potentially viable patients.

It is recommended that regional or local EMS authorities use the BLS termination rule to develop protocols for the termination of resuscitative efforts by BLS providers for adult victims of cardiac arrest in areas where advanced life support is not available or may be significantly delayed. (Class I, LOE A) (2010 Part 3)

The reliability and validity of this rule is uncertain if modified. (Class IIb, LOE A) (2010 Part 3)

Implementation of the rule includes real-time contacting of medical control when the rule suggests termination.

Before the protocol is implemented, EMS providers require training in sensitive communication with the family about the outcome of the resuscitative attempt to ensure that providers are familiar with the protocol requirements and can give appropriate support of the grieving family.

Support for the prehospital protocol should be sought from collaborating external agencies (eg, destination hospital emergency departments [EDs], coroner, medical directors, and police) before implementation.
Advanced Life Support Out-of-Hospital System

A different rule may be useful when the additional diagnostic and therapeutic capabilities of an advanced life support (ALS) EMS response are available to the victim. The National Association of EMS Physicians (NAEMSP) suggested that resuscitative efforts could be terminated in patients who do not respond to at least 20 minutes of ALS care.

An ALS termination of resuscitation rule was derived from a diverse population of rural and urban EMS settings. This rule recommends considering terminating attempted resuscitation when ALL of the following criteria apply before moving to the ambulance for transport (see Figure 2): (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. This rule has been retrospectively externally validated for adult patients in several regions in the US, Canada, and Europe, and it is reasonable to employ this rule in all ALS services. (Class IIa, LOE B) (2010 Part 3) (See Figure 2.)

Figure 2: ALS Termination of Resuscitation Criteria
This is a preview, select a link below to view this image in a variety of formats, including a full text description.
Combined BLS and ALS Out-of-Hospital System

In a tiered ALS- and BLS-provider system, the use of a universal termination of resuscitation rule can avoid confusion at the scene of a cardiac arrest without compromising diagnostic accuracy. The BLS rule is reasonable to use in these services. (Class IIa, LOE B) (2010 Part 3)
Transport Implications

Field termination greatly reduces unnecessary transport to the hospital using either the BLS rule or the ALS rule, reducing associated road hazards that put the provider, patient, and public at risk.

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement.

More importantly the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to the hospital.

Intra-arrest Prognostic Factors for Out-of-Hospital Cardiac Arrest in Infants and Children

For infants and children with OHCA, age of less than 1 year, longer duration of cardiac arrest, and presentation with a nonshockable rhythm have all been associated with poor patient outcome.

Multiple variables should be used when attempting to prognosticate outcomes during cardiac arrest in infants and children. (Class I, LOE C-LD) (2015 Part 3)

Although there are factors associated with better or worse outcomes, no single factor that was studied predicts outcome with sufficient accuracy to recommend termination or continuation of CPR.

Use of Extracorporeal CPR (ECPR) with OHCA

The use of extracorporeal CPR (ECPR) may allow providers additional time to treat reversible underlying causes of cardiac arrest (eg, acute coronary artery occlusion, pulmonary embolism, refractory ventricular fibrillation, profound hypothermia, cardiac injury, myocarditis, cardiomyopathy, congestive heart failure, drug intoxication) or serve as a bridge for left ventricular assist device implantation or cardiac transplant. For further information, see Extracorporeal CPR in Parts 6 and 7.

There is insufficient evidence to recommend the routine use of ECPR for adult patients with cardiac arrest.

ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers. (Class IIb, LOE C-LD) (2019 ACLS)

There is insufficient evidence to recommend for or against the use of ECPR for pediatric patients experiencing OHCA or for pediatric patients with noncardiac disease experiencing IHCA refractory to conventional CPR. (2019 PALS)

In-Hospital Cardiac Arrest (IHCA)

Use of ECPR in IHCA

There is insufficient evidence to recommend the routine use of ECPR for adult patients with cardiac arrest. ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers. (Class IIb, LOE C-LD) (2019 ACLS)

ECPR may be considered for pediatric patients with cardiac diagnoses who have IHCA in settings with existing ECMO protocols, expertise, and equipment. (Class IIb; LOE C-LD) (2019 PALS)

Limitation of Interventions and Withdrawal of Life-Sustaining Therapies for In-Hospital Cardiac Arrest

Not initiating resuscitation and discontinuing life-sustaining treatment of IHCA during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support on ethical grounds when functional survival is highly unlikely.

A decision to limit interventions or withdraw life support is justifiable if the patient is determined to be brain dead, if the physician and patient or surrogate agree that treatment goals cannot be met, or if the burden to the patient of continued treatment is believed to exceed any benefits.

Patients in the end stage of an incurable disease should receive care that ensures their autonomy, comfort, and dignity.

  • Interventions that minimize suffering and pain, dyspnea, delirium, convulsions, and other terminal complications should always be provided. For such patients it is ethically acceptable to gradually increase the doses of narcotics and sedatives to relieve pain and other suffering, even to levels that might concomitantly shorten the patient’s life.
  • The care team should initiate plans for future care by collaborative discussions and the resolution of any conflicts with nurses, consultants, residents, fellows, the patient (when capable of participating), surrogate decision makers, and the family. Nursing and comfort care (eg, oral hygiene, skin care, patient positioning, and measures to relieve pain and suffering) must always be continued.

In the absence of evidence of an incurable disease in the end stage, decisions to withdraw or limit interventions in the post-arrest patient are often challenging, given the difficulties of accurate prognostication, especially in the era of treatment advances such as therapeutic hypothermia. For further information, see Post-Cardiac Arrest Care (Part 8) and also the Post-Cardiac Arrest Care section in Pediatric Advanced Life Support (Part 12)

Criteria for Not Starting CPR in Neonatal, Pediatric and Adult IHCA

Few criteria can accurately predict the futility of continued resuscitation. In light of this uncertainty, all pediatric and adult patients who suffer cardiac arrest in the hospital setting should have resuscitative attempts initiated unless the patient has a valid DNAR order or has objective signs of irreversible death (eg, dependent lividity).
DNAR Orders in IHCA

Unlike other medical interventions, CPR is initiated without a physician’s order, based on implied consent for emergency treatment. A licensed physician’s order is necessary to withhold CPR in the hospital setting.

Physicians should initiate a discussion about the use of CPR with all patients admitted for medical and surgical care or with their surrogates. Terminally ill patients may fear abandonment and pain more than death, so physicians should also reassure the patient and family that control of pain and other symptoms as well as other aspects of support will continue even if resuscitation is withheld.

The attending physician should write the DNAR order in accordance with local policy in the patient’s chart, with a note explaining the rationale for the DNAR order, and other specific limitations of care, and documenting discussions with the patient, surrogate, and family. Oral DNAR orders are not acceptable. The limitation-of-treatment order should provide explicit instructions for specific emergency interventions that may arise, including the use of vasopressor agents, mechanical ventilation, blood products, or antibiotics. The scope of a DNAR order should specify which interventions are to be withheld.

It is important to emphasize that all care other than resuscitation should be administered without delay and as appropriate for all patients. A DNAR order does not automatically preclude interventions such as administration of parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors, unless these are included in the order. Some patients may choose to accept defibrillation and chest compressions but not intubation and mechanical ventilation. DNAR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately and communicated to members of the healthcare team.

DNAR orders should be reviewed periodically as per local protocol, particularly if the patient’s condition changes. DNAR orders should also be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability in the operating suite and during the immediate postoperative recovery period.
Criteria for Withholding CPR in Newly Born Infant IHCA

Parents desire a larger role in decisions related to the initiation of resuscitation and continuation of support of severely compromised newborns. The desires of the parents should be considered under circumstances when the outcome of the newly born infant remains unclear.

There are prescribed recommendations to guide the initiation of resuscitative efforts in newly born infants. When gestational age, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples may include extreme prematurity (gestational age <23 weeks or birth weight <400 g), anencephaly, and some major chromosomal abnormalities such as trisomy 13. (Class IIb, LOE C) (2010 Part 3 and Part 15)

In conditions associated with uncertain prognosis where survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. (Class IIb, LOE C) (2010 Part 3 and Part 15)

A consistent and coordinated approach is needed from the obstetric and neonatal teams in applying these guidelines and in communicating with the parents to develop an agreed-upon management plan.
Use of a Prognostic Score in the Delivery Room for Preterm Infants

The data regarding prognostic scores are challenging to evaluate because of the difficulty in distinguishing outcomes that are driven by practice and current belief about survivability, outcomes determined by parental decision making, and outcomes affected by actual physiologic limitations of prematurity.

Antenatal assignment of prognosis for survival and/or disability of the neonate born extremely preterm has generally been made on the basis of gestational age alone. Scoring systems for including additional variables such as gender, use of maternal antenatal steroids, and multiplicity have been developed in an effort to improve prognostic accuracy.

There is no evidence to support the prospective use of any particular delivery room prognostic score presently described, over gestational age assessment alone, in preterm infants at less than 25 weeks of gestation. Importantly, no score has been shown to improve the clinician’s ability to estimate likelihood of survival through the first 18 to 22 months after birth. However, in individual cases, when counseling a family and constructing a prognosis for survival at gestations below 25 weeks, it is reasonable to consider variables such as perceived accuracy of gestational age assignment, the presence or absence of chorioamnionitis, and the level of care available for the location of delivery. It is also recognized that decisions about appropriateness of resuscitation below 25 weeks of gestation will be influenced by region-specific guidelines. The most useful data for antenatal counseling provides outcome figures for infants alive at the onset of labor, not only for those born alive or admitted to a neonatal intensive care unit. (Class IIb, LOE C-LD) (2015 Part 3 and Part 13)

Criteria for Discontinuing CPR in Newborns, Infants, Children and Adults in IHCA
Terminating Resuscitative Efforts in Term Infants

Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes.

Non-initiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes.

An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants.

In infants with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop assisted ventilation; however, the decision to continue or discontinue resuscitative efforts must be individualized. Variables to be considered may include whether the resuscitation was considered optimal; availability of advanced neonatal care, such as therapeutic hypothermia; specific circumstances before delivery (eg, known timing of the insult); and wishes expressed by the family. (Class IIb, LOE C-LD) (2015 Part 3 and Part 13)

For further information, see “Part 13: Neonatal Resuscitation.”
Terminating Cardiac Arrest Resuscitation Efforts in Pediatric IHCA

Although there are factors associated with better or worse outcomes, no single factor studied predicts outcome with sufficient accuracy to recommend termination or prolongation of CPR.

Multiple variables should be used when attempting to prognosticate outcomes during cardiac arrest in infants and children. (Class I, LOE C-LD) (2015 Part 3)
Use of ETCO2 in Decisions to Terminate Adult CPR

In intubated adult patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts, but should not be used in isolation. (Class IIb, LOE C-LD) (2015 Part 3 and Part 7)

In nonintubated patients, a specific ETCO2 cutoff value at any time during CPR should not be used as an indication to end resuscitative efforts. (Class III: Harm, LOE C-EO) (2015 Part 3 and Part 7)

Providing Emotional Support to the Family

Providing Emotional Support to the Family During Resuscitative Efforts in Cardiac Arrest

Parents and other family members seldom ask if they can be present unless they are encouraged to do so by healthcare providers.

In the absence of data documenting harm and in light of data suggesting that it may be helpful, offering select family members the opportunity to be present during a resuscitation is reasonable and desirable (assuming that the patient, if an adult, has not raised a prior objection). (Class IIa, LOE C for adults and Class I, LOE B for pediatric patients) (2010 Part 3)

Resuscitation team members should be sensitive to the presence of family members during resuscitative efforts, assigning a team member to remain with the family to answer questions, clarify information, and otherwise offer comfort.

Providing Emotional Support to the Family After Termination of Resuscitation Efforts in Cardiac Arrest

Notifying family members of the death of a loved one is an important aspect of a resuscitation that should be performed compassionately, with care taken to consider the family‘s culture, religious beliefs and preconceptions surrounding death, and any guilt family members may feel associated with the event or circumstances preceding the event.

Prognostication After Resuscitation in Cardiac Arrest

Predicting Neurologic Outcome in Pediatric Patients After ROSC

There continues to be insufficient evidence to recommend or describe an approach to accurately predict the neurologic outcome of pediatric patients after cardiac arrest.

Early and reliable prognostication of neurologic outcome in pediatric survivors of cardiac arrest may be helpful for effective planning and family support and can inform decisions to continue or discontinue life- sustaining therapy.

Postresuscitation Use of Electroencephalography for Prognosis in Pediatric Survivors of Cardiac Arrest

There is insufficient data to recommend an approach to the use of EEG to predict long-term outcome in pediatric survivors of cardiac arrest

EEGs performed within the first 7 days after pediatric cardiac arrest may be considered in prognosticating neurologic outcome at the time of hospital discharge (Class IIb, LOE C-LD) but should not be used as the sole criterion. (2015 Part 3 and Part 12)

The reliability of any 1 variable for prognostication in children after cardiac arrest has not been established.

Practitioners should consider multiple factors when predicting outcomes in infants and children who achieve ROSC after cardiac arrest. (Class I, LOE C-LD) (2015 Part 3 and Part 12)

In situations where children have minimal prospects for recovery, we emphasize the use of multiple variables to inform treatment decisions.

The decision to withdraw life-sustaining therapies is complex and continues to rest with the treating physician and family. For further information, see “Part 12, Pediatric Advanced Life Support.”

Predicting Neurologic Outcomes in Adult Patients After Cardiac Arrest

The primary purpose in accurately correlating specific data with poor neurologic outcome is to allow clinicians and families to make informed, but often difficult choices for a patient who remains comatose after ROSC following cardiac arrest.

To date, there is no one specific test that can predict with certainty a poor neurologic recovery in this patient population.

In making decisions, particularly the decision of whether to continue or withdraw life- sustaining therapies, clinicians and families need the most accurate information possible; typically, this information is an aggregate of clinical, electrographic, radiographic, and laboratory (eg, biomarkers) findings (see “Part 8: Post–Cardiac Arrest Care”).

Timing of Prognostication in Post–Cardiac Arrest Adults

There are no clinical neurologic signs, electrophysiologic studies, biomarkers, or imaging modalities that can reliably predict death or poor neurologic outcome (eg, Cerebral Performance Category of 3, 4, or 5) within the first 24 hours after cardiac arrest in patients treated with or without TTM.

Sedatives or neuromuscular blockers received during TTM may be metabolized more slowly in patients after cardiac arrest, and injured brains may be more sensitive than normal brains to the depressant effects of many drugs. Residual sedation or paralysis can confound accurate clinical examinations.

The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be a confounder, may be 72 hours after return to normothermia. (Class IIb, LOE C-EO) (2015 Part 3 and Part 8)

We recommend the earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest. (Class I, LOE B-NR) (2015 Part 3 and Part 8)

In patients not treated with TTM, the earliest time to prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination. (Class IIa, LOE C-LD) (2015 Part 3 and Part 8)

Operationally, the timing for prognostication is typically 4.5 to 5 days after ROSC for patients treated with TTM. This approach minimizes the possibility of obtaining false-positive (eg,, erroneously pessimistic) results because of drug-induced depression of neurologic function.

In making this recommendation, it is recognized that in some instances, withdrawal of life support may occur appropriately before 72 hours because of underlying terminal disease, brain herniation, or other clearly nonsurvivable situations.

Prognostic Testing in Adult Patients After Cardiac Arrest

The use of TTM has demonstrated the potential to improve the neurologic outcome in certain adult patients after cardiac arrest who might otherwise have a poor neurologic outcome.

There are few differences in the types of tests used for prognosticating neurologic outcome in those who are and are not treated with TTM.

For further information, see “Part 8: Post–Cardiac Arrest Care.”
Clinical Exam Findings

In comatose patients who are not treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is a reasonable exam finding with which to predict poor neurologic outcome (FPR [false-positive rate], 0%; 95% CI, 0%–8%). (Class IIa, LOE B-NR) (2015 Part 3 and Part 8)

In comatose patients who are treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is useful to predict poor neurologic outcome (FPR, 0%; 95% CI, 0%–3%). (Class I, LOE B-NR) (2015 Part 3 and Part 8)

We recommend that, given their high FPRs [false positive rates], the findings of either absent motor movements or extensor posturing should not be used alone for predicting a poor neurologic outcome (FPR, 10%; 95% CI, 7%–15% to FPR, 15%; 95% CI, 5%– 31%). (Class III: Harm, LOE B-NR) (2015 Part 3 and Part 8)

The motor examination may be a reasonable means to identify the population who need further prognostic testing to predict poor outcome. (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)

We recommend that the presence of myoclonus, which is distinct from status myoclonus, should not be used to predict poor neurologic outcomes because of the high FPR (FPR, 5%; 95% CI, 3%–8% to FPR, 11%; 95% CI, 3%–26%). (Class III: Harm, LOE B-NR) (2015 Part 3 and Part 8)

In combination with other diagnostic tests at 72 or more hours after cardiac arrest, the presence of status myoclonus during the first 72 to 120 hours after cardiac arrest is a reasonable finding to help predict poor neurologic outcomes (FPR, 0%; 95% CI, 0%–4%). (Class IIa, LOE B-NR) (2015 Part 3 and Part 8)
EEG Findings

In comatose post–cardiac arrest patients who are treated with TTM, it may be reasonable to consider persistent absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest, and persistent burst suppression on EEG after rewarming, to predict a poor outcome (FPR, 0%; 95% CI, 0%–3%). (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)

Intractable and persistent (more than 72 hours) status epilepticus in the absence of EEG reactivity to external stimuli may be reasonable to predict poor outcome. (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)

In comatose post–cardiac arrest patients who are not treated with TTM, it may be reasonable to consider the presence of burst suppression on EEG at 72 hours or more after cardiac arrest, in combination with other predictors, to predict a poor neurologic outcome (FPR, 0%; 95% CI, 0%–11%). (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)
Evoked Potentials

In patients who are comatose after resuscitation from cardiac arrest regardless of treatment with TTM, it is reasonable to consider bilateral absence of the N20 somatosensory evoked potentials (SSEP) wave 24 to 72 hours after cardiac arrest or after rewarming a predictor of poor outcome (FPR, 1%; 95% CI, 0%–3%). (Class IIa, LOE B-NR) (2015 Part 3 and Part 8)

SSEP recording requires appropriate skills and experience, and utmost care should be taken to avoid electrical interference from muscle artifacts or from the intensive care unit environment.

Sedative drugs or temperature manipulation affect SSEPs less than they affect the EEG and clinical examination.
Imaging Tests

In patients who are comatose after resuscitation from cardiac arrest and are not treated with TTM, it may be reasonable to use the presence of a marked reduction of the gray-white ratio on brain computed tomography obtained within 2 hours after cardiac arrest to predict poor outcome. (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)

It may be reasonable to consider extensive restriction of diffusion on brain magnetic resonance imaging at 2 to 6 days after cardiac arrest in combination with other established predictors for predicting a poor neurologic outcome. (Class IIb, LOE B-NR) (2015 Part 3 and Part 8)

Note that acquisition and interpretation of imaging studies have not been fully standardized and are affected by interobserver variability. Therefore, brain imaging studies for prognostication should be performed only in centers where specific experience is available.
Blood Markers

Given the possibility of high FPRs, blood levels of neuron-specific enolase and S-100B should not be used alone to predict a poor neurologic outcome. (Class III: Harm, LOE C-LD) (2015 Part 3 and Part 8)

When performed with other prognostic tests at 72 hours or more after cardiac arrest, it may be reasonable to consider high serum values of neuron-specific enolase at 48 to 72 hours after cardiac arrest to support the prognosis of a poor neurologic outcome (Class IIb, LOE B-NR), especially if repeated sampling reveals persistently high values. (Class IIb, LOE C-LD) (2015 Part 3 and Part 8)

Ethics of Organ and Tissue Donation

Situations that offer the opportunity for organ donation include:

  • donation after neurologic determination of death,
  • controlled donation after circulatory determination of death,
  • uncontrolled donation after circulatory determination of death.

Controlled donation after circulatory death usually takes place in the hospital after a patient whose advanced directives or surrogate, family, and medical team agree to allow natural death and withdraw life support.

Uncontrolled donation usually takes place in an emergency department or critical care unit after exhaustive efforts at resuscitation have failed to achieve ROSC.

We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation. (Class I, LOE B-NR) (2015 Part 3)

Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist. (Class IIb, LOE B-NR) (2015 Part 3)

In making this recommendation, the decisions for termination of resuscitative efforts and the pursuit of organ donation need to be independent processes (see “Part 8: Post–Cardiac Arrest Care”).

When communities do not optimize the retrieval of organ and tissue donations, protracted waiting time and greater suffering can result for patients awaiting organ transplantation.

The Emergency Cardiovascular Care community of the American Heart Association supports efforts to optimize the ethical acquisition of organ and tissue donations.

Studies suggest no difference in functional outcomes of organs transplanted from patients who are determined to be brain dead as a consequence of cardiac arrest when compared with donors who are brain dead from other causes.

It is reasonable to suggest that all communities should optimize retrieval of tissue and organ donations in brain dead post–cardiac arrest patients (in-hospital) and those pronounced dead in the out- of-hospital setting. (Class IIa, LOE B) (2010 Part 3)

Most important to this process is advance planning and infrastructure support to allow organ donation to occur in a manner sensitive to the needs of the donor’s family and without undue burden on the staff.

Medical directors of EMS agencies, emergency departments (EDs), and critical care units (CCUs) should develop protocols and implementation plans with the regional organ and tissue donation program to optimize donation following a cardiac arrest death (Class I, LOE C) (2010 Part 3), including:

  • a process by which permission for organ and tissue donations will be obtained
  • the establishment of clearly defined guidelines for organ and tissue procurement that will be available to all healthcare providers both in and out of the hospital
  • information to address the possible differences between applicable laws and societal values in procedures for organ procurement
  • the emotional support to be offered to providers post event
  • a system to acquire organ and tissue donations from individuals pronounced dead in the out-of-hospital setting. This discussion should include input from the coroner, EMS, police, and lay people representing the target community


There is often insufficient evidence to recommend for or against specific interventions due to the uncertainty of determining a prognosis and predicting a particular outcome. As such, a solid understanding of the ethical principles surrounding autonomy and decision making must be coupled with the best information available at the time.

Beyond decisions regarding the initiation and termination of life support, family presence during resuscitations and organ donation also require healthcare providers to consider both science and ethics when providing patient-centered care.

Authorship and Disclosures

2015 Writing Team

Mary E. Mancini, Chair; Douglas S. Diekema; Theresa A. Hoadley; Kelly D. Kadlec; Marygrace H. Leveille; Jane E. McGowan; Michele M. Munkwitz; Ashish R. Panchal; Michael R. Sayre; Elizabeth H. Sinz

Table 1: Part 3: Ethical Issues: 2015 Guidelines Update Writing Group Disclosures

2010 Writing Team

Laurie J. Morrison, Chair; Gerald Kierzek; Douglas S. Diekema; Michael R. Sayre; Scott M. Silvers; Ahamed H. Idris; Mary E. Mancini

Table 2: 2010 - Guidelines Part 3: Ethics: Writing Group Disclosures

2010 Acknowledgements

Neonatal Task Force Chair Jeffrey M. Perlman for his contributions to the manuscript and Andrew H. Travers and Thomas D. Rea for their insightful review and editing.


The American Heart Association requests that this document be cited as follows:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 3: Ethical Issues.

© Copyright 2015 American Heart Association, Inc.


Close OutlineOutline
Part 3: Ethical Issues